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Inselman JW, Jeffery MM, Maddux JT, Lam RW, Shah ND, Rank MA, Ngufor CG. A prediction model for asthma exacerbations after stopping asthma biologics. Ann Allergy Asthma Immunol 2023; 130:305-311. [PMID: 36509405 PMCID: PMC9992017 DOI: 10.1016/j.anai.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Little is known regarding the prediction of the risks of asthma exacerbation after stopping asthma biologics. OBJECTIVE To develop and validate a predictive model for the risk of asthma exacerbations after stopping asthma biologics using machine learning models. METHODS We identified 3057 people with asthma who stopped asthma biologics in the OptumLabs Database Warehouse and considered a wide range of demographic and clinical risk factors to predict subsequent outcomes. The primary outcome used to assess success after stopping was having no exacerbations in the 6 months after stopping the biologic. Elastic-net logistic regression (GLMnet), random forest, and gradient boosting machine models were used with 10-fold cross-validation within a development (80%) cohort and validation cohort (20%). RESULTS The mean age of the total cohort was 47.1 (SD, 17.1) years, 1859 (60.8%) were women, 2261 (74.0%) were White, and 1475 (48.3%) were in the Southern region of the United States. The elastic-net logistic regression model yielded an area under the curve (AUC) of 0.75 (95% confidence interval [CI], 0.71-0.78) in the development and an AUC of 0.72 in the validation cohort. The random forest model yielded an AUC of 0.75 (95% CI, 0.68-0.79) in the development cohort and an AUC of 0.72 in the validation cohort. The gradient boosting machine model yielded an AUC of 0.76 (95% CI, 0.72-0.80) in the development cohort and an AUC of 0.74 in the validation cohort. CONCLUSION Outcomes after stopping asthma biologics can be predicted with moderate accuracy using machine learning methods.
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Affiliation(s)
- Jonathan W Inselman
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Molly M Jeffery
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Regina W Lam
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; OptumLabs, Cambridge, Massachusetts
| | - Matthew A Rank
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Arizona.
| | - Che G Ngufor
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Murphy VE, Jensen ME, Gibson PG. Exacerbations of asthma following step-up and step-down inhaled corticosteroid and long acting beta agonist therapy in the managing asthma in pregnancy study. J Asthma 2020; 59:362-369. [PMID: 33158369 DOI: 10.1080/02770903.2020.1847934] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Guidelines for asthma management contain a consensus recommendation that inhaled corticosteroid (ICS) dose should not be stepped down in pregnancy. However, this is not consistent with consumer preferences and pharmacological principles to minimize medication exposure during pregnancy. We investigated exacerbations after changes to ICS and long acting beta agonist (LABA) therapy in pregnant women with asthma. METHODS Pregnant women (n = 220) were recruited to a randomized controlled trial (RCT) where maintenance treatment was adjusted monthly based on either symptoms (control group), or fractional exhaled nitric oxide (FeNO, to alter ICS) and symptoms (to alter LABA, FeNO group). Exacerbations were monitored prospectively. RESULTS ICS were used by 137 (62.3%) women at some time during pregnancy. ICS dose remained unchanged in 16 women (11.7%, 95% confidence interval [CI] 7-18%), increased in 37 women (27%, 95%CI 20-35%), decreased in 34 women (24.8%, 95%CI 18%-33%), or both increased and decreased in 50 women (36.5%, 95%CI 29-45%). Exacerbations occurred within 14 days of ICS step-down in 11 women (13%, 95%CI 7.5%-22%). This was not significantly different from exacerbations occurring within 14 days of step-up, in 7 women (8.1%, 95%CI 4%-16%, P = 0.294). There were no differences between management groups. Exacerbations occurred within 14 days of step-down in 14.7% (95%CI 7%-30%) of women in the control group, and in 12% (95%CI 6%-24%) of women in the FENO group. CONCLUSIONS ICS step-down could be considered when eosinophilic inflammation or symptoms are low, and may be a useful management approach for women, doctors, and midwives wishing to minimize ICS exposure during pregnancy.
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Affiliation(s)
- Vanessa E Murphy
- Priority Research Centre GrowUpWellTM, University of Newcastle and Hunter Medical Research Institute, Callaghan, NSW, Australia
| | - Megan E Jensen
- Priority Research Centre GrowUpWellTM, University of Newcastle and Hunter Medical Research Institute, Callaghan, NSW, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, University of Newcastle and Hunter Medical Research Institute, New Lambton, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
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Koskela HO, Nurmi HM, Purokivi MK. Cough-provocation tests with hypertonic aerosols. ERJ Open Res 2020; 6:00338-2019. [PMID: 32337214 PMCID: PMC7167210 DOI: 10.1183/23120541.00338-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/23/2020] [Indexed: 12/19/2022] Open
Abstract
Recent advances in cough research suggest a more widespread use of cough-provocation tests to demonstrate the hypersensitivity of the cough reflex arc. Cough-provocation tests with capsaicin or acidic aerosols have been used for decades in scientific studies. Several factors have hindered their use in everyday clinical work: i.e. lack of standardisation, the need for special equipment and the limited clinical importance of the response. Cough-provocation tests with hypertonic aerosols (CPTHAs) involve provocations with hypertonic saline, hypertonic histamine, mannitol and hyperpnoea. They probably act via different mechanisms than capsaicin and acidic aerosols. They are safe and well tolerated and the response is repeatable. CPTHAs can assess not only the sensitivity of the cough reflex arc but also the tendency of the airway smooth muscles to constrict (airway hyper-responsiveness). They can differentiate between subjects with asthma or chronic cough and healthy subjects. The responsiveness to CPTHAs correlates with the cough-related quality of life among asthmatic subjects. Furthermore, the responsiveness to them decreases during treatment of chronic cough. A severe response to CPTHAs may indicate poor long-term prognosis in chronic cough. The mannitol test has been stringently standardised, is easy to administer with simple equipment, and has regulatory approval for the assessment of airway hyper-responsiveness. Manual counting of coughs during a mannitol challenge would allow the measurement of the function of the cough reflex arc as a part of clinical routine. Cough-provocation tests with hypertonic aerosols offer the possibility to measure the function of the cough reflex arc even in everyday clinical workhttp://bit.ly/2RTOfMI
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Affiliation(s)
- Heikki O Koskela
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, Kuopio, Finland.,School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Hanna M Nurmi
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, Kuopio, Finland.,School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Minna K Purokivi
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, Kuopio, Finland
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Pizzichini MMM, Carvalho-Pinto RMD, Cançado JED, Rubin AS, Cerci Neto A, Cardoso AP, Cruz AA, Fernandes ALG, Blanco DC, Vianna EO, Cordeiro Junior G, Rizzo JA, Fritscher LG, Caetano LSB, Pereira LFF, Rabahi MF, Oliveira MAD, Lima MA, Almeida MBD, Stelmach R, Pitrez PM, Cukier A. 2020 Brazilian Thoracic Association recommendations for the management of asthma. J Bras Pneumol 2020; 46:e20190307. [PMID: 32130345 PMCID: PMC7462684 DOI: 10.1590/1806-3713/e20190307] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/07/2019] [Indexed: 02/06/2023] Open
Abstract
The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.
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Affiliation(s)
| | - Regina Maria de Carvalho-Pinto
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Adalberto Sperb Rubin
- . Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS) Brasil
- . Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS) Brasil
| | - Alcindo Cerci Neto
- . Universidade Estadual de Londrina - UEL - Londrina (PR) Brasil
- . Pontifícia Universidade Católica do Paraná - PUCPR - Londrina (PR) Brasil
| | | | - Alvaro Augusto Cruz
- . Universidade Federal da Bahia - UFBA - Salvador (BA) Brasil
- . Fundação ProAR, Salvador (BA) Brasil
| | | | - Daniella Cavalet Blanco
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS - Porto Alegre (RS), Brasil
| | - Elcio Oliveira Vianna
- . Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Gediel Cordeiro Junior
- . Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte (MG), Brasil
- . Hospital Júlia Kubitschek, Belo Horizonte (MG), Brasil
| | | | - Leandro Genehr Fritscher
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS - Porto Alegre (RS), Brasil
| | | | | | - Marcelo Fouad Rabahi
- . Faculdade de Medicina, Universidade Federal de Goiás - UFG - Goiânia (GO) Brasil
| | | | | | | | - Rafael Stelmach
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Alberto Cukier
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Martínez-Moragón E, Delgado J, Mogrovejo S, Fernández-Sánchez T, López JJ, Orenes MÁM, Montaño PP, Toro MT, Oliver BC, Torres ÁF, Delgado PG, Rodríguez TWJ, Auli BV, Yebenes JJZ, Berasategui MTA, Jiménez MF, Ruibio NHDM, Azagra MV, Fernández JAÁ, Sainz SA, González RMB, Nieves MEG, Carpio DA, Sellés NA, García CB, Lessmann AC, Carrillo DDLR, Pla JJ, Giraldo AL, Sánchez OL, Rivera CM, Olondris PM, Gall XM, Nogués EP, Coimerma FP, Carroz KP, Blanch AR, Ortún MLR, Berenguer DS, Batlles JS, Mitjà PS, Sagardía AS, Retes LS, Combas JV, Giralte XV, Zubeldia IA, Ercoreca IA, Peña MH, Pascual MMI, Michelena CJ, Castro AL, Legarreta AL, Llorente PL, Prieto JP, Lorenzo VZ, Gil LA, Muñoz JPG, Durantez MM, Miguel TP, Ahmida T, Izquierdo MIA, Olbah MA, Muñoz AA, Núñez IG, Fernández DG, Camacho AL, Pellon LF, Miguel EMM, Portal FO, Raducan I, Prats JAR, Segarra MDS, Soler FT, Naon AL, Bonilla PG, Muñoz FLG, Calderón PM, Costa LME, Aparicio MB, Pazos JMG, Paz VG, Barcala FJG, Sotes PI, Rodríguez PJM, Nieto FM, Orjales RN, Martín CS, Antelo JS, Rodríguez JT, Español SA, Nieto CS, Talaverano GS, Rodríguez MME, López JFF, Jiménez MÁL, Vílchez MJR, Palacín SC, Quintana SD, Echeverria JAN, Guardia EFDL, Jara BH, García VM, Vazquez LV, De Sus JC, Santonio J, López JAA, Campillo EA, Molina CVJMC, Venegas ADS, Martínez PB, Reinosa BB, Parra BF, García DF, Gutiérrez VS, Lobera AVRD, Alcon SL, González FC, Fernández TG, Lázaro JM, Macenlle NM, Viteri SA, Amerigo DA, Bobolea I, Aguirre MDPC, Contreras RC, Arias FC, Álvarez MC, Martínez EBDH, Campos RMD, Cano MDMG, Rodríguez LG, Tejada JAGRD, Mancebo EG, Seco EG, Torralba FG, Santana AH, Herrera PDLH, Mosquete MRH, Rodríguez PL, Ballesteros BLM, Vicente EM, Chacón BM, Fernández AM, García EM, Castillejo EO, Serrano FP, Acevedo YPA, Rojo RP, Ruiz-Rico NQ, Pinedo ÁR, Jiménez BR, Rodríguez MR, Ingelmo AR, Peña AR, González MJS, Trujillo MJT, Fuertes LV, Albelda CV, Meniz AY, Grovas RIAP, Ramírez JARA, Muñoz JMB, Manzanares MB, Martínez GDL, Núñez IG, Luna FLD, Paez AM, Tejada EOSD, Galo AP, Cornejo MPE, Esojo CS, Alemán ÁFA, Rumayor MCA, Espinosa RA, Mora RB, Lancharro FJC, Urra TG, Martín SH, Lizaldre AR, Quintas RD. Factors that determine the loss of control when reducing therapy by steps in the treatment of moderate-severe asthma in standard clinical practice: A multicentre Spanish study. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Diagnostic and Therapeutic Long-term Management of Eosinophilic Esophagitis- Current Concepts and Perspectives for Steroid Use. Clin Transl Gastroenterol 2019; 9:e212. [PMID: 30802222 PMCID: PMC6303250 DOI: 10.1038/s41424-018-0074-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus, which requires short- and long-term treatment. In addition, patients under long-term treatment for any chronic condition should have a structured follow-up. The mainstays in EoE treatment are drugs (such as swallowed topical corticosteroids [STC] and proton pump inhibitors), dietary exclusions, and endoscopic dilations. STC are the most widely used treatment and have proven efficacy in inducing clinical, endoscopic and histological remission in active EoE. However, data regarding maintaining disease remission and long-term management are limited. Ongoing disease activity and relapses despite STC treatment are frequently observed. This sheds light on the urgent need for adequate maintenance strategies, which have not been well defined. In terms of follow-up concepts, to date neither guidelines nor consensus recommendations have been published. To summarize the current knowledge on long-term diagnostic and therapeutic STC management of EoE, we conducted a literature search using PubMed and Embase applying the following key search items: Eosinophilic esophagitis, eosinophils, esophagus, swallowed topical corticosteroids, fluticasone, budesonide, long-term, treatment, therapy, and follow-up. In addition, we present empirically developed long-term management concepts applied at two large EoE centers, with a special focus on STC treatments. Finally, we highlight areas of future research and perspectives regarding the long-term management of EoE.
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Martínez-Moragón E, Delgado J, Mogrovejo S, Fernández-Sánchez T, Jesús JL, Ángel MOM, Patricia PM, Miguel TT, Begoña CO, Ángel FT, Purificación GD, Wilfox JRT, Brian VA, José ZYJ, Teresa ABM, Marta FJ, Nieves HDMR, Marta VA, Antonio ÁFJ, Sara AS, Rosa BGM, Estela GNM, Diego AC, Núria AS, Cristina BG, Astrid CL, David DLRC, Jordi JP, Alejandra LG, Olga LS, Carlos MR, Pilar MO, Xavier MG, Ester PN, Francisco PC, Karina PC, Antoni RB, Luisa ROM, Dan SB, Joan SB, Pere SM, Ana SS, Lorena SR, Joan VC, Xavier VG, Ignacio AZ, Ignacio AE, Miguel HP, Milagros IPM, Carmen JM, Adolfo LC, Amaia LL, Paula LL, Joaquina PP, Vanessa ZL, Lidia AG, Pablo GMJ, Marisa MD, Teresa PM, Tahar A, Isabel AIM, Michael AO, Aurelio AM, Ignacio GN, Diego GF, Antonio LC, Luis FP, Maria MME, Félix OP, Isabela R, Antonio RPJ, Dolores SSM, Frederic TS, Alberto LN, Pedro GB, Luis GMF, Patricia MC, Manuel ECL, Marina BA, Manuel GPJ, Vanessa GP, Francisco-Javier GB, Pilar IS, Jorge MRP, Fernando MN, Ramón NO, Carracedo SM, Juan SA, Julia TR, Santiago AE, Carlos SN, Gladis ST, Mar ERM, Fernando FLJ, Ángeles LJM, José RVM, Susana CP, Silvia DQ, Antonio NEJ, Eduardo FDLG, Belén HJ, Victoria MG, Lucía VV, Joaquín CDS, Santonio CVJ, Alfonso ALJ, Eduardo AC, María CMJ, Dolores SVA, Patricia BM, Begoña BR, Beatriz FP, Domingo FG, Virginia SG, Adolfo VRDL, Silvia LA, Francisco CG, Teresa GF, Joaquín ML, Noemí MM, Soledad AV, Darío AA, Irina B, Puerto CAMD, Remedios CC, Fernando CA, Mercedes CÁ, Belén DHME, Magdalena DCR, Mar GCMD, Leticia GR, Andrés GRDTJ, Eloina GM, Emma GS, Fernando GT, Aythamy HS, Lys HHPD, Ruth HMM, Pedro LR, Belén LMB, Ester MV, Beatriz MC, Antonio MF, Esther MG, Elena OC, Fernando PS, Yesenia PAA, Raquel PR, Natividad QRR, Ángela RP, Beatriz RJ, Mercedes RR, Ana RI, Antonio RP, José SGM, Jesús TTM, Laura VF, Concepción VA, Alexandra YM, Ismael APGR, José ARAR, Manuel BMJ, Miguel BM, Gustavo DLM, Ignacio GN, Francisco LDL, Alfonso MP, Ezequiel OSDT, Alicia PG, Manuel PEC, Carmen SE, Francisco AAÁ, Consuelo ARM, Rubén AE, Roberto BM, Javier CLF, Tamara GU, Sonia HM, Alfredo RL, Raquel DQ. Factors that determine the loss of control when reducing therapy by steps in the treatment of moderate-severe asthma in standard clinical practice: A multicentre Spanish study. Rev Clin Esp 2019; 220:86-93. [PMID: 31350049 DOI: 10.1016/j.rce.2019.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/01/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although the clinical practice guidelines recommend continuous adjustment of asthma treatment and reducing the maintenance drugs when achieving control (step-down), there are few studies of standard clinical practice aimed at collecting information on the factors that determine step-down failure. OBJECTIVE To determine the factors that determine step-down failure in standard clinical practice of patients with moderate-severe asthma controlled by a combination of inhaled glucocorticoids and long-acting beta agonists. METHODS A multicentre retrospective study included 374 patients with moderate-severe asthma controlled with inhaled glucocorticoids and long-acting beta agonists for whom the physician indicated a step-down in 2016. RESULTS The step-down failed in 41.7% of the patients. The following factors were related to failure: greater patient age (P=.006), presence of at least 2 comorbidities (P=.016), greater severity level (severe persistent vs. moderate persistent) (P<.001), greater age at diagnosis (>40 years) (P=.045), the higher the therapeutic step before (P=.003) and after the change (P<.001), the shorter the time of improvement/control prior to the change (P=.019), lower FEV1 (P=.001) and a poorer Asthma Control Test score or Asthma Control Questionnaire score before the step-down (P<.001). The logistic regression analysis showed a higher probability of step-down failure in the more elderly patients (OR, 0.983; 95% CI 0.969-0.997) and those with severe asthma compared to those with moderate asthma (OR, 0.537; 95% CI 0.292-0.985), as well as an increased probability of success if the patients had the disease controlled for more than 6 months (OR, 2.253; 95% CI 1.235-4.112). CONCLUSION In standard clinical practice conditions, step-down fails in a high percentage of patients, and the suggestion is to indicate step-down when the patient has had more than 6 months of disease control.
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Affiliation(s)
| | - J Delgado
- Unidad de Gestión Clínica de Alergología, Hospital Virgen Macarena, Sevilla, España
| | - S Mogrovejo
- Neumología, Hospital Universitario Dr. Peset, Valencia, España
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Chipps BE, Bacharier LB, Murphy KR, Lang D, Farrar JR, Rank M, Oppenheimer J, Zeiger RS. The Asthma Controller Step-down Yardstick. Ann Allergy Asthma Immunol 2018; 122:241-262.e4. [PMID: 30550809 DOI: 10.1016/j.anai.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/02/2018] [Accepted: 12/03/2018] [Indexed: 12/11/2022]
Abstract
Asthma guidelines recommend a control-based approach to disease management in which the assessment of impairment and risk is linked to step-based therapy. Using this model, controller treatment is adjusted-upward or downward-according to a patient's level of asthma control over time. Strategies for stepping up controller therapy are well described, and the adult and pediatric Asthma Yardsticks provide operational recommendations based on patient profiles. Strategies for stepping down controller treatment are less clear, although stepping down to the minimum effective therapy is important and should be considered when a patient's asthma has been well controlled for an adequate period as defined by risk and impairment. This Yardstick presents recommendations for when and how to step down asthma controller therapy according to guideline-defined control levels. The objective is to provide clinicians who treat patients with asthma with a practical and clinically relevant framework for implementing a step-down in controller therapy.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
| | - Leonard B Bacharier
- Washington University School of Medicine and St. Louis Children's Hospital, Division of Allergy, Immunology and Pulmonary Medicine, Saint Louis, Missouri
| | - Kevin R Murphy
- Boys Town National Research Hospital, Boys Town, Nebraska
| | - David Lang
- Division of Allergy and Clinical Immunology, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Matthew Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | | | - Robert S Zeiger
- Kaiser Permanente Southern California Region, Department of Allergy and Research and Evaluation, San Diego and Pasadena, California
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Pérez de Llano L, García-Rivero JL, Urrutia I, Martínez-Moragón E, Ramos J, Cebollero P, Carballada F, Blanco-Aparicio M, Vennera MDC, Merino M, Torralba-García Y, Plaza V. A Simple Score for Future Risk Prediction in Patients with Controlled Asthma Who Undergo a Guidelines-Based Step-Down Strategy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1214-1221.e3. [PMID: 30368006 DOI: 10.1016/j.jaip.2018.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 10/13/2018] [Accepted: 10/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The minimum controlling dose of treatment must be established in patients with asthma, but the outcome of step-down is unpredictable. OBJECTIVE To identify factors associated with risk of control loss when stepping down asthma treatment and to develop a score to predict this risk. METHODS A prospective, multicenter study including adults with well-controlled asthma was performed. Treatment was stepped up or stepped down over a 12-month period to maintain asthma control. We determined associations between clinical and functional variables and step-down failure. Finally, we derived a score to predict loss of control in 1 cohort and validated it in an independent cohort. RESULTS The derivation cohort consisted of 228 patients; 218 completed at least 1 step-down episode and a total of 495 step-down episodes were evaluated. A medical-record documented postbronchodilator spirometry result of <70% forced expiratory volume in 1 second (FEV1)/forced vital capacity (odds ratio [OR] = 2.08; 95% confidence interval [CI]: 1.26-3.43), current FEV1 < 80% (OR = 1.80; 95% CI: 1.03-3.14), ≥1 severe exacerbation in the previous 12 months (OR = 2.43; 95% CI: 1.48-4.01), and Asthma Control Test score < 25 (OR = 2.30; 95% CI: 1.35-3.92) were independently associated with failure. The score showed an area under the curve of 0.690 (95% CI: 0.633-0.747; P < .05) in the derivation cohort and 0.76 (95% CI: 0.643-0.882; P < .001) in a validation cohort of 114 patients. A score <4.5 implies a low risk of failure (<20%), whereas a score >8 implies a high risk (>40%). CONCLUSION This score can facilitate the prediction of step-down failure before medication taper in patients with well-controlled asthma.
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Affiliation(s)
| | | | - Isabel Urrutia
- Pneumology Service, Hospital de Galdakao, Bizkaia, Spain
| | | | - Jacinto Ramos
- Pneumology Service, Complejo Asistencial de Salamanca, Salamanca, València, Spain
| | - Pilar Cebollero
- Pneumology Service, Complejo Hospitalario de Navarra, Navarra, Spain
| | | | - Marina Blanco-Aparicio
- Pneumology Service, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain
| | - María Del Carmen Vennera
- Servei de Pneumologia i Allèrgia Respiratòria, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - María Merino
- Health Outcomes Research Department, Weber, Economía y Salud, Madrid, Spain
| | - Yolanda Torralba-García
- Servei de Pneumologia i Allèrgia Respiratòria, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Vicente Plaza
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Department of Medicine, Barcelona, Spain
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10
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Rogers L, Sugar EA, Blake K, Castro M, Dimango E, Hanania NA, Happel KI, Peters SP, Reibman J, Saams J, Teague WG, Wise RA, Holbrook JT. Step-Down Therapy for Asthma Well Controlled on Inhaled Corticosteroid and Long-Acting Beta-Agonist: A Randomized Clinical Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:633-643.e1. [PMID: 28974349 DOI: 10.1016/j.jaip.2017.07.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Stepping down therapy when asthma is well controlled on combination inhaled corticosteroids (ICSs) and long-acting beta-agonists (LABAs) is recommended, but it is not known whether lowering the ICS dose or stopping LABA is superior. OBJECTIVE To evaluate whether step-down therapy with LABA is superior to one without; and, secondarily, to evaluate whether reducing the ICS dose while maintaining LABA is noninferior to remaining on stable-ICS/LABA. METHODS The study was a randomized, double-masked 3-arm parallel group trial in participants aged 12 years or older. Following an 8-week run-in, 459 participants were randomly assigned to continue medium-dose ICS/LABA, reduced-dose ICS/LABA, or ICS alone (LABA-step-off) and followed for 48 weeks. The primary outcome was time to treatment failure, a composite of health care utilization, systemic corticosteroid use, increase in rescue therapy, decline in lung function, or participant or physician decision. RESULTS Time to treatment failure did not differ significantly between reduced- ICS/LABA and LABA-step-off (hazard ratio, 1.07; 95.3% CI, 0.69-1.65, P = .76). Nor was there a difference between stable-ICS/LABA and reduced-ICS/LABA (hazard ratio, 1.11; 95% CI, 0.70-1.76; P = .67), but the 10% noninferiority margin was exceeded. Lung function declines and hospitalization rates were significantly greater in the LABA-step-off group. CONCLUSIONS The 2 step-down regimens did not differ in terms of treatment failure, although stopping LABA was associated with a decline in lung function and more hospitalizations. There was no evidence to support the noninferiority of reduced-ICS/LABA as compared with stable-ICS/LABA.
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Affiliation(s)
- Linda Rogers
- Icahn School of Medicine at Mt Sinai, New York, NY
| | | | | | - Mario Castro
- Washington University School of Medicine, St Louis, Mo
| | - Emily Dimango
- Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Kyle I Happel
- Louisiana State University School of Medicine, New Orleans, La
| | | | - Joan Reibman
- New York University School of Medicine, New York, NY
| | - Joy Saams
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - W Gerald Teague
- University of Virginia School of Medicine, Charlottesville, Va
| | - Robert A Wise
- Johns Hopkins University School of Medicine, Baltimore, Md.
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11
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Jabbal S, Manoharan A, Anderson W, Lipworth J, Lipworth B. Real-life effect of long-acting β 2-agonist withdrawal in patients with controlled step 3 asthma. Ann Allergy Asthma Immunol 2016; 117:430-431. [PMID: 27519578 DOI: 10.1016/j.anai.2016.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/21/2016] [Accepted: 07/15/2016] [Indexed: 01/05/2023]
Affiliation(s)
- Sunny Jabbal
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom
| | - Arvind Manoharan
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom
| | - William Anderson
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom
| | - Joseph Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom.
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom
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