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Almonacid-Sánchez C, Cosío BG, Trisán-Alonso A, Callejas-González FJ, Cisneros C, Martínez-Moragón E, Plaza Moral V, Vera E, Soto-Campos JG, Martínez-Rivera C, Alcazar-Navarrete B, Urrutia Landa I, García-Rivero JL, Padilla Galo A, Álvarez-Gutierrez F, Ramos-González J, Carretero-Gracia JÁ, Lluch I, Puente L, Andujar-Espinosa R, Pérez-de-Llano L. Therapeutic Goals and Treatable Traits: Long-Term Trends in a Severe Asthma Population. Arch Bronconeumol 2023; 59:842-845. [PMID: 37865605 DOI: 10.1016/j.arbres.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 10/23/2023]
Affiliation(s)
| | - Borja G Cosío
- Hospital Universitario Son Espases-IdISBa-CIBERES, Palma de Mallorca, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Luis Puente
- Hospital General Universitario Gregorio Marañón, Facultad de Medicina Complutense de Madrid, Madrid, Spain
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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3
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Cazzola M, Page CP, Matera MG, Rogliani P, Hanania NA. Revisiting asthma pharmacotherapy: where do we stand and where do we want to go? Eur Respir J 2023; 62:2300700. [PMID: 37474159 DOI: 10.1183/13993003.00700-2023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/25/2023] [Indexed: 07/22/2023]
Abstract
Several current guidelines/strategies outline a treatment approach to asthma, which primarily consider the goals of improving lung function and quality of life and reducing symptoms and exacerbations. They suggest a strategy of stepping up or down treatment, depending on the patient's overall current asthma symptom control and future risk of exacerbation. While this stepwise approach is undeniably practical for daily practice, it does not always address the underlying mechanisms of this heterogeneous disease. In the last decade, there have been attempts to improve the treatment of severe asthma, such as the addition of a long-acting antimuscarinic agent to the traditional inhaled corticosteroid/long-acting β2-agonist treatment and the introduction of therapies targeting key cytokines. However, despite such strategies several unmet needs in this population remain, motivating research to identify novel targets and develop improved therapeutic and/or preventative asthma treatments. Pending the availability of such therapies, it is essential to re-evaluate the current conventional "one-size-fits-all" approach to a more precise asthma management. Although challenging, identifying "treatable traits" that contribute to respiratory symptoms in individual patients with asthma may allow a more pragmatic approach to establish more personalised therapeutic goals.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, UK
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
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4
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Padró-Casas C, Basagaña M, Rivera-Ortún ML, García-Olivé I, Pollan-Guisasola C, Teniente-Serra A, Martínez-Cáceres E, Navarro JT, Abad-Capa J, Rosell A, Roger A, Martínez-Rivera C. Characterization and Factors Associated with Poor Asthma Control in Adults with Severe Eosinophilic Asthma. J Pers Med 2023; 13:1173. [PMID: 37511786 PMCID: PMC10381894 DOI: 10.3390/jpm13071173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
A study was conducted in 98 adult patients diagnosed with severe eosinophilic asthma (73.5% women, mean age 47.2 years) and followed prospectively for 1 year. The aim of the study was to characterize this population and to identify factors associated with poor prognosis at 1 year of follow-up. At the initial visit, uncontrolled severe asthma was diagnosed in 87.7% of patients. Allergic sensitization was observed in 81.7% (polysensitization in 17.3%), with clinically significant allergic asthma in 45%. The mean percentage of sputum eosinophils was 4.7% (standard deviation(SD) 6.3%) and the mean (SD) blood eosinophil count 467 (225) cells/µL. Almost half of the patients (48.3%) had sputum eosinophilia (>3% eosinophils). Sputum eosinophils correlated significantly with peripheral eosinophilia (p = 0.004) and, to a lesser extent, with fractional exhaled nitric oxide (FeNO) (p = 0.04). After 1 year, 48 patients (49%) had uncontrolled asthma in all visits, and 50 (51%) had controlled asthma in some visits. Airway obstruction (FEV1 < 80% predicted) was the main reason for uncontrolled asthma. In the multivariate analysis, an obstructive pattern (odds ratio (OR) 7.45, 95% confidence interval (CI) 2.41-23.03, p < 0.0001) and the patient's age (OR 1.045, 95% CI 1.005-1.086, p = 0.026) were independent predictors of poor asthma control. In adult-onset and long-standing asthma, serum interleukin (IL) IL-17 was higher in the uncontrolled asthma group. This study contributes to characterizing patients with severe eosinophilic asthma in real-world clinical practice.
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Affiliation(s)
- Clara Padró-Casas
- Severe Asthma Unit, Allergy Section, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - María Basagaña
- Severe Asthma Unit, Allergy Section, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - María Luisa Rivera-Ortún
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Ignasi García-Olivé
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Carlos Pollan-Guisasola
- Severe Asthma Unit, Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Aina Teniente-Serra
- Severe Asthma Unit, Immunology Department, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Eva Martínez-Cáceres
- Severe Asthma Unit, Head of the Immunology Department, Department of Cell Biology, Physiology and Immunology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Associate Professor of Immunology, Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - José-Tomás Navarro
- Department of Hematology, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Jorge Abad-Capa
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Antoni Rosell
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Albert Roger
- Severe Asthma Unit, Allergy Section, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Carlos Martínez-Rivera
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
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Casas-Maldonado F, Álvarez-Gutiérrez FJ, Blanco Aparicio M, Domingo Ribas C, Cisneros Serrano C, Soto Campos G, Román Bernal B, González-Barcala FJ. Treatment Patterns of Monoclonal Antibodies in Patients With Severe Uncontrolled Asthma Treated by Pulmonologists in Spain. OPEN RESPIRATORY ARCHIVES 2023; 5:100252. [PMID: 37810425 PMCID: PMC10556773 DOI: 10.1016/j.opresp.2023.100252] [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: 02/08/2023] [Accepted: 04/24/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction and objectives The use of monoclonal antibody (mAb)-based therapies is becoming the new standard of care for severe uncontrolled asthma (SUA). Even though patients may qualify for one or more of these targeted treatments, based on different clinical criteria, a global vision of mAb prescription management in a large sample of hospitals is not well characterised in Spain.The objective was to give a global vision of mAb prescription management in a large sample of hospitals in Spain. Materials and methods We used an aggregate data survey method to interview pulmonology specialists in a large sample of Spanish centres (90). The following treatment-related information was obtained on patients treated with mAbs: specific mAbs prescribed, treatment interruption, switch and restart and the reasons for these treatment changes. Results mAb prescription was more frequent in females (13.3% females vs 7.4% males; p < 0.001). There were no differences in prevalence by hospital complexity level. In contrast, there were differences by geographical area. Omalizumab was the most prescribed mAb (6.2%), followed by mepolizumab (2.9%). Discontinuation of Omalizumab (due to a lack of effectivity) and switches from this mAb to mepolizumab were more frequent. Very few restarts to the first treatment were observed after a switch from ≥2 mAbs. Conclusions Omalizumab appeared as the most prescribed mAb in SUA but was also the most withdrawn; a specific and objective characterisation of patients with SUA, along with asthma phenotyping, and together with further evaluation of safety and effectiveness profiles, will lead to future progress in the management of SUA with mAbs.
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Affiliation(s)
- Francisco Casas-Maldonado
- Servicio de Neumología, Hospital Universitario Clínico San Cecilio, Avenida de la Investigación, s/n, Granada, Spain
| | | | | | - Christian Domingo Ribas
- Servei de Pneumologia, Corporació Sanitària Parc Taulí, Parc Taulí, 1, Sabadell, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona (UAB), Bellatera, Cerdanyola del Vallès, Spain
| | - Carolina Cisneros Serrano
- Servicio de Neumología, Hospital Universitario La Princesa, Madrid, Spain
- Fundación de Investigación Biomédica La Princesa, Calle de Diego de León, 62, Madrid, Spain
| | - Gregorio Soto Campos
- Servicio de Neumología y Alergia, Hospital Universitario de Jerez, Ctra. Trebujena, s/n, Jerez de la Frontera, Cádiz, Spain
| | - Berta Román Bernal
- Servicio de Neumología, Hospital Dr. José Molina Orosa, Crta. Arrecife-San Bartolomé, Km 1, 3, Arrecife, Las Palmas, Spain
| | - Francisco-Javier González-Barcala
- Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Rúa da Choupana, s/n, Santiago de Compostela, A Coruña, Spain
- Departamento de Medicina-Universidad de Santiago de Compostela, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias – CIBERES, Santiago de Compostela, Spain
- Grupo Traslational Research in Airway Diseases-FIDIS, Spain
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Blanco-Aparicio M, Domínguez-Ortega J, Cisneros C, Colás C, Casas F, Del Cuvillo A, Alobid I, Quirce S, Mullol J. Consensus on the management of united airways disease with type 2 inflammation: a multidisciplinary Delphi study. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:34. [PMID: 37088840 PMCID: PMC10124060 DOI: 10.1186/s13223-023-00780-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/27/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Scientific evidence on patients with multimorbid type 2 asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) from a united airways disease (UAD) perspective remains scarce, despite the frequent coexistence of these entities. We aimed to generate expert consensus-based recommendations for the management of UAD patients. METHODS Using a two-round Delphi method, Spanish expert allergists, pulmonologists and otolaryngologists expressed their agreement on 32 statements (52 items) on a 9-point Likert scale, classified as appropriate (median 7-9), uncertain (4-6) or inappropriate (1-3). Consensus was considered when at least two-thirds of the panel scored within the range containing the median. RESULTS A panel of 30 experts reached consensus on the appropriateness of 43 out of the 52 (82.7%) items. The usefulness of certain biomarkers (tissue and peripheral blood eosinophil count, serum total IgE, and fraction of exhaled nitric oxide [FeNO]) in the identification and follow-up of type 2 inflammation, and assessment of the response to biologics, were agreed. Some of these biomarkers were also associated with disease severity and/or recurrence after endoscopic sinus surgery (ESS). Consensus was achieved on treatment strategies related to the prescription of anti-IL-4/IL-13 or anti-IgE agents, concomitant treatment with systemic corticosteroids, and combining or switching to biologics with a different mechanism of action, considering a number of UAD clinical scenarios. CONCLUSION We provide expert-based recommendations to assist in clinical decision-making for the management of patients with multimorbid type 2 asthma and CRSwNP. Specific clinical trials and real-world studies focusing on the single-entity UAD are required to address controversial items.
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Affiliation(s)
- Marina Blanco-Aparicio
- Department of Respiratory Medicine, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Javier Domínguez-Ortega
- Department of Respiratory Medicine, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Carolina Cisneros
- Department of Pulmonology, Hospital Universitario La Princesa, Health Research Institute (IP), Madrid, Spain
| | - Carlos Colás
- Department of Allergy, Hospital Clínico-Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Francisco Casas
- Department of Respiratory Medicine, Hospital Universitario Clínico San Cecilio, Granada, Spain
| | - Alfonso Del Cuvillo
- Rhinology & Asthma Unit, ENT Department, Hospital Universitario de Jerez, Cádiz, Spain
| | - Isam Alobid
- Rhinology Unit & Smell Clinic, ENT Department, CIBERES, Hospital Clinic Barcelona, Universitat de Barcelona, C/ Villarroel 170, 08036, Barcelona, Spain
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, Institute for Health Research (IdiPAZ), CIBER of Respiratory Diseases (CIBERES), Madrid, Spain
| | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, CIBERES, Hospital Clinic Barcelona, Universitat de Barcelona, C/ Villarroel 170, 08036, Barcelona, Spain.
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Kim JH, Lee H, Park SY, Kim JY, Choi SH, Kwon HS, Song WJ, Kim SH, Yu J, Song DJ, Cho YS, Lim DH, Cho YJ, Chang SI, Kim TB. Epidemiology of patients with asthma in Korea: Analysis of the NHISS database 2006-2015. World Allergy Organ J 2023; 16:100768. [PMID: 37128250 PMCID: PMC10148228 DOI: 10.1016/j.waojou.2023.100768] [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: 06/18/2022] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 05/03/2023] Open
Abstract
Background There has been a concerning increase in the prevalence and socioeconomic burden of asthma in Korea. Korea's National Health Insurance System (NHIS) covers insurance payment and claims management for all Koreans. Using National Health Insurance Sharing Service (NHISS) claims data. This study aimed to investigate patterns of healthcare utilization and direct cost in patients with asthma over a 10-year period. Methods In this retrospective population-based study, we examined NHISS claims records between July 2005 and June 2016 and investigated healthcare utilization among patients with asthma based on age group and severity of disease (non-severe asthma [NSA] and severe asthma [SA]). Results From 2006 to 2015, the total number of patients with asthma in Korea steadily increased from 743 968 to 2 286 309, with a corresponding increase in prevalence from 1.62% to 4.74%. The proportion of patients with SA decreased from 3.16% in 2006 to 1.56% in 2015; the proportion was consistently higher in men than in women. In addition, patients with SA had a higher cost per outpatient visit than patients with NSA, and the number of outpatient visits per year increased. The inhaled corticosteroid (ICS) prescription rate among patients with asthma decreased from 22.9% in 2006 to 15.7% in 2015. Furthermore, for a period of 10 years, more than 40% of patients with SA have been prescribed short-acting β-2 agonists (SABAs). Conclusions Although patients with SA comprised a small proportion of patients with asthma, they incurred greater medical costs per person. The pharmaceutical prescription pattern indicated a lack of ICS-based prescriptions and frequent SABA prescriptions.
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Affiliation(s)
- Jung-Hyun Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Korean Armed Forces Capital Hospital, Seongnam, South Korea
| | - Hyesung Lee
- Department of Biohealth Regulatory Science School of Pharmacy, SungKyunKwan University, Seongnam, South Korea
| | - So-Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
- Division of Pulmonary, Allergy and Critical Care Medicine, Chung-Ang University Gwangmyeong Medical Center, Gwangmyeong, South Korea
| | - Ju-Young Kim
- Department of Internal Medicine, Dankook University Hospital, Cheonan, South Korea
| | - Sun Hee Choi
- Kyung Hee University School of Medicine, Seoul, South Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jinho Yu
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Jin Song
- Department of Pediatrics, Korea University College of Medicine and Environmental Health Center for Childhood Asthma, Korea University Anam Hospital, Seoul, South Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Hyun Lim
- Department of Pediatrics, School of Medicine, Inha University, Incheon, South Korea
| | - Young-Joo Cho
- Department of Internal Medicine, Ewha Women University School of Medicine, Seoul, South Korea
| | - Suk-Il Chang
- Department of Internal Medicine, Sung-Ae Hospital, Seoul, South Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Corresponding author. Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea.
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Pallarés-Sanmartín A, Mosteiro-Añón MDM, Macía M, Blanco N, Barros-Casas D, Corbacho Abelaira MD, Fernández-Sánchez T, Fiorentino F. Predictors of success/failure in the control of asthmatic smoking patients under conditions of clinical practice. J Asthma 2023:1-8. [PMID: 36847640 DOI: 10.1080/02770903.2023.2185153] [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: 03/01/2023]
Abstract
BACKGROUND Tobacco smoking directly affects the airway, where it triggers a very strong local inflammatory response. OBJECTIVE To determine the predictors of improvement or worsening of asthma control in asthmatic smokers. METHODS Observational, prospective, multicenter, single cohort study, carried out in the outpatient pulmonology departments with a follow-up period of 6 months. The treatment was adjusted according to the indications of standard clinical practice. RESULTS 196 patients were included, with a mean age of 54.64 years.39% of the patients were active smokers. Interpreting an Asthma Control Questionnaire (ACQ) score of ≤ 0.75 as asthma control, this was achieved in 30.2% of the cases. Patients with greater adherence were more likely to improve their asthma symptoms (p < 0.05), defined as a decrease in ACQ of 0.5 points or more at the final visit, while taking concomitant medication was a negative risk factor for improvement (p < 0.001). An eosinophil value >300 was a predictor for achieving control (p < 0.01). Patients treated with fluticasone propionate/formoterol versus those receiving budesonide/formoterol or beclomethasone/formoterol had a lower ACQ score (p < 0.01 and p < 0.01, respectively). CONCLUSION Asthmatic patients with active tobacco exposure and a higher number of anti-asthma medications are more likely to have poorer control. Correct adherence to treatment is the main intervention to be performed to achieve the control. An eosinophil count greater than 300 was the main predictor for achieving control. Fluticasone propionate/formoterol FP/FORM was associated with a greater likelihood of improving ACQ score.
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Affiliation(s)
| | | | - María Macía
- Pulmonology Service, Son Llatzer, Universitary Hospital, Palma de Mallorca, Spain
| | - Nagore Blanco
- Pulmonology Service, Lucus Augusti Universitary Hospital, Lugo, Spain
| | | | | | | | - Federico Fiorentino
- Pulmonology Service, Son Espasses, Universitary Hospital, Palma de Mallorca, Spain
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9
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Agusti A, Gibson PG, McDonald VM. Treatable Traits in Airway Disease: From Theory to Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:713-723. [PMID: 36737342 DOI: 10.1016/j.jaip.2023.01.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 02/04/2023]
Abstract
Chronic airway diseases such as asthma and chronic obstructive pulmonary disease are prevalent and complex conditions that often coexist in the same patient. To address this complexity in clinical practice, and to move forward toward personalized and precision medicine of airway diseases, a strategy based on the identification and treatment of so-called "treatable traits" (TTs) has been proposed. A TT is a recognizable phenotypic or endotypic characteristic that can be assessed and successfully targeted by therapy to improve a clinical outcome in a patient with airway disease. Importantly, TTs can coexist in the same patient, so they are not mutually exclusive. The TT strategy proposes to investigate in each individual patient with chronic airway disease the number and type of TTs present and to treat each of them according to guideline recommendations. This strategy is agnostic (ie, independent) to the traditional diagnostic labels (asthma, chronic obstructive pulmonary disease), so it can be applied to any patient with airway disease. Currently, there is firm evidence supporting the adequacy and validity of the TT strategy. Here, we review the current state of the art of this topic, first by presenting its theoretical background and then by discussing how to best implement it in clinical practice.
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Affiliation(s)
- Alvar Agusti
- Respiratory Institute, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
| | - Peter G Gibson
- Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Vanessa M McDonald
- Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
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Almonacid C, Fitas E, Sánchez-Covisa J, Gutiérrez H, Rebollo P. Geographical differences in the use of oral corticosteroids in patients with severe asthma in Spain: heat map based on existing databases analyses. BMC Pulm Med 2023; 23:3. [PMID: 36600236 PMCID: PMC9812540 DOI: 10.1186/s12890-022-02295-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 12/22/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Although there are currently alternative treatments to the long-term use of oral corticosteroids (OCS) in severe asthma, recent studies show excessive use depending on geography and differences in medical practice. The objective of the study was to describe the differences in OCS use for severe asthma across the Spanish geography. METHODS This is a real-world study using existing databases (year 2019): longitudinal patient database (EMR), based on electronic medical records, and database of pharmacological consumption (Sell-in) in basic healthcare areas. With EMR, the percentage of OCS prescriptions corresponding to patients with severe asthma (ICD-9 "asthma" and prescription of biological treatment and/or high dose of inhaled corticosteroids/long-acting inhaled β2 agonists) was calculated. This percentage was transferred to the OCS consumption of each basic healthcare area as reported in the Sell-in database and a national heat map was created. The estimation of OCS use in patients with severe asthma per 100,000 inhabitants for each region was calculated by grouping basic healthcare areas and the mean OCS use per patient for different regions in Spain was also estimated. RESULTS Patients with severe asthma in Spain were mostly female (69.6%), with a mean age (SD) of 57.6 years (18.01). Median time (Pc25-Pc75) since asthma diagnosis was 83.1 months (34.65-131.56). Of all patients with OCS prescriptions in 2019 identified in EMR, 4.4% corresponded to patients with severe asthma. Regions with the highest OCS use were Asturias, Andalucía, and Galicia, whereas those with the lowest use were Navarra, Baleares, Madrid and País Vasco. The mean OCS use per patient with severe asthma in 2019 throughout Spain was 1099.85 mg per patient, ranging from 782.99 mg in Navarra to 1432.64 in Asturias. CONCLUSIONS There are geographical differences between Spanish regions with respect to the use of OCS in patients with severe asthma. The national mean consumption of OCS per patient with severe asthma and year is above the limits that indicate good asthma control.
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Affiliation(s)
- Carlos Almonacid
- grid.418888.50000 0004 1766 1075Pulmonology Unit, Complejo Hospitalario de Toledo, Av. del Río Guadiana, 45007 Toledo, Spain
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11
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Mareque M, Climente M, Martinez-Moragon E, Padilla A, Oyagüez I, Touron C, Torres C, Martinez A. COST-EFFECTIVENESS OF BENRALIZUMAB VERSUS MEPOLIZUMAB AND DUPILUMAB IN PATIENTS WITH SEVERE UNCONTROLLED EOSINOPHILIC ASTHMA IN SPAIN. J Asthma 2022; 60:1210-1220. [PMID: 36322679 DOI: 10.1080/02770903.2022.2139718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of benralizumab (benra) vs. mepolizumab (mepo) and dupilumab (dupi) for the treatment of patients with severe uncontrolled asthma from the Spanish Health System perspective. METHODS Exacerbations avoided, quality-adjusted life years (QALYs) gained and costs in a 5-year period were estimated with a Markov model for a cohort of 1,000 patients in which, based on published evidence, 31% of the patients received biologics + oral corticosteroids (OCS) and 69% received only biologics. Efficacy data (exacerbation reduction and OCS elimination) were derived from a matching-adjusted indirect comparison. Published EQ-5D utilities per health state (biologic alone, biologic + OCS, standard of care + OCS, exacerbations, and post-exacerbations) were used for QALY estimation. Utility decrements associated with exacerbation management [-0.1 (OCS or emergency visits), -0.2 (hospitalization)] derived from the literature were applied. Costs (€, 2022) included drug acquisition (ex-factory price), administration and disease management. An expert panel (2 pneumologists and 1 pharmacist) validated all inputs. RESULTS Benra was more effective (52.21 QALYs) than mepo (51.39 QALYs) and dupi (51.30 QALYs). Benra avoided more exacerbations (2.87 exacerbations) compared to mepo (4.70 exacerbations) and dupi (5.11 exacerbations) for the 5-year horizon. Total costs/patient were €56,093.77 (benra), €59,280.45 (mepo) and €62,991.76 (dupi), resulting in benra dominating (more QALYs with lower costs) vs. mepo and dupi. CONCLUSIONS Benralizumab can be considered as a dominant treatment alternative vs. other biologic drugs for the treatment of uncontrolled severe eosinophilic asthma patients in Spain.
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Affiliation(s)
- M Mareque
- Pharmacoeconomics & Outcomes Research Iberia (PORIB), Madrid, Spain
| | - M Climente
- Hospital Universitario Doctor Peset, Valencia, Spain
| | | | | | - I Oyagüez
- Pharmacoeconomics & Outcomes Research Iberia (PORIB), Madrid, Spain
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12
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Zhu M, Yang J, Chen Y. Efficacy and safety of treatment with benralizumab for eosinophilic asthma. Int Immunopharmacol 2022; 111:109131. [PMID: 35998507 DOI: 10.1016/j.intimp.2022.109131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 12/01/2022]
Abstract
Eosinophilic asthma accounts for 40% to 50% of asthmatic patients. However, 5% to 10% of patients with asthma need high-dose drug control, which is clinically referred to as severe asthma patients. Interleukin (IL)-5 plays an important role in the proliferation, maturation, and migration of eosinophils. Benralizumab, as an antagonist of the IL-5 receptor, can treat eosinophilic asthma by promoting the apoptosis of eosinophils. The implications for efficacy and/or adverse events are unclear. This article reviews the findings about benralizumab in the treatment of severe eosinophilic asthma in recent years. Results indicated the effectiveness of benralizumab for the treatment of severe asthma.
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Affiliation(s)
- Miaojuan Zhu
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.
| | - Jiong Yang
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.
| | - Yifei Chen
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.
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13
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Muñoz Gall X, Domínguez-Ortega J, Pascual S, Cabrera López C, Gustavo R, Nuevo J, Monteagudo G. Clinical burden related to oral corticosteroid treatment of severe asthma in Spain: LEVANTE study. J Asthma 2022; 60:890-899. [PMID: 35862653 DOI: 10.1080/02770903.2022.2103428] [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: 10/17/2022]
Abstract
Background: Severe asthma treatment with oral corticosteroids (OCS) added to inhaled corticosteroids and a long-acting β2-agonist (ICS-LABA) may result in more treatment burden and increased adverse effects.Objective and Methods: This ambispective multicenter observational study aimed at describing the clinical burden in patients with severe asthma on stable high-dose ICS-LABA who received OCS during ≥6 months (maintenance group) or ≥2 cycles in the previous 12 months (bursts group). Data collection comprised a retrospective 12-month baseline period and 2 follow-up visits at 3 and 6 months. Results: Eighty-nine patients were evaluable (30 on maintenance, 59 on bursts). At baseline, mean (SD) daily prednisone equivalent exposure in the total population was 24.6 (14.7) mg: 13.8 (9.4) mg on maintenance and 29.9 (14.3) mg on bursts. During the 6-month follow-up period, mean (SD) daily dose in the total cohort was 22.5 (18.8) mg: 17.2 (18.6) mg on maintenance and 28.4 (20.6) mg on bursts. The overall annual severe exacerbations rate during the 12-month baseline period was 2.05 per patient-year and 1.5 per patient-year over the 6-month follow-up, and frequency of hospitalizations and emergency department visits were similar on both maintenance and bursts use. Conclusions: Results show a suboptimal control of severe asthma despite such high doses of OCS and persistence of disease burden regardless of the prescribing pattern in maintenance or bursts. There is therapeutic inertia to continue using OCS despite the increased risk of adverse effects and the availability of biologics.
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Affiliation(s)
| | - Javier Domínguez-Ortega
- Department of Allergy, Hospital La Paz Institute for Health Research, Respiratory Disease Network Biomedical Research Center (CIBERES), Madrid, Spain
| | - Silvia Pascual
- Department of Pneumology, Hospital de Galdakao, Bizkaia, Spain
| | - Carlos Cabrera López
- Department of Pneumology, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Resler Gustavo
- Medical Department, Medical Affairs, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Madrid, Spain
| | - Javier Nuevo
- Medical Department, Evidence Generation Manager, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Madrid, Spain
| | - Gema Monteagudo
- Medical Department, Medical Affairs, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Madrid, Spain
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Abstract
Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.
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Unmet Needs and the Future of Asthma-Chronic Pulmonary Obstructive Disease Overlap. Immunol Allergy Clin North Am 2022; 42:691-700. [DOI: 10.1016/j.iac.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Melhorn J, Howell I, Pavord ID. Should we apply a treatable traits approach to asthma care? Ann Allergy Asthma Immunol 2022; 128:390-397. [PMID: 35172180 DOI: 10.1016/j.anai.2022.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/01/2022] [Accepted: 02/09/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To explore the evidence for adopting a "treatable traits" approach to asthma management. DATA SOURCES PubMed, Medline, and Google Scholar. STUDY SELECTIONS The above-mentioned databases were searched for randomized, controlled phase III or IV trials of adults containing the word "asthma" in the title published in the previous 10 years and for all articles containing the title words "treatable AND trait(s)," "asthma AND biomarker(s) OR smoking OR obesity OR laryngeal OR management" published within the previous 5 years. Articles were excluded if they were not published in English. Our search identified 257 articles for consideration. We also manually searched the reference lists of studies identified and searched the websites of the British Thoracic Society, European Respiratory Society, National Institute for Health and Care Excellence, and Global Initiative for Asthma for specific guidance related to asthma management. RESULTS The "treatable traits" are described within 3 domains of pulmonary, extrapulmonary, or behavioral and lifestyle traits. We consider whether treatment should be targeted toward these traits where they are present in asthma patients, based on currently available evidence, rather than increasing treatment in response to symptoms in line with current step-up, step-down asthma management guidelines. CONCLUSION We advocate that a treatable traits approach should be applied more broadly to the assessment and management of inadequately controlled asthma, rather than a step-up, step-down approach based on patient symptoms. This approach should be focused on the 2 treatable pulmonary traits of TH2 inflammation and airflow obstruction along with smoking cessation, in the first instance.
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Affiliation(s)
- James Melhorn
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Imran Howell
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ian D Pavord
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Lee YQ, Selvakumar A, See KC. Treatable Traits in Chronic Respiratory Disease: A Comprehensive Review. Cells 2021; 10:3263. [PMID: 34831485 PMCID: PMC8624727 DOI: 10.3390/cells10113263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/07/2021] [Accepted: 11/20/2021] [Indexed: 12/05/2022] Open
Abstract
Chronic respiratory diseases are major contributors to the global burden of disease. While understanding of these diseases has improved, treatment guidelines have continued to rely on severity and exacerbation-based approaches. A new personalised approach, termed the "treatable traits" approach, has been suggested to address the limitations of the existing treatment strategies. We aim to systematically review the current evidence regarding treatable traits in chronic respiratory diseases and to identify gaps in the current literature. We searched the PubMed and Embase databases and included studies on treatable traits and chronic respiratory diseases. We then extracted information on prevalence, prognostic implications, treatment options and benefits from these studies. A total of 58 papers was included for review. The traits identified were grouped into five broad themes: physiological, biochemical, psychosocial, microbiological, and comorbidity traits. Studies have shown advantages of the treatable traits paradigm in the clinical setting. However, few randomised controlled trials have been conducted. Findings from our review suggest that multidisciplinary management with therapies targeted at treatable traits has the potential to be efficacious when added to the best practices currently implemented. This paradigm has the potential to improve the holistic care of chronic respiratory diseases.
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Affiliation(s)
- Yong Qin Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore; (Y.Q.L.); (K.C.S.)
| | - Asvin Selvakumar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore; (Y.Q.L.); (K.C.S.)
| | - Kay Choong See
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore; (Y.Q.L.); (K.C.S.)
- Division of Respiratory & Critical Care Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
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de Llano LP, Naval E, Mejía N, Domínguez-Ortega J. Inhaled indacaterol/glycopyrronium/mometasone furoate fixed-dose combination in moderate-to-severe asthma. Expert Rev Respir Med 2021; 16:1-15. [PMID: 34783265 DOI: 10.1080/17476348.2021.2005585] [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: 10/19/2022]
Abstract
INTRODUCTION Fixed-dose long-acting beta2-agonist (LABA)/inhaled corticosteroid (ICS) combinations and add-on therapies as needed are the mainstay for maintenance therapy in asthma. However, more than 40% of patients have an inadequately controlled disease. The development of triple fixed-dose combinations consisting of long-acting muscarinic antagonist (LAMA)/LABA/ICS has paved the way for a new approach to reach therapeutic goals of an optimal control of symptoms and an effective prevention of future exacerbations. AREAS COVERED A search was conducted on PubMed (MEDLINE), using the MeSH terms [asthma] + [indacaterol] + [glycopyrronium] +[mometasone furoate] + [treatment], until October 2021. Original data from clinical trials, prospective and retrospective studies and reviews were selected. Clinical studies with IND/MF/GLY (Enerzair Breezhaler) are summarized, and its place in current asthma therapy is examined. EXPERT OPINION Triple therapy has been shown to be an effective and safe therapeutic option for asthma patients who remain uncontrolled despite ICS/LABA combination. The recently approved single-inhaler indacaterol/glycopyrronium/mometasone fixed dose combination has demonstrated to significantly reduce exacerbations, improve FEV1, symptoms and quality of life compared to ICS/LABA, including, salmeterol/fluticasone combination. Moreover, once-daily dosing may improve adherence.
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Affiliation(s)
- Luis Pérez de Llano
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte, Lugo, Spain
| | - Elsa Naval
- Pneumology Service, Hospital Universitario de la Ribera, Alzira, Valencia, Spain
| | - Natalia Mejía
- Medical Affairs Department. Novartis Farmacéutica, Barcelona, Spain
| | - Javier Domínguez-Ortega
- Allergy Department, Hospital La Paz Institute for Health Research, Madrid, Spain.,Respiratory Disease Network Biomedical Research Centre (CIBERES), Madrid, Spain
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Cazzola M, Matera MG, Rogliani P, Calzetta L, Ora J. Step-up and step-down approaches in the treatment of asthma. Expert Rev Respir Med 2021; 15:1159-1168. [PMID: 34032534 DOI: 10.1080/17476348.2021.1935245] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Significant intraindividual and temporal variability in symptom control is a feature of asthma that requires careful monitoring and the need to periodically review and adjust therapy. Both NHLBI/NAEPP and GINA offer helpful algorithms for a stepping approach to asthma.Areas covered: The problems arisen in applying the stepwise approach to the treatment of asthma proposed by NHLBI/NAEPP and GINA algorithms and their possible alternatives.Expert opinion: The current therapeutic stepping approach to asthma, which takes into account lung function, symptoms and quality of life, is certainly useful, but it does not consider the underlying mechanisms. Furthermore, patient's overestimation or underestimation of the severity of the disease and differences in the opinions on the level of asthma control required between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks. A reassessment of the conventional stepping approach to management of asthma is now needed. A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma which, when therapeutically targeted, will in many cases help to achieve the goals, seems more reasonable than the present stepping approach.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Division of Respiratory Medicine, University Hospital "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital "Tor Vergata", Rome, Italy
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Pérez de Llano L, Dávila I, Martínez-Moragón E, Domínguez-Ortega J, Almonacid C, Colás C, García-Rivero JL, Carmona L, García de Yébenes MJ, Cosío BG. Development of a Tool to Measure the Clinical Response to Biologic Therapy in Uncontrolled Severe Asthma: The FEV 1, Exacerbations, Oral Corticosteroids, Symptoms Score. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2725-2731. [PMID: 33549843 DOI: 10.1016/j.jaip.2021.01.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is a lack of tools to quantify the response to monoclonal antibodies (mAbs) holistically in severe uncontrolled asthma patients. OBJECTIVE To develop a valid score to assist specialists in this clinical context. METHODS The score was developed in four subsequent phases: (1) elaboration of the theoretical model of the construct intended to be measured (response to mAbs); (2) definition and selection of items and measurement instruments by Delphi survey; (3) weight assignment of the selected items by multicriteria decision analysis using the Potentially All Pairwise RanKings of All Possible Alternatives methodology using the 1000minds software; and (4) face validity assessment of the obtained score. RESULTS Four core items, with different levels of response for each, were selected: severe exacerbations, oral corticosteroid use, symptoms (evaluated by Asthma Control Test), and bronchial obstruction (assessed by FEV1 percent predicted). Severe exacerbations and oral corticosteroid maintenance dose were weighted most heavily (38% each), followed by symptoms (13%) and FEV1 (11%). Higher scores in the weighted system indicate a better response and the range of responses runs from 0 (worsening) to 100 (best possible response). Face validity was high (intraclass correlation coefficient of 0.86). CONCLUSIONS The FEV1, exacerbations, oral corticosteroids, symptoms score allows clinicians to quantify response in severe uncontrolled asthma patients who are being treated with mAbs.
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Affiliation(s)
- Luis Pérez de Llano
- Pneumology Service, Hospital Lucus Augusti, EOXI Lugo, Monforte, Cervo, Lugo, Spain.
| | - Ignacio Dávila
- Department of Allergy, University Hospital of Samanca, Salamanca, Spain
| | | | - Javier Domínguez-Ortega
- Allergy Department, La Paz Hospital Institute for Health Research, Madrid, Spain; CIBER of Respiratory Diseases CIBERES, Spain
| | - Carlos Almonacid
- Pneumology Service, Hospital Ramón y Cajal, Irycis, Madrid, Spain
| | - Carlos Colás
- Hospital Clínico-Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | | | | | | | - Borja G Cosío
- Department of Respiratory Medicine, Hospital Universitario Son Espases-IdISBa-Ciberes, Palma de Mallorca, Spain
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Agache I, Akdis CA, Akdis M, Canonica GW, Casale T, Chivato T, Corren J, Chu DK, Del Giacco S, Eiwegger T, Flood B, Firinu D, Gern JE, Hamelmann E, Hanania N, Hernández‐Martín I, Knibb R, Mäkelä M, Nair P, O’Mahony L, Papadopoulos NG, Papi A, Park H, Pérez de Llano L, Pfaar O, Quirce S, Sastre J, Shamji M, Schwarze J, Palomares O, Jutel M. EAACI Biologicals Guidelines-Recommendations for severe asthma. Allergy 2021; 76:14-44. [PMID: 32484954 DOI: 10.1111/all.14425] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 12/20/2022]
Abstract
Severe asthma imposes a significant burden on patients, families and healthcare systems. Management is difficult, due to disease heterogeneity, co-morbidities, complexity in care pathways and differences between national or regional healthcare systems. Better understanding of the mechanisms has enabled a stratified approach to the management of severe asthma, supporting the use of targeted treatments with biologicals. However, there are still many issues that require further clarification. These include selection of a certain biological (as they all target overlapping disease phenotypes), the definition of response, strategies to enhance the responder rate, the duration of treatment and its regimen (in the clinic or home-based) and its cost-effectiveness. The EAACI Guidelines on the use of biologicals in severe asthma follow the GRADE approach in formulating recommendations for each biological and each outcome. In addition, a management algorithm for the use of biologicals in the clinic is proposed, together with future approaches and research priorities.
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine Transylvania University Brasov Romania
| | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Davos Switzerland
- Christine‐Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | - Mubeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Davos Switzerland
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy Humanitas Clinical and Research Center IRCCS Rozzano Italy
| | - Thomas Casale
- Division of Allergy and Immunology University of South Florida Morsani College of Medicine Tampa FL USA
| | - Tomas Chivato
- School of Medicine University CEU San Pablo Madrid Spain
| | | | - Derek K. Chu
- Department of Health Research Methods, Evidence and Impact Division of Immunology and Allergy, and Department of Medicine McMaster University Hamilton ON Canada
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - Thomas Eiwegger
- Translational Medicine Program, Research Institute Hospital for Sick Children Toronto ON Canada
- Department of Immunology University of Toronto Toronto ON Canada
- Division of Immunology and Allergy Food Allergy and Anaphylaxis Program The Hospital for Sick Children Departments of Paediatrics and Immunology University of Toronto Toronto ON Canada
| | - Breda Flood
- European Federation of Allergy and Airway Diseases Brussels Belgium
| | - Davide Firinu
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - James E. Gern
- Department of Pediatrics School of Medicine and Public Health University of Wisconsin Madison WI USA
| | - Eckard Hamelmann
- Children’s Center Bethel Evangelical Hospital Bethel University of Bielefeld Bielefeld Germany
| | - Nicola Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine Baylor College of Medicine Houston TX USA
| | | | - Rebeca Knibb
- Department of Psychology School of Life and Health Sciences Aston University Birmingham UK
| | - Mika Mäkelä
- Skin and Allergy Hospital Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Parameswaran Nair
- Division of Respirology Department of Medicine McMaster University Hamilton ON Canada
- Firestone Institute for Respiratory Health St Joseph's Healthcare Hamilton ON Canada
| | - Liam O’Mahony
- Departments of Medicine and Microbiology APC Microbiome Ireland University College Cork Cork Ireland
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine University of Manchester Manchester UK
- Allergy Department 2nd Pediatric Clinic National Kapodistrian University of Athens Athens Greece
| | - Alberto Papi
- Research Center on Asthma and COPD Department of Medical Sciences University of Ferrara Ferrara Italy
| | - Hae‐Sim Park
- Department of Allergy and Clinical Immunology Ajou University Ajou Korea
| | | | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | - Santiago Quirce
- Department of Allergy La Paz University Hospital IdiPAZ CIBER of Respiratory Diseases (CIBERES) Universidad Autónoma de Madrid Madrid Spain
| | - Joaquin Sastre
- Facultad de Medicina Universidad Autónoma de Madrid Madrid Spain
| | - Mohamed Shamji
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair, Development National Heart and Lung Institute London UK
- Imperial College NIHR Biomedical Research Centre Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Jurgen Schwarze
- Centre for Inflammation Research, Child Life and Health The University of Edinburgh Edinburgh UK
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Chemistry School Complutense University of Madrid Madrid Spain
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- All‐MED Medical Research Institute Wroclaw Poland
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Padilla-Galo A, Levy-Abitbol RC, Olveira C, Valencia Azcona B, Pérez Morales M, Rivas-Ruiz F, Tortajada-Goitia B, Moya-Carmona I, Levy-Naon A. Real-life experience with benralizumab during 6 months. BMC Pulm Med 2020; 20:184. [PMID: 32600318 PMCID: PMC7325276 DOI: 10.1186/s12890-020-01220-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/18/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Benralizumab is a monoclonal antibody that binds to the human interleukin-5 (IL-5) receptor (IL-5R), thereby preventing IL-5 from binding to its receptor and inhibiting differentiation and maturation of eosinophils in the bone marrow. Because of its recent marketing approval, sufficient real-life evidence is lacking to confirm the efficacy and safety data from clinical trials. The purpose of this study was to evaluate the efficacy and safety of benralizumab for the treatment of severe refractory eosinophilic asthma in a real-world cohort of patients. METHODS This was a cross-sectional multicentre study of consecutive patients with severe refractory eosinophilic asthma who received treatment with benralizumab during at least 6 months. Patient follow-up was performed in specialised severe asthma units. RESULTS A total of 42 patients were enrolled and treated with benralizumab. Asthma control, as measured by the asthma control test (ACT), improved in all patients both at 3 months of treatment compared with baseline (13.9 ± 4 vs 20.1 ± 3.7, p < 0.001) and at 6 months of treatment compared with the results obtained at 3 months (20.1 ± 3.7 vs 21 ± 2.7, p = 0.037). Similarly, the number of emergency department visits decreased both at 3 months compared with baseline (1 [IR:0.7] vs 0 [IR:0.75], p < 0.001) and at 6 months compared with the results at 3 months (0 [IR:0.75] vs 0 [IR:0], p = 0.012). Reductions in the number of oral corticosteroid cycles, percentage of corticosteroid-dependent patients, and mean daily dose of oral or inhaled corticosteroid were also evidenced. Finally, mean lung function improvement was 291 mL (p < 0.001), and FEV1% improved both at 3 months compared with baseline (64.4 ± 9.3 vs 73.1 ± 9.1, p < 0.001) and at 6 months compared to 3 months (73.1 ± 9.1 vs 76.1 ± 12, p = 0.002). Side effects were mild and did not lead to treatment discontinuation. CONCLUSIONS This study confirms the efficacy and safety of benralizumab in a real-life setting with improved asthma control and lung function, and a reduced oral and inhaled corticosteroid use as well as fewer emergency department visits. In addition to a rapid initial improvement, it appears that patients continue to improve during the first 6 months of treatment.
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Affiliation(s)
- A. Padilla-Galo
- Pneumology Unit, 4th floor. Agencia Sanitaria Costa del Sol. Carretera Nacional 340, Km 187, 29603, Marbella, Málaga, Spain
| | | | - C. Olveira
- Pneumology Department, IBIMA (Institute for Biomedical Research of Málaga), Regional University Hospital of Málaga/ University of Málaga, Málaga, Spain
- Avenida Carlos Haya, 29010 Málaga, Spain
| | - B. Valencia Azcona
- Pneumology Unit, 4th floor. Agencia Sanitaria Costa del Sol. Carretera Nacional 340, Km 187, 29603, Marbella, Málaga, Spain
| | - M. Pérez Morales
- Pneumology Unit, 4th floor. Agencia Sanitaria Costa del Sol. Carretera Nacional 340, Km 187, 29603, Marbella, Málaga, Spain
| | - F. Rivas-Ruiz
- Research Unit, Red de Investigación en Servicios de Salud en Enfermedades Crónicas, REDISSEC (Spanish healthcare network for chronic diseases), Agencia Sanitaria Costa del Sol. Carretera Nacional 340, Km 187, 29603, Marbella, Málaga, Spain
| | - B. Tortajada-Goitia
- Pharmacy and Nutrition Service, Agencia Sanitaria Costa del Sol. Carretera Nacional 340, Km 187, 29603 Marbella, Málaga Spain
| | - I. Moya-Carmona
- Pharmacy and Nutrition Service, Hospital Universitario Virgen de la Victoria, Campus de Teatinos s/n, 29010 Málaga, Spain
| | - A. Levy-Naon
- Pneumology Department, Hospital Universitario Virgen de la Victoria, Campus de Teatinos s/n, 29010 Málaga, Spain
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23
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Sicras-Mainar A, Capel M, Navarro-Artieda R, Nuevo J, Orellana M, Resler G. Real-life retrospective observational study to determine the prevalence and economic burden of severe asthma in Spain. J Med Econ 2020; 23:492-500. [PMID: 31958257 DOI: 10.1080/13696998.2020.1719118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: We determined the percentage of patients with severe asthma and exacerbations and evaluated the costs of the disease based on blood eosinophil counts.Methods: A retrospective observational study based on the review of medical records in Spain was carried out. Patients ≥18 years of age requiring care during the years 2014-2015; diagnosed with asthma with at least 2 years of continuous records (at least one year prior to the index date defined as the first asthma medication prescription and at least one year after the index date) were included. Study groups: eosinophil counts <300 cells/μl and ≥300 cells/μl. Main variables: comorbidity, clinical parameters, exacerbations and annual asthma total costs.Results: A total of 268 severe asthmatic patients in Spain were included, representing 6.3% of the asthma population, with 58.6% having eosinophil count ≥300 cells/μl and 41.4% eosinophil count <300 cells/μl. The mean age was 56.1 years (63.4% women). Patients with eosinophilic inflammation (≥300 cells/μl) had lower FEV1 values (54.3% vs. 60.7%; p < .001), poorer treatment adherence (65.6% vs. 77.3%; p < .001), and a greater mean number of exacerbations (3.3 vs. 1.9; p < .001). Exacerbations were correlated to FEV1 (β=‒.606), eosinophils (β = .255), immunoglobulin E (β = .152), and age (β = .128), p < .001. The mean total asthma annual cost (ANCOVA) was 6222 vs. 4152 euros, respectively (p = .016). Health costs were associated with age (β = .323), FEV1 (β = .239), eosinophils (β = .177) and exacerbations (β = .158), p < .01.Limitations: Those inherent to retrospective studies; the possible inaccuracy of diagnostic coding referring to severe asthma and other comorbidities and the external validity of the results.Conclusions: Health costs of patients with severe asthma were high. Total annual asthma costs and resource use were greater in patients with ≥300 cells/μl. Age, eosinophilia, exacerbations and FEV1 were associated with greater resource utilization and costs for the health system.
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Affiliation(s)
| | - Margarita Capel
- Health Economics and Outcomes Research, AstraZeneca, Madrid, Spain
| | | | - Javier Nuevo
- Medical Evidence Observational Research, AstraZeneca, Madrid, Spain
| | | | - Gustavo Resler
- Medical and Regulatory Affairs, AstraZeneca, Madrid, Spain
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24
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Agache I, Beltran J, Akdis C, Akdis M, Canelo‐Aybar C, Canonica GW, Casale T, Chivato T, Corren J, Del Giacco S, Eiwegger T, Firinu D, Gern JE, Hamelmann E, Hanania N, Mäkelä M, Hernández‐Martín I, Nair P, O'Mahony L, Papadopoulos NG, Papi A, Park H, Pérez de Llano L, Posso M, Rocha C, Quirce S, Sastre J, Shamji M, Song Y, Steiner C, Schwarze J, Alonso‐Coello P, Palomares O, Jutel M. Efficacy and safety of treatment with biologicals (benralizumab, dupilumab, mepolizumab, omalizumab and reslizumab) for severe eosinophilic asthma. A systematic review for the EAACI Guidelines - recommendations on the use of biologicals in severe asthma. Allergy 2020; 75:1023-1042. [PMID: 32034960 DOI: 10.1111/all.14221] [Citation(s) in RCA: 202] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 12/13/2022]
Abstract
Five biologicals have been approved for severe eosinophilic asthma, a well-recognized phenotype. Systematic reviews (SR) evaluated the efficacy and safety of benralizumab, dupilumab, mepolizumab, omalizumab and reslizumab (alphabetical order) compared to standard of care for severe eosinophilic asthma. PubMed, Embase and Cochrane Library were searched to identify RCTs and health economic evaluations, published in English. Critical and important asthma-related outcomes were evaluated for each of the biologicals. The risk of bias and the certainty of the evidence were assessed using GRADE. 19 RCTs (three RCTs for benralizumab, three RCTs for dupilumab, three RCTs for mepolizumab, five RCTs for omalizumab and five RCTs for reslizumab), including subjects 12 to 75 years old (except for omalizumab including also subjects 6-11 years old), ranging from 12 to 56 weeks were evaluated. All biologicals reduce exacerbation rates with high certainty of evidence: benralizumab incidence rate ratio (IRR) 0.53 (95% CI 0.39 to 0.72), dupilumab (IRR) 0.43 (95% CI 0.32 to 0.59), mepolizumab IRR 0.49 (95% CI 0.38 to 0.66), omalizumab (IRR) 0.56 (95% CI 0.40 to 0.77) and reslizumab (IRR) 0.46 (95% CI 0.37 to 0.58). Benralizumab, dupilumab and mepolizumab reduce the daily dose of oral corticosteroids (OCS) with high certainty of evidence. All evaluated biologicals probably improve asthma control, QoL and FEV1 , without reaching the minimal important difference (moderate certainty). Benralizumab, mepolizumab and reslizumab slightly increase drug-related adverse events (AE) and drug-related serious AE (low to very low certainty of evidence). The incremental cost-effectiveness ratio per quality-adjusted life year value is above the willingness to pay threshold for all biologicals (moderate certainty). Potential savings are driven by decrease in hospitalizations, emergency and primary care visits. There is high certainty that all approved biologicals reduce the rate of severe asthma exacerbations and for benralizumab, dupilumab and mepolizumab for reducing OCS. There is moderate certainty for improving asthma control, QoL, FEV1 . More data on long-term safety are needed together with more efficacy data in the paediatric population.
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25
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Moore WC, Panettieri RA, Trevor J, Ledford DK, Lugogo N, Soong W, Chipps BE, Carr W, Belton L, Gandhi H, Trudo F, Ambrose CS. Biologic and maintenance systemic corticosteroid therapy among US subspecialist-treated patients with severe asthma. Ann Allergy Asthma Immunol 2020; 125:294-303.e1. [PMID: 32304877 DOI: 10.1016/j.anai.2020.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/01/2020] [Accepted: 04/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Severe asthma (SA) often requires subspecialist management and treatment with biologic therapies or maintenance systemic corticosteroids (mSCS). OBJECTIVE To describe contemporary, real-world biologic and mSCS use among US subspecialist-treated patients with SA. METHODS CHRONICLE is an ongoing, noninterventional study of US adults with SA treated by allergists/immunologists or pulmonologists. Eligible patients are receiving biologics or mSCS or are uncontrolled on high-dosage inhaled corticosteroids with additional controllers. Biologic and mSCS use patterns and patient characteristics were summarized for patients enrolled between February 2018 and February 2019. RESULTS Among protocol-eligible patients, 58% and 12% were receiving biologics and mSCS, respectively, with 7% receiving both. Among 796 enrolled, most were women (67%), non-Hispanic white (71%), of suburban residence (50%), and had elevated body mass index (median: 31). Respiratory and nonrespiratory comorbidities were highly prevalent. With biologics (n = 557), 51% were anti-immunoglobulin E and 48% were anti-interleukin (IL)-5/IL-5Rα; from May 2018, 76% of initiations were anti-IL-5/IL-5Rα. In patients receiving mSCS, median prednisone-equivalent daily dose was 10 mg. Multivariate logistic regression found that patients of hospital clinics, sites with fewer nonphysician staff, and with a recorded concurrent chronic obstructive pulmonary disease diagnosis were less likely to receive biologics and more likely to receive mSCS. CONCLUSION In this real-world sample of US subspecialist-treated patients with SA not controlled by high-dosage inhaled corticosteroids with additional controllers, mSCS use was infrequent and biologic use was common, with similar prevalence of anti-immunoglobulin E and anti-IL-5/IL-5Rα biologics. Treatment differences associated with patient and site characteristics should be investigated to ensure equitable access to biologics and minimize mSCS use. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03373045.
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Affiliation(s)
- Wendy C Moore
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Weily Soong
- Alabama Allergy & Asthma Center, Birmingham, Alabama
| | - Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California
| | - Warner Carr
- Allergy & Asthma Associates of Southern California, Mission Viejo, California
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26
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Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.
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Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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