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Nakwan N, Ruklerd T, Taptawee P. A Pilot Randomized Trial of As-needed Budesonide-formoterol for Stepping Down Controller Treatment in Moderate Asthma with Complete Remission. Tuberc Respir Dis (Seoul) 2022; 85:227-236. [PMID: 35645167 PMCID: PMC9263339 DOI: 10.4046/trd.2022.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background The use of low-dose inhaled corticosteroid-formoterol as reliever monotherapy has recently been recommended in the asthma treatment guidelines. However, the efficacy of this treatment strategy has not yet been determined during the stepping-down period in moderate asthma. This study aimed to evaluate the feasibility of reducing treatment to as-needed budesonide-formoterol (BFM) in moderate asthma with complete remission. Methods We randomly assigned 31 patients (8 males and 23 females with a mean age of 57.2 years) with complete remission of asthma by inhaled BFM (160/4.5 μg) twice daily to receive BFM (160/4.5 μg) as needed (16 patients), or budesonide (BUD) (200 μg) twice daily (15 patients). The study was an open-label study done for 48 weeks, with the primary outcome as the cumulative percentages of patients with treatment failure (asthma exacerbation or loss of asthma control or lack of satisfaction after using medications) in the two groups. Results Six patients (42%) using as-needed BFM had treatment failure, as compared with three patients (21.4%) using BUD maintenance (hazards ratio for as-needed BFM, 1.77; 95% confidential interval, 0.44–7.12; p=0.41). The changes in forced expiratory volume in 1 second were −211.3 mL with as-needed BFM versus −97.8 mL with BUD maintenance (difference, 113.5 mL; p=0.75) and the change in fractional exhaled nitric oxide was significantly higher in both groups, at 8.68 parts per billion (ppb) in the as-needed BFM group and 2.5 ppb. in the BUD maintenance group (difference, 6.18 ppb; p=0.049). Conclusion Compared with BUD maintenance, there were no significant differences in treatment failure rate in patients who received as-needed BFM during the stepping down period in moderate asthma. However, they showed reduced lung function and relapsed airway inflammation. The results are limited by imprecision, and further large RCTs are needed.
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Affiliation(s)
- Narongwit Nakwan
- Division of Pulmonology, Department of Medicine, Hat Yai Medical Education Center, Hat Yai Hospital, Songkhla, Thailand
- Address for correspondence Narongwit Nakwan, M.D. Division of Pulmonology, Department of Medicine, Hat Yai Medical Education Center, Hat Yai Hospital, Songkhla 90110, Thailand Phone 66-74261093 Fax 66-74273100 E-mail
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Damadoglu E, Demir AU. The Dilemma: How to Step Down from Step 3 Asthma Treatment? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3647-3648. [PMID: 34627535 DOI: 10.1016/j.jaip.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Ebru Damadoglu
- Department of Pulmonology, Division of Allergy and Clinical Immunology, Hacettepe University, School of Medicine, Ankara, Turkey.
| | - Ahmet Ugur Demir
- Department of Pulmonology, Hacettepe University, School of Medicine, Ankara, Turkey
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Kim SH, Lee T, Jang AS, Park CS, Jung JW, Kim MH, Kwon JW, Moon JY, Yang MS, Lee J, Choi JH, Shin YS, Kim HK, Kim S, Kim JH, Lee SY, Nam YH, Kim SH, Kim TB. Pragmatic Randomized Controlled Trial for Stepping Down Asthma Controller Treatment in Patients Controlled with Low-Dose Inhaled Corticosteroid and Long-Acting β 2-Agonist: Step-Down of Intervention and Grade in Moderate Asthma Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3638-3646.e3. [PMID: 33940213 DOI: 10.1016/j.jaip.2021.04.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current asthma guidelines recommend stepping down controller treatment when the condition is well-controlled for a certain time. However, the optimal step-down strategy for well-controlled patients receiving a low-dose inhaled corticosteroid (ICS) with a long-acting β2-agonist (LABA) remains unclear. OBJECTIVE This study was a randomized, open-label, three-arm, parallel pragmatic trial comparing two kinds of step-down approaches for maintaining treatment. METHODS Adults with asthma who were aged 18 years or older, and who had been stable with low-dose ICS/LABA for at least 3 months, were enrolled. Subjects (n = 225) were randomly allocated into one of three groups (maintaining low-dose ICS/LABA [G1], discontinuing LABA [G2], and reducing ICS/LABA to once daily [G3]), and were observed for 6 months. The primary end point was a change in Asthma Control Test (ACT) scores between randomization and the final 6-month follow-up. RESULTS The change in ACT was analyzed in the per-protocol population; noninferiority was not demonstrated in either step-down group compared with the maintenance group (95% confidence interval of the difference, G2 vs G1 = -1.40-0.55; G3 vs G1 = -1.19-0.77). Although over 90% of patients were fine, higher rates of treatment failure were observed in step-down groups (G1: 0%; G2: 9.46%; and G3: 9.09%; P = .027). There were no significant differences between step-down approaches in terms of ACT change or treatment failure. CONCLUSIONS Both step-down methods were not noninferior to maintenance of treatment. Step-down therapy can be attempted when patients are stable, but appropriate monitoring and supervision are necessary with precautions regarding loss of disease control.
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Affiliation(s)
- Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Taehoon Lee
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - An-Soo Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Chan Sun Park
- Department of Internal Medicine, Inje Unversity, Haeundae Paik Hospital, Busan, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, Ewha Woman University College of Medicine, Seoul, Korea
| | - Jae-Woo Kwon
- Department of Internal Medicine, Kangwon University School of Medicine, Chuncheon, Korea
| | - Ji-Yong Moon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, SMG-SNU Borame Medical Center, Seoul, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jeong-Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea; Allergy and Clinical Immunology Research Center, Hallym University College of Medicine, Chuncheon, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hee-Kyoo Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine Kyungbook National University, Daegu, Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Suh-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young-Hee Nam
- Department of Internal Medicine, Dong-A University School of Medicine, Busan, Korea
| | - Sang-Hoon Kim
- Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Beigh AH, Rasool R, Kawoosa F, Manzoor S, Rashid R, Andrabi KI, Shah ZA, Qureshi T. Improved pulmonary function test (PFT) after 1 one year of Sublingual Immunotherapy (SLIT) in unison with pharmacotherapy in mild allergic asthmatics. Immunol Lett 2020; 230:36-41. [PMID: 33340589 DOI: 10.1016/j.imlet.2020.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Allergen immunotherapy (AIT) is a promising treatment for allergic disease that induces immunological tolerance through the administration of specific allergens. The study of AIT is in its early stage and its clinical effects are not well elucidated. The present study was aimed at determining the effect of AIT on pulmonary function and serum variables of mild allergic asthma patients. METHODS A total of 80 patients with mild allergic asthma were recruited for the study. Allergen Specific Immunotherapy was administered in the form of Sublingual Immunotherapy and consisted of a build up phase followed by a maintenance phase (six months each respectively). Total serum IgE and vitamin D levels were quantified by ELISA. The percent eosinophill count was determined by cell analyzers. Pulmonary function test was performed at the baseline and after the end of study period. Subjective symptom score was recorded in the form of asthma control questionnaire score. RESULTS There was a significant increase in the pre FEV1% and pre FEV1/FVC post AIT administration. A significant decrease in the total serum IgE was found post AIT. A decrease in Asthma control Questionnaire (ACQ) scores indicated an improvement in clinical symptoms. Besides there was a significant effect on ICS discontinuation after AIT. CONCLUSION The study supports SLIT as an effective treatment for Immunomodulation in mild allergic asthmatics besides it gives us significant information regarding the safety and efficacy of SLIT in such patients.
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Affiliation(s)
- Afaq H Beigh
- Allergy Clinic, Department of Immunology, and Molecular Medicine, Sher I Kashmir Institute of Medical Sciences Srinagar Kashmir, India
| | - Roohi Rasool
- Allergy Clinic, Department of Immunology, and Molecular Medicine, Sher I Kashmir Institute of Medical Sciences Srinagar Kashmir, India.
| | - Fizalah Kawoosa
- Allergy Clinic, Department of Immunology, and Molecular Medicine, Sher I Kashmir Institute of Medical Sciences Srinagar Kashmir, India
| | - Sharika Manzoor
- Allergy Clinic, Department of Immunology, and Molecular Medicine, Sher I Kashmir Institute of Medical Sciences Srinagar Kashmir, India
| | - Rabiya Rashid
- Allergy Clinic, Department of Immunology, and Molecular Medicine, Sher I Kashmir Institute of Medical Sciences Srinagar Kashmir, India
| | | | - Zafar A Shah
- Allergy Clinic, Department of Immunology, and Molecular Medicine, Sher I Kashmir Institute of Medical Sciences Srinagar Kashmir, India
| | - Taha Qureshi
- Allergy Clinic, Department of Immunology, and Molecular Medicine, Sher I Kashmir Institute of Medical Sciences Srinagar Kashmir, India
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Davies G, Jordan S, Thayer D, Tucker D, Humphreys I. Medicines prescribed for asthma, discontinuation and perinatal outcomes, including breastfeeding: A population cohort analysis. PLoS One 2020; 15:e0242489. [PMID: 33296383 PMCID: PMC7725302 DOI: 10.1371/journal.pone.0242489] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To explore associations between exposures to medicines prescribed for asthma and their discontinuation in pregnancy and preterm birth [<37 or <32 weeks], SGA [<10th and <3rd centiles], and breastfeeding at 6-8 weeks. METHODS Design. A population-based cohort study. Setting. The Secure Anonymised Information Linkage [SAIL] databank in Wales, linking maternal primary care data with infant outcomes. Population. 107,573, 105,331, and 38,725 infants born 2000-2010 with information on premature birth, SGA and breastfeeding respectively, after exclusions. Exposures. maternal prescriptions for asthma medicines or their discontinuation in pregnancy. Methods. Odds ratios for adverse pregnancy outcomes were calculated for the exposed versus the unexposed population, adjusted for smoking, parity, age and socio-economic status. RESULTS Prescriptions for asthma, whether continued or discontinued during pregnancy, were associated with birth at<32 weeks' gestation, SGA <10th centile, and no breastfeeding (aOR 1.33 [1.10-1.61], 1.10 [1.03-1.18], 0.93 [0.87-1.01]). Discontinuation of asthma medicines in pregnancy was associated with birth at<37 weeks' and <32 weeks' gestation (aOR 1.22 [1.06-1.41], 1.53 [1.11-2.10]). All medicines examined, except ICS and SABA prescribed alone, were associated with SGA <10th centile. CONCLUSIONS Prescription of asthma medicines before or during pregnancy was associated with higher prevalence of adverse perinatal outcomes, particularly if prescriptions were discontinued during pregnancy. Women discontinuing medicines during pregnancy could be identified from prescription records. The impact of targeting close monitoring and breastfeeding support warrants exploration.
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Affiliation(s)
- Gareth Davies
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | - Sue Jordan
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | - Daniel Thayer
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | | | - Ioan Humphreys
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
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Wang K, Verbakel JY, Oke J, Fleming-Nouri A, Brewin J, Roberts N, Harada N, Atsuta R, Takahashi K, Mori K, Fujisawa T, Shirai T, Kawayama T, Inoue H, Lazarus S, Szefler S, Martinez F, Shaw D, Pavord ID, Thomas M. Using fractional exhaled nitric oxide to guide step-down treatment decisions in patients with asthma: a systematic review and individual patient data meta-analysis. Eur Respir J 2020; 55:13993003.02150-2019. [PMID: 32139458 DOI: 10.1183/13993003.02150-2019] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND High exhaled nitric oxide fraction (F ENO) levels are associated with greater risk of asthma exacerbation. However, it is not clear how F ENO can be used to guide safe reductions in inhaled corticosteroid (ICS) doses in asthma patients. This study assesses the ability of F ENO to guide ICS reductions. METHODS Systematic searching of electronic databases identified prospective observational studies and randomised controlled trials which recruited participants with mild-to-moderate asthma aged ≥12 years and measured F ENO before reducing ICS. We performed multilevel mixed-effects logistic regression in relation to acute exacerbations and estimated each participant's exacerbation risk using our logistic regression model. RESULTS We included data from seven out of eight eligible studies, representing 384 participants. ICS doses were halved in four studies and withdrawn in three studies. A baseline F ENO measurement of ≥50 ppb was associated with increased risk of exacerbations (crude OR 3.14, 95% CI 1.41-7.00, p=0.005; adjusted OR 3.08, 95% CI 1.36-6.98, p=0.007) and corresponded to an estimated exacerbation risk cut-off of 15%. Reducing ICS when estimated exacerbation risk was <15% versus <10% would result in fewer patients remaining on the same ICS dose (40 (10.4%) out of 384 versus 141 (36.7%) out of 384), but similar proportions of patients avoiding exacerbations (222 (91.4%) out of 243, 95% CI 87.1-94.6% versus 311 (90.4%) out of 344, 95% CI 86.8-93.3%). CONCLUSION In patients with mild-to-moderate asthma, gradual ICS reduction when F ENO is <50 ppb may help decrease ICS use without increasing exacerbations. Future research should aim to validate these findings in larger populations.
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Affiliation(s)
- Kay Wang
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Y Verbakel
- KU Leuven, Dept of Public Health and Primary Care, Leuven, Belgium
| | - Jason Oke
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Josh Brewin
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Norihiro Harada
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Ryo Atsuta
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazuhisa Takahashi
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazutaka Mori
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hammamatsu, Japan
| | - Tomoyuki Fujisawa
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hammamatsu, Japan
| | - Toshihiro Shirai
- Dept of Respiratory Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Kurume University School of Medicine, Kurume, Japan
| | - Hiromasa Inoue
- Dept of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Stephen Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Stanley Szefler
- Children's Hospital Colorado, The Breathing Institute, Dept of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Fernando Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Oxford Respiratory NIHR BRC and Respiratory Medicine Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care, Population Sciences and Medical Education (PPM), University of Southampton, Southampton, UK
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Dinh-Xuan AT, Brusselle G. F ENO as a biomarker guide for inhaled corticosteroid step down in patients with mild-to-moderate well-controlled asthma. Eur Respir J 2020; 55:55/5/2001319. [PMID: 32439733 DOI: 10.1183/13993003.01319-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Anh Tuan Dinh-Xuan
- Respiratory Physiology Unit, Dept of Respiratory Medicine, Cochin Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Guy Brusselle
- Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.,Depts of Epidemiology and Respiratory Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Weinstein CLJ, Ryan N, Zhang X, Shekar T, Gates D, Lane SJ, Agache I, Nathan RA. Serious Asthma Outcomes and Asthma Exacerbations with Maintenance on Inhaled Corticosteroid (Mometasone Furoate)/Long-Acting Beta Agonist (Formoterol) Combination Compared to Step Down to Mometasone Monotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1634-1644.e1. [PMID: 31981733 DOI: 10.1016/j.jaip.2020.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Because of historical safety concerns with the use of long-acting β-agonists (LABA) in asthma, step-down from inhaled corticosteroid (ICS)/LABA combination therapy to ICS monotherapy is recommended once asthma control is achieved. OBJECTIVE To evaluate the benefit/risk question about whether patients with asthma who achieve disease control on fixed-dose ICS/LABA combination therapy, such as mometasone furoate/formoterol fumarate (MF/F), should continue with this therapy or be stepped down to ICS monotherapy, such as MF. METHODS Using data from 8447 clinically stable patients with persistent asthma in the Safety Pharma Investigation of Respiratory Outcomes trial who had been receiving a stable dose of ICS/LABA for ≥4 weeks, this post hoc analysis evaluated the risk of serious asthma outcomes (SAOs) (adjudicated hospitalization, intubation, or death) and asthma exacerbation (AEX) (composite of hospitalizations ≥24 hours, emergency visits <24 hours requiring systemic corticosteroid, or systemic corticosteroid for ≥3 consecutive days) in participants randomized to remain on ICS/LABA (MF/F) or step down to ICS (MF) for 26 weeks. RESULTS There was no significant difference in SAO risk among patients maintained on ICS/LABA with MF/F compared with those who stepped down from ICS/LABA to MF (hazard ratio [HR], 1.03 [95% confidence interval (CI): 0.61, 1.75], P = .913). The risk of AEX was significantly lower in patients maintained on ICS/LABA with MF/F compared with those who stepped down from ICS/LABA to MF (HR, 0.87 [95% CI: 0.78, 0.98], P = .020). CONCLUSIONS In this post hoc analysis of a large clinical trial dataset, maintenance on ICS/LABA with MF/F is not associated with an increased risk of SAOs and also significantly reduces the risk of AEX compared with step-down from ICS/LABA to MF.
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Affiliation(s)
- Cindy L J Weinstein
- Respiratory and Immunology Clinical Development, Merck & Co., Inc., Kenilworth, NJ.
| | - Nicholas Ryan
- Clinical Sciences, Merck & Co., Inc., Kenilworth, NJ
| | | | - Tulin Shekar
- Biostatistics, Merck & Co., Inc., Kenilworth, NJ
| | - Davis Gates
- Biostatistics, Merck & Co., Inc., Kenilworth, NJ
| | - Stephen J Lane
- The Professional Respiratory Centre, Tallaght Hospital, Dublin, Ireland
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Robert A Nathan
- Asthma and Allergy Associates and Research Center, Colorado Springs, Colo
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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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Esden J, Pesta-Walsh N. Diagnosis and Treatment of Asthma in Nonpregnant Women. J Midwifery Womens Health 2018; 64:18-27. [PMID: 30484945 DOI: 10.1111/jmwh.12907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 11/28/2022]
Abstract
Asthma is a common condition affecting 8.3% of the adult population in the United States. The disease is characterized by chronic airway inflammation that leads to airway hyperresponsiveness and obstruction that results in coughing, wheezing, shortness of breath, and a feeling of chest tightness. The diagnosis and classification of asthma is based on reported symptoms, physical examination findings, and spirometry. Pharmacologic therapy is prescribed using a stepwise approach that begins with inhaled short-acting beta2 -agonists for intermittent asthma with the addition of daily inhaled corticosteroids for more persistent cases. Individuals with asthma are reevaluated on a regular basis to monitor symptoms, and pharmacologic treatments are adjusted as needed. Familiarity with the stepwise approach for asthma management and confidence in the efficacy and safety profiles of inhaled medications will assist clinicians in successful management of asthma in the primary care setting.
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Zhang Z, Cheng X, Ge D, Wang S, Qi B. Protective Effects of Astragaloside IV Combined with Budesonide in Bronchitis in Rats by Regulation of Nrf2/Keap1 Pathway. Med Sci Monit 2018; 24:8481-8488. [PMID: 30471087 PMCID: PMC6270885 DOI: 10.12659/msm.911150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This study was conducted to evaluate the effects of astragaloside IV and budesonide on bronchitis in rats and to explore the mechanism involved. MATERIAL AND METHODS Eighty Sprague-Dawley (SD) rats were randomly divided into 5 groups, including a Bronchitis model group (BM), a Budesonide group (BG), an Astragaloside IV group (AG), an Astragaloside IV combined with Budesonide group (CG), and a blank control group (BC). Lung tissue was stained with hematoxylin and eosin (H&E). The activity of catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and malondialdehyde (MDA) were detected by enzyme-linked immunosorbent assay (ELISA). The nuclear factor erythroid 2 [NF-E2]-related factor 2 (Nrf2), Kelch-like erythroid cell-derived protein with CNC homology [ECH]-associated protein 1 (Keap1), BTB and CNC homology 1 (Bach1), B-cell lymphoma-2(Bcl-2), and BCl-2-associated X protein (Bax) mRNA and protein were examined by RT-PCR and Western blot, respectively. RESULTS Compared with the Bronchitis model group, the lung tissue lesions in the Budesonide group, Astragaloside IV group, and Astragaloside IV combined with Budesonide group were effectively ameliorated and the airway resistance was significantly decreased. The activities of SOD, GSH-Px, and CAT were increased after treatment with drugs, while the content of MDA was decreased. The levels of Nrf2, Keap1, and Bcl-2 proteins were increased and the levels of Bach1 and Bax were decreased after treatment with Budesonide and Astragaloside IV. CONCLUSIONS Astragaloside IV combined with budesonide can ameliorate the lesions caused by bronchitis in rats through activating the Nrf2/Keap1 pathway, which plays a protective role on anti-oxidative stress injury.
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Affiliation(s)
- Zhijie Zhang
- Department of Anesthesiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China (mainland)
| | - Xiaoyan Cheng
- Department of Anesthesiology, Weifang People's Hospital, Weifang, Shandong, China (mainland)
| | - Dongjian Ge
- Department of Anesthesiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China (mainland)
| | - Shanshan Wang
- Department of Anesthesiology, Huaiyin Hospital of Huaian City, Huai'an, Jiangsu, China (mainland)
| | - Bin Qi
- Department of Anesthesiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China (mainland)
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Ye Q, He XO, D’Urzo A. A Review on the Safety and Efficacy of Inhaled Corticosteroids in the Management of Asthma. Pulm Ther 2017. [DOI: 10.1007/s41030-017-0043-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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