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Beasley R, Ferreira DS, Papi A. As-needed Dual Inhaled Corticosteroid-Formoterol in Mild Asthma: Scientific Evidence. Arch Bronconeumol 2024; 60:197-199. [PMID: 38326118 DOI: 10.1016/j.arbres.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024]
Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand.
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Krings JG, Beasley R. The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:870-879. [PMID: 38237858 PMCID: PMC10999356 DOI: 10.1016/j.jaip.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/14/2023] [Accepted: 01/01/2024] [Indexed: 02/05/2024]
Abstract
The Global Initiative for Asthma (GINA) recommends that short-acting β2-agonist (SABA) monotherapy should no longer be prescribed, and that as-needed combination inhaled corticosteroids (ICS)-formoterol is the preferred reliever therapy in adults and adolescents with mild asthma. These recommendations are based on the risks of SABA monotherapy, the evidence that ICS-formoterol reliever therapy markedly decreases the occurrence of severe asthma exacerbations compared with SABA reliever therapy alone, and because ICS-formoterol reliever therapy has a favorable risk/benefit profile compared with maintenance ICS plus SABA reliever therapy. Data supporting the use of combination ICS-albuterol reliever therapy in mild asthma are more limited, but there are studies that inform its use in this population. In this review, we compare, using a pros and cons format, the (1) long-term safety and efficacy of ICS-formoterol reliever therapy versus SABA reliever therapy alone, (2) long-term safety and efficacy of ICS-albuterol reliever therapy versus SABA reliever therapy alone, (3) immediate bronchodilator effects of ICS-formoterol versus SABA alone, and (4) clinical and regulatory factors that may inform reliever therapy prescription decisions. By presenting the evidence of these reliever inhaler options, we hope to inform the reader while also calling for necessary future effectiveness and implementation research.
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Affiliation(s)
- James G Krings
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, Mo.
| | - Richard Beasley
- Medical Research Institute of New Zealand Victoria University of Wellington, Wellington, New Zealand
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Roche N, Yorgancıoğlu A, Cruz AA, Garcia G, Lavoie KL, Abhijith PG, Verma M, Majumdar A, Chatterjee S. Systematic literature review of traits and outcomes reported in randomised controlled trials of asthma with regular dosing of inhaled corticosteroids with short-acting β 2-agonist reliever, as-needed ICS/formoterol, or ICS/formoterol maintenance and reliever therapy. Respir Med 2024; 221:107478. [PMID: 38008385 DOI: 10.1016/j.rmed.2023.107478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/17/2023] [Accepted: 11/19/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION Asthma treatments based solely on diagnostic label do not benefit patients equally. To identify patient traits that may be associated with improved treatment response to regular inhaled corticosteroid (ICSs) dosing with short-acting β2-agonist reliever or ICS/formoterol-containing therapy, a systematic literature review (SLR) was conducted. METHODS Searches of databases including MEDLINE and Embase identified randomised controlled trials (RCTs) of patients with asthma, aged ≥12 years, published 1998-2022, containing ≥1 regular ICS dosing or ICS/formoterol-containing treatment arm, and reporting patient traits and outcomes of interest. Relevant data was extracted and underwent a feasibility assessment to determine suitability for meta-analysis. RESULTS The SLR identified 39 RCTs of 72,740 patients and 90 treatment arms, reporting 11 traits and 11 outcomes. Five patient traits (age, body mass index, FEV1, smoking history, asthma control) and five outcomes (exacerbation rate, lung function, asthma control, adherence, time to first exacerbation) were deemed feasible for inclusion in meta-analyses due to sufficient comparable reporting. Subgroups of clinical outcomes stratified by levels of patient traits were reported in 16 RCTs. CONCLUSION A systematic review of studies of regular ICS dosing with SABA or ICS/formoterol-containing treatment strategies in asthma identified consistent reporting of five traits and outcomes, allowing exploration of associations with treatment response. Conversely, many other traits and outcomes, although being potentially relevant, were inconsistently reported and limited subgroup reporting meant analyses of treatment response for subgroups of traits was not possible. We recommend more consistent measurement and reporting of clinically relevant patient traits and outcomes in respiratory RCTs.
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Affiliation(s)
- Nicolas Roche
- Pneumology, AP-HP Centre Université Paris Cité, Hôpital Cochin, Paris, France
| | | | - Alvaro A Cruz
- ProAR and Universidade Federal da Bahia, Salvador, Brazil
| | | | - Kim L Lavoie
- University of Quebec at Montreal (UQAM), Montreal, Canada; Montreal Behavioural Medicine Centre, CIUSSS-NIM, Hopital du Sacre-Coeur de Montreal, Montreal, Canada
| | - P G Abhijith
- GSK, Global Medical Affairs, General Medicine, Amsterdam, the Netherlands
| | - Manish Verma
- GSK, Global Medical Affairs, General Medicine, Mumbai, India.
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Yu Y, Cao W, Xiao Y, Li A, Huang H, Liu K, Hu L, Hou X, Xiang L, Wang X. Budesonide/formoterol maintenance and reliever therapy in childhood asthma: Real-world effectiveness and economic assessment. Pediatr Pulmonol 2023; 58:3406-3415. [PMID: 37818789 DOI: 10.1002/ppul.26647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/18/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION The study aims to compare the real-world effectiveness and economy of the budesonide/formoterol reliever and maintenance therapy (SMART) with fixed-dose inhaled corticosteroids (ICS)/long-acting b-agonist (LABA) or ICS alone plus as-needed, short-acting β2 agonists (SABA) in pediatric patients. METHODS The outpatient data warehouse of a hospital in China was used. A total of 103 patients under 18 years old in the SMART group and 63 patients in the control group were included from January 1, 2020 to December 31, 2021. The effectiveness was assessed using asthma attacks and lung function at baseline, 6 months and 12 months follow-up. Cost-effectiveness analysis was performed with a three-state Markov model from the healthcare system perspective. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to check the robustness of the results. RESULTS The SMART regimen was more effective than other strategies in reducing the risk of mild and severe attacks in the real-life management of childhood asthma. Patients in both groups showed significant improvement in lung function at 6 and 12 months in contrast to baseline. Compared with other strategies, the forced expiratory volume in 1 s (FEV1 ) level in the SMART group was markedly improved at 6 months. The total cost of outpatient service using the SMART regimen was lower than that of other strategies, while the drug costs were similar in different groups. Incremental cost-effectiveness analysis results showed that using the SMART regimen reduced the total cost by approximately CNY 10,516.11 per year with a 0.12 quality-adjusted life year (QALYs) increase. Sensitive analyses supported that the SMART regimen was the dominant choice at the willingness-to-pay threshold of CNY 85,698, per capita GDP in China. CONCLUSIONS Collectively, our findings indicate that the real-world effectiveness and economy of the SMART regimen are superior to the traditional strategies in pediatric asthma patients.
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Affiliation(s)
- Yuncui Yu
- Clinical Research Center, National Clinical Research Center for Respiratory Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wang Cao
- Clinical Research Center, National Clinical Research Center for Respiratory Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yue Xiao
- National Health Development Research Center, National Health Commission, Beijing, China
| | - Ang Li
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Huijie Huang
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Kejun Liu
- National Health Development Research Center, National Health Commission, Beijing, China
| | - Lihua Hu
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoling Hou
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Li Xiang
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoling Wang
- Clinical Research Center, National Clinical Research Center for Respiratory Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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5
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Thomas M, Beasley R. The treatable traits approach to adults with obstructive airways disease in primary and secondary care. Respirology 2023; 28:1101-1116. [PMID: 37877554 DOI: 10.1111/resp.14610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.
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Affiliation(s)
- Mike Thomas
- Primary Care Research, School of Primary Care, Population Sciences and Medical Education (PPM), Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Richard Beasley
- Medicine, Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
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Lanz MJ, Gilbert IA, Gandhi HN, Pollack M, Tkacz JP, Lugogo NL. Patterns of rescue and maintenance therapy claims surrounding a clinical encounter for an asthma exacerbation. Ann Allergy Asthma Immunol 2023; 131:458-465.e1. [PMID: 37343824 DOI: 10.1016/j.anai.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND A "window of opportunity" has been proposed where anti-inflammatory therapy administration in response to symptoms could prevent exacerbation. OBJECTIVE To evaluate rescue and maintenance therapy claims surrounding a severe asthma exacerbation serious enough to require a face-to-face clinical encounter. METHODS Merative MarketScan research databases (US administrative claims 2011 to 2017) were analyzed for patients aged ≥4 years, with an asthma diagnosis code, who filled short-acting β2-agonist (SABA) and Global Initiative for Asthma Steps 3 to 5 maintenance therapies. Patients were indexed on a random SABA claim and had 12 months' continuous health plan eligibility pre- and post-index. Serious exacerbations were severe exacerbations requiring systemic corticosteroids prescribed from an outpatient clinic, urgent care or emergency department, or hospitalization for asthma. SABA and maintenance claims 30 days pre- and post-event were analyzed. RESULTS Of 319,342 patients (30% children 4 to 11 years; 70% adults or adolescents ≥12 years), 27.2% of children and 16.8% of adolescents or adults experienced ≥ 1 serious exacerbation (unadjusted odds ratio [OR], 1.85 [95% confidence interval, 1.81-1.88]). In the 30 days pre-event, 42.6% filled ≥1 SABA (children: 44.3%; adolescents or adults: 41.5%; OR, 1.12 [1.09-1.16]) and 57.4% filled maintenance (children: 59.0%; adolescents or adults: 56.3%; OR, 1.12 [1.08-1.15]). In the 30 days post-event, 61.4% filled SABA (children: 69.7%; adolescents or adults: 55.6%; OR, 1.84 [1.78-1.90]) and 94.8% filled maintenance (children: 98.6%; adolescents or adults: 92.2%; OR, 6.09 [5.45-6.81]). CONCLUSION Many patients treated as having moderate-to-severe asthma escalate SABA claims before a serious exacerbation, but approximately 40% have no anti-inflammatory maintenance fill, highlighting a "window of opportunity" to prevent exacerbations using inhaled corticosteroids concomitantly with SABA as rescue.
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Affiliation(s)
- Miguel J Lanz
- Allergy and Asthma, AAADRS Clinical Research Center, Coral Gables, Florida, USA
| | - Ileen A Gilbert
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware, USA.
| | - Hitesh N Gandhi
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware, USA
| | - Michael Pollack
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware, USA
| | - Joseph P Tkacz
- Health Economics and Outcomes Research, Inovalon, Bowie, Maryland, USA
| | - Njira L Lugogo
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Bruce P, Hatter L, Houghton C, Kearns C, Holliday M, Anderson AJ, Eathorne A, Martindale J, Semprini A, Weatherall M, Pavord I, Harrison T, Papi A, Horne R, Beasley R. The Anti-Inflammatory Reliever (AIR) Algorithm Study: a protocol for a single-group study of an AIR stepwise approach to the treatment of adult asthma. ERJ Open Res 2023; 9:00239-2023. [PMID: 37753283 PMCID: PMC10518889 DOI: 10.1183/23120541.00239-2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/03/2023] [Indexed: 09/28/2023] Open
Abstract
Background The stepwise approach to long-term asthma management, which traditionally incorporates short-acting β2-agonist reliever therapy, has been a core feature of asthma guidelines for over 30 years. There have been no studies, however, directly investigating the use of an entire guideline-recommended track. Recently, inhaled corticosteroid-formoterol has been recommended as the preferred reliever therapy in adult asthma, in accordance with a stepwise "Anti-Inflammatory Reliever" (AIR) treatment track. Objective The aim of this study was to evaluate the AIR stepwise approach recommended by the New Zealand adolescent and adult asthma guidelines, in combination with a novel algorithm for transitioning between treatment steps. Methods This 52-week, open-label, single-group study will recruit 100 adults aged 18 to 75 years with mild, moderate and moderate-severe asthma (ACTRN12620001010987). Participants will be allocated to budesonide-formoterol 200/6 µg, one actuation as needed (Step 1), one actuation twice daily and as needed (Step 2), or two actuations twice daily and one as needed (Step 3). Treatment steps will be adjusted throughout the study, in response to reliever use and asthma attacks, according to a stepwise AIR algorithm. Following a 26-week period of investigator-led transitions, participants will adjust their own treatment step. The primary outcome is participant satisfaction as measured by the Global Satisfaction score of the Treatment Satisfaction Questionnaire for Medication. Secondary outcomes will assess efficacy and safety, and describe patterns of medication use and participant flow through the treatment steps. Conclusion This is the first trial to assess the AIR treatment track and algorithm. The results will provide knowledge to guide the clinical use of this approach.
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Affiliation(s)
- Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ciléin Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Holliday
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - John Martindale
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Alex Semprini
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Weatherall
- Department of Medicine, University of Otago, Wellington, New Zealand
| | | | - Tim Harrison
- University of Nottingham, Nottingham, UK
- Global Medical Affairs, AstraZeneca, UK
| | | | - Rob Horne
- University College London, London, UK
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
- School of Biological Sciences, Victoria University Wellington, Wellington, New Zealand
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Hatter L, Eathorne A, Hills T, Bruce P, Houghton C, Weatherall M, Beasley R. Patterns of Asthma Medication Use in New Zealand After Publication of National Asthma Guidelines. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2757-2764.e5. [PMID: 37178765 DOI: 10.1016/j.jaip.2023.04.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND In June 2020, the New Zealand (NZ) adolescent and adult asthma guidelines recommended budesonide/formoterol, taken as maintenance and/or reliever therapy, as the preferred therapeutic approach. OBJECTIVE To investigate whether these recommendations were associated with changes in clinical practice indicated by asthma medication use trends. METHODS NZ national dispensing data for inhaler medications from January 2010 to December 2021 were reviewed. Monthly "dispensings" of inhaled budesonide/formoterol, inhaled corticosteroid (ICS), other ICS/long-acting β2-agonists (LABA), and inhaled short-acting β2-agonists (SABA), for the 12+ age group, were displayed graphically with piecewise regression used to produce plots of rates by time with a July 1, 2020, break point. The number of dispensings in the last 6 months that data were available (July-December 2021) was compared with the corresponding period, July-December 2019. RESULTS Budesonide/formoterol dispensing increased markedly after July 1, 2020 (regression coefficient 41.1 inhalers dispensed/100,000 population per month [95% confidence interval (CI): 36.3-45.6, P < .0001]; 64.7% increase in the number of dispensings between July-December 2019 and July-December 2021), in contrast to "other ICS/LABA" (regression coefficient: -15.9 [95% CI: -22.2 to -9.6, P < .0001]; -1.7% decrease) and SABA (regression coefficient: -14.7 [95% CI: -29.7 to 0.3, P = .055]; -10.6% decrease), respectively. CONCLUSION In NZ, a progressive increase in budesonide/formoterol dispensing, accompanied by a reduction in SABA and "other ICS/LABA" dispensing, occurred after publication of the 2020 NZ asthma guidelines. While acknowledging the limitations in the interpretation of temporal associations, these findings suggest that the transition to ICS/formoterol reliever-based therapy can be achieved if recommended and promoted as the preferred therapeutic approach in national guidelines.
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Affiliation(s)
- Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand; School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Tom Hills
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Weatherall
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand; School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand.
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Lommatzsch M, Criée CP, de Jong CCM, Gappa M, Geßner C, Gerstlauer M, Hämäläinen N, Haidl P, Hamelmann E, Horak F, Idzko M, Ignatov A, Koczulla AR, Korn S, Köhler M, Lex C, Meister J, Milger-Kneidinger K, Nowak D, Nothacker M, Pfaar O, Pohl W, Preisser AM, Rabe KF, Riedler J, Schmidt O, Schreiber J, Schuster A, Schuhmann M, Spindler T, Taube C, Christian Virchow J, Vogelberg C, Vogelmeier CF, Wantke F, Windisch W, Worth H, Zacharasiewicz A, Buhl R. [Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]. Pneumologie 2023; 77:461-543. [PMID: 37406667 DOI: 10.1055/a-2070-2135] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.
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Affiliation(s)
- Marek Lommatzsch
- Zentrum für Innere Medizin, Abt. für Pneumologie, Universitätsmedizin Rostock
| | | | - Carmen C M de Jong
- Abteilung für pädiatrische Pneumologie, Abteilung für Pädiatrie, Inselspital, Universitätsspital Bern
| | - Monika Gappa
- Klinik für Kinder und Jugendliche, Evangelisches Krankenhaus Düsseldorf
| | | | | | | | - Peter Haidl
- Abteilung für Pneumologie II, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg
| | - Eckard Hamelmann
- Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld
| | | | - Marco Idzko
- Abteilung für Pulmologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien
| | - Atanas Ignatov
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum Magdeburg
| | - Andreas Rembert Koczulla
- Schön-Klinik Berchtesgadener Land, Berchtesgaden
- Klinik für Innere Medizin Schwerpunkt Pneumologie, Universitätsklinikum Marburg
| | - Stephanie Korn
- Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg
| | - Michael Köhler
- Deutsche Patientenliga Atemwegserkrankungen, Gau-Bickelheim
| | - Christiane Lex
- Klinik für Kinder- und Jugendmedizin, Universitätsmedizin Göttingen
| | - Jochen Meister
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Aue
| | | | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V
| | - Oliver Pfaar
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Sektion für Rhinologie und Allergie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg
| | - Wolfgang Pohl
- Gesundheitszentrum Althietzing, Karl Landsteiner Institut für klinische und experimentelle Pneumologie, Wien
| | - Alexandra M Preisser
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Klaus F Rabe
- Pneumologie, LungenClinic Großhansdorf, UKSH Kiel
| | - Josef Riedler
- Abteilung für Kinder- und Jugendmedizin, Kardinal Schwarzenberg Klinikum Schwarzach
| | | | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg
| | - Antje Schuster
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf
| | | | | | - Christian Taube
- Klinik für Pneumologie, Universitätsmedizin Essen-Ruhrlandklinik
| | | | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Wolfram Windisch
- Lungenklinik Köln-Merheim, Lehrstuhl für Pneumologie, Universität Witten/Herdecke
| | - Heinrich Worth
- Pneumologische & Kardiologische Gemeinschaftspraxis, Fürth
| | | | - Roland Buhl
- Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz
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10
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Reddel HK, Brusselle G, Lamarca R, Gustafson P, Anderson GP, Jorup C. Safety and Effectiveness of As-Needed Formoterol in Asthma Patients Taking Inhaled Corticosteroid (ICS)-Formoterol or ICS-Salmeterol Maintenance Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2104-2114.e3. [PMID: 37054881 DOI: 10.1016/j.jaip.2023.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND As-needed low-dose inhaled corticosteroid (ICS)-formoterol reliever is recommended in patients with asthma prescribed maintenance ICS-formoterol. Clinicians often ask whether ICS-formoterol reliever can be used with other maintenance ICS-long-acting β2-agonists. OBJECTIVE To evaluate the safety and effectiveness of as-needed formoterol in patients taking maintenance ICS-formoterol or ICS-salmeterol from the RELIEF study. METHODS RELIEF (SD-037-0699) was a 6-month, open-label study that randomized 18,124 patients with asthma to as-needed formoterol 4.5 μg or salbutamol 200 μg on top of maintenance therapy. This post hoc analysis included patients on maintenance ICS-formoterol or ICS-salmeterol (n = 5436). The primary safety outcome was a composite of serious adverse events (SAEs) and/or adverse events leading to discontinuation (DAEs); the primary effectiveness outcome was time-to-first exacerbation. RESULTS For both maintenance groups and both relievers, similar numbers of patients had ≥1 SAE and/or DAE. In patients taking maintenance ICS-salmeterol, but not ICS-formoterol, significantly more non-asthma-related and nonserious DAEs occurred with as-needed formoterol versus as-needed salbutamol (P = .0066 and P = .0034, respectively). In patients taking maintenance ICS-formoterol, there was a significantly lower risk in time-to-first exacerbation with as-needed formoterol versus as-needed salbutamol (hazard ratio [HR]: 0.82, 95% confidence interval [CI]: 0.70, 0.95; P = .007). In patients taking ICS-salmeterol maintenance, time-to-first exacerbation was not significantly different between treatment arms (HR: 0.95, 95% CI: 0.84, 1.06; P = .35). CONCLUSIONS As-needed formoterol significantly reduced exacerbation risk compared with as-needed salbutamol when added to maintenance ICS-formoterol, but not to maintenance ICS-salmeterol. More DAEs were seen with ICS-salmeterol maintenance therapy plus as-needed formoterol. Further research is needed to assess whether this is relevant to as-needed combination ICS-formoterol.
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Affiliation(s)
- Helen Kathryn Reddel
- The Woolcock Institute of Medical Research, The University of Sydney, and Macquarie University, Sydney, Australia.
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Rosa Lamarca
- BioPharmaceuticals R&D, Late-Stage Development, Respiratory & Immunology, AstraZeneca, Barcelona, Spain
| | - Per Gustafson
- BioPharmaceuticals Medical, Respiratory & Immunology, AstraZeneca, Gothenburg, Sweden
| | - Gary P Anderson
- Lung Health Research Centre, Department of Biochemistry and Pharmacology, University of Melbourne, Melbourne, VIC, Australia
| | - Carin Jorup
- BioPharmaceuticals R&D, Late-Stage Development, Respiratory & Immunology, AstraZeneca, Gothenburg, Sweden
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11
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Beydon N, Taillé C, Corvol H, Valcke J, Portal JJ, Plantier L, Mangiapan G, Perisson C, Aubertin G, Hadchouel A, Briend G, Guilleminault L, Neukirch C, Cros P, Appere de Vecchi C, Mahut B, Vicaut E, Delclaux C. Digital Action Plan (Web App) for Managing Asthma Exacerbations: Randomized Controlled Trial. J Med Internet Res 2023; 25:e41490. [PMID: 37255277 PMCID: PMC10365576 DOI: 10.2196/41490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/30/2022] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND A written action plan (WAP) for managing asthma exacerbations is recommended. OBJECTIVE We aimed to compare the effect on unscheduled medical contacts (UMCs) of a digital action plan (DAP) accessed via a smartphone web app combined with a WAP on paper versus that of the same WAP alone. METHODS This randomized, unblinded, multicenter (offline recruitment in private offices and public hospitals), and parallel-group trial included children (aged 6-12 years) or adults (aged 18-60 years) with asthma who had experienced at least 1 severe exacerbation in the previous year. They were randomized to a WAP or DAP+WAP group in a 1:1 ratio. The DAP (fully automated) provided treatment advice according to the severity and previous pharmacotherapy of the exacerbation. The DAP was an algorithm that recorded 3 to 9 clinical descriptors. In the app, the participant first assessed the severity of their current symptoms on a 10-point scale and then entered the symptom descriptors. Before the trial, the wordings and ordering of these descriptors were validated by 50 parents of children with asthma and 50 adults with asthma; the app was not modified during the trial. Participants were interviewed at 3, 6, 9, and 12 months to record exacerbations, UMCs, and WAP and DAP use, including the subjective evaluation (availability and usefulness) of the action plans, by a research nurse. RESULTS Overall, 280 participants were randomized, of whom 33 (11.8%) were excluded because of the absence of follow-up data after randomization, leaving 247 (88.2%) participants (children: n=93, 37.7%; adults: n=154, 62.3%). The WAP group had 49.8% (123/247) of participants (children: n=45, 36.6%; mean age 8.3, SD 2.0 years; adults: n=78, 63.4%; mean age 36.3, SD 12.7 years), and the DAP+WAP group had 50.2% (124/247) of participants (children: n=48, 38.7%; mean age 9.0, SD 1.9 years; adults: n=76, 61.3%; mean age 34.5, SD 11.3 years). Overall, the annual severe exacerbation rate was 0.53 and not different between the 2 groups of participants. The mean number of UMCs per year was 0.31 (SD 0.62) in the WAP group and 0.37 (SD 0.82) in the DAP+WAP group (mean difference 0.06, 95% CI -0.12 to 0.24; P=.82). Use per patient with at least 1 moderate or severe exacerbation was higher for the WAP (33/65, 51% vs 15/63, 24% for the DAP; P=.002). Thus, participants were more likely to use the WAP than the DAP despite the nonsignificant difference between the action plans in the subjective evaluation. Median symptom severity of the self-evaluated exacerbation was 4 out of 10 and not significantly different from the symptom severity assessed by the app. CONCLUSIONS The DAP was used less often than the WAP and did not decrease the number of UMCs compared with the WAP alone. TRIAL REGISTRATION ClinicalTrials.gov NCT02869958; https://clinicaltrials.gov/ct2/show/NCT02869958.
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Affiliation(s)
- Nicole Beydon
- Unité Fonctionnelle de Physiologie-Explorations Fonctionnelles Respiratoires, Institut National de la Santé et de la Recherche Médicale 938, Centre de Recherche Saint Antoine, Hôpital Armand Trousseau, Assistance Publique Hôpitaux de Paris, F-75012, Paris, France
| | - Camille Taillé
- Service de Pneumologie et Centre de Référence Constitutif des Maladies Pulmonaires Rares, Hôpital Bichat, Assistance Publique Hôpitaux de Paris, Institut National de la Santé et de la Recherche Médicale 1152, Université Paris Cité, F-75018, Paris, France
| | - Harriet Corvol
- Service de Pneumologie Pédiatrique, Hôpital Armand Trousseau, Assistance Publique Hôpitaux de Paris, Institut National de la Santé et de la Recherche Médicale Centre de Recherche Saint-Antoine, Sorbonne Université, F-75012, Paris, France
| | - Judith Valcke
- Service de Pneumologie, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, F-75015 Paris, Hôpital Privé Armand Brillard, F-94130, Paris, France
| | - Jean-Jacques Portal
- Clinical Research Unit Saint-Louis Lariboisière, Assistance Publique Hôpitaux de Paris, Université de Paris Cité, F-75010, Paris, France
| | - Laurent Plantier
- Département de Pneumologie et Explorations Fonctionnelles Respiratoires, Centre Hospitalier Universitaire de Tours, Institut National de la Santé et de la Recherche Médicale unité 1100, Université de Tours, F-37000, Tours, France
| | - Gilles Mangiapan
- Service de Pneumologie, Centre Hospitalier Interrégional de Créteil, F-94010, Créteil, France
| | - Caroline Perisson
- Service de Pneumologie Pédiatrique, Hôpital Armand Trousseau, Assistance Publique Hôpitaux de Paris, Institut National de la Santé et de la Recherche Médicale Centre de Recherche Saint-Antoine, Sorbonne Université, F-75012, Paris, France
| | - Guillaume Aubertin
- Centre de pneumologie et d'allergologie de l'enfant, F-92100, Boulogne Billancourt, France
| | - Alice Hadchouel
- Service de Pneumologie Pédiatrique, Centre de Référence pour les Maladies Respiratoires Rares de l'Enfant, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Université de Paris Cité, F-75015, Paris, France
| | - Guillaume Briend
- Service de Pneumologie, Centre hospitalier de Pontoise, F-95303, Cergy Pontoise, France
| | - Laurent Guilleminault
- Département de Pneumologie et Allergologie, Centre Hospitalo-Universitaire Purpan, Centre National de la Recherche Scientifique U5282, Institut National de la Santé et de la Recherche Médicale U1291, Toulouse Institute for Infectious, Inflammatory Disease, Toulouse, France
| | - Catherine Neukirch
- Service de Pneumologie et Centre de Référence Constitutif des Maladies Pulmonaires Rares, Hôpital Bichat, Assistance Publique des Hôpitaux de Paris, Institut National de la Santé et de la Recherche Médicale 1152, F-75018, Paris, France
| | - Pierrick Cros
- Département de Pédiatrie, Hôpital Universitaire Morvan, F-29200, Brest, France
| | | | | | - Eric Vicaut
- Clinical Research Unit Saint-Louis Lariboisière, Assistance Publique Hôpitaux de Paris, Université de Paris Cité, F-75010, Paris, France
| | - Christophe Delclaux
- Service de Physiologie Pédiatrique-Centre du Sommeil, Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris, Institut National de la Santé et de la Recherche Médicale NeuroDiderot, Université de Paris Cité, F-75019, Paris, France
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12
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Domingo C, Singh D. The Changing Asthma Management Landscape and Need for Appropriate SABA Prescription. Adv Ther 2023; 40:1301-1316. [PMID: 36715896 PMCID: PMC10070225 DOI: 10.1007/s12325-022-02410-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/14/2022] [Indexed: 01/31/2023]
Abstract
Short-acting β2 agonists (SABAs) have been a mainstay of asthma treatment since the 1950s, and have been mainly recommended as-needed for symptom relief alongside daily inhaled corticosteroid (ICS)-based maintenance treatment for the past 30 years. However, patient adherence to regular ICS-based anti-inflammatory maintenance therapy is frequently poor, leading to SABA overuse for symptom relief and associated poor outcomes. At present, there is a lack of consensus between treatment guidelines on how SABA should be used, and as-needed ICS-formoterol is suggested by some as an alternative reliever therapy. Here, we examine the pharmacology and current use of inhaled SABAs, identify that regular dosing of ICS can encourage appropriate SABA use, and appraise the evidence used to support the changing reliever treatment recommendations. We conclude that SABA continues to play an important role in the asthma management landscape, and give our views on how it should be used in patients with mild-moderate asthma, to complement regular ICS-based maintenance treatment.
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Affiliation(s)
- Christian Domingo
- Autonomous University of Barcelona (UAB), Sabadell, Barcelona Spain
- S. Pneumologia, Planta Primera, Edifici Tauli Nou, Corporació Sanitària Parc Tauli, Parc Tauli 1, 08208 Sabadell, Barcelona Spain
| | - Dave Singh
- University of Manchester, Manchester University National Health Service Foundation Trust, Manchester, UK
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13
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Niimi A, Fukunaga K, Taniguchi M, Nakamura Y, Tagaya E, Horiguchi T, Yokoyama A, Yamaguchi M, Nagata M. Executive summary: Japanese guidelines for adult asthma (JGL) 2021. Allergol Int 2023; 72:207-226. [PMID: 36959028 DOI: 10.1016/j.alit.2023.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/25/2023] Open
Abstract
Asthma is characterized by chronic airway inflammation, variable airway narrowing, and sensory nerve irritation, which manifest as wheezing, dyspnea, chest tightness, and cough. Longstanding asthma may result in airway remodeling and become intractable. Despite the increased prevalence of asthma in adults, asthma-associated deaths have decreased in Japan (0.94 per 100,000 people in 2020). The goals of asthma treatment include the control of symptoms and reduction of future risks. A functional partnership between physicians and patients is indispensable for achieving these goals. Long-term management with medications and the elimination of triggers and risk factors are fundamental to asthma treatment. Asthma is managed via four steps of pharmacotherapy ("controllers"), ranging from mild to intensive treatments, depending on disease severity; each step involves daily administration of an inhaled corticosteroid, which varies from low to high dosage. Long-acting β2 agonists, leukotriene receptor antagonists, sustained-release theophylline, and long-acting muscarinic antagonists are recommended as add-on drugs. Allergen immunotherapy is a new option that is employed as a controller treatment. Further, as of 2021, anti-IgE antibody, anti-IL-5 and anti-IL-5 receptor α-chain antibodies, and anti-IL-4 receptor α-chain antibodies are available for the treatment of severe asthma. Bronchial thermoplasty can be performed for asthma treatment, and its long-term efficacy has been reported. Algorithms for their usage have been revised. Comorbidities, such as allergic rhinitis, chronic rhinosinusitis, chronic obstructive pulmonary disease, and aspirin-exacerbated respiratory disease, should also be considered during the treatment of chronic asthma. Depending on the severity of episodes, inhaled short-acting β2 agonists, systemic corticosteroids, short-acting muscarinic antagonists, oxygen therapy, and other approaches are used as needed ("relievers") during exacerbation.
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Affiliation(s)
- Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Koichi Fukunaga
- Pulmonary Division, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masami Taniguchi
- Center for Immunology and Allergology, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Yoichi Nakamura
- Medical Center for Allergic and Immune Diseases, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Etsuko Tagaya
- Department of Respiratory Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Takahiko Horiguchi
- Department of Respiratory Medicine, Toyota Regional Medical Center, Toyota, Japan
| | - Akihito Yokoyama
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Masao Yamaguchi
- Division of Respiratory Medicine, Third Department of Medicine, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Makoto Nagata
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan; Allergy Center, Saitama Medical University Hospital, Saitama Medical University, Saitama, Japan
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14
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Cardet JC, Papi A, Reddel HK. "As-Needed" Inhaled Corticosteroids for Patients With Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:726-734. [PMID: 36702246 PMCID: PMC10006338 DOI: 10.1016/j.jaip.2023.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/25/2023]
Abstract
Prevention of severe asthma exacerbations is a primary management goal for asthma across the severity spectrum. Inhaled corticosteroids (ICSs) decrease the risk of asthma exacerbations, but patient adherence to ICS-containing medications as a daily maintenance therapy is poor, and many patients overuse short-acting beta2-agonist relievers; both are associated with increased risk of severe exacerbations and death. Airway inflammation also varies over time, influenced by exposures such as viral infections and allergen. As-needed ICS strategies, in which patients receive ICSs (or additional ICSs, if already taking controller therapy) whenever they take their reliever inhaler, empower patients to adjust their ICS intake in response to symptom fluctuation. These strategies can improve asthma morbidity outcomes, particularly by reducing severe exacerbations and reducing the risk of adverse effects of oral corticosteroids. In this review, the evidence for combination ICS-formoterol in a single inhaler, ICS and short-acting beta2-agonists in separate inhalers, and combination ICS-albuterol in a single inhaler is presented, along with practical considerations, evidence gaps, and implications for clinical practice for each strategy, presented by level of asthma severity and age group. Improving access to such strategies on a global scale is imperative to improve asthma outcomes and achieve equity across populations.
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Affiliation(s)
- Juan Carlos Cardet
- Division of Allergy and Immunology, Internal Medicine Department, Morsani College of Medicine, University of South Florida, Tampa, Fla.
| | - Alberto Papi
- Respiratory Medicine, CEMICEF, University of Ferrara, Ferrara, Italy
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
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15
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Beasley R, Bruce P, Houghton C, Hatter L. The ICS/Formoterol Reliever Therapy Regimen in Asthma: A Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:762-772.e1. [PMID: 36639054 DOI: 10.1016/j.jaip.2023.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
The Global Initiative for Asthma recommends that low-dose inhaled corticosteroid (ICS)/formoterol be preferred to short-acting beta2-agonists as reliever therapy in adolescents and adults with asthma, across the range of asthma severity. This recommendation represents the most fundamental change in asthma management for many decades. In this commentary, we review the rationale for combination ICS/formoterol therapy, the evidence on which this recommendation has been made, the limitations in the evidence, the practical issues relevant to the implementation of ICS/formoterol reliever-based regimens in clinical practice, and the emerging evidence for the efficacy and safety of combination ICS/salbutamol reliever therapy regimens.
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Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand; Capital and Coast District Health Board, Wellington, New Zealand; Victoria University of Wellington, Wellington, New Zealand.
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand; Victoria University of Wellington, Wellington, New Zealand
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16
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Beasley R, Hatter L. Over-the-counter Dispensing: Widening Access to Inhaled Corticosteroid/Formoterol Reliever Therapy. Am J Respir Crit Care Med 2023; 207:377-379. [PMID: 36548806 PMCID: PMC9940135 DOI: 10.1164/rccm.202212-2297ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Richard Beasley
- Medical Research Institute of New ZealandWellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New ZealandWellington, New Zealand
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17
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Krings JG, Gerald JK, Blake KV, Krishnan JA, Reddel HK, Bacharier LB, Dixon AE, Sumino K, Gerald LB, Brownson RC, Persell SD, Clemens CJ, Hiller KM, Castro M, Martinez FD. A Call for the United States to Accelerate the Implementation of Reliever Combination Inhaled Corticosteroid-Formoterol Inhalers in Asthma. Am J Respir Crit Care Med 2023; 207:390-405. [PMID: 36538711 PMCID: PMC9940146 DOI: 10.1164/rccm.202209-1729pp] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- James G. Krings
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Joe K. Gerald
- Department of Community Environment and Policy, Mel and Enid Zuckerman College of Public Health
- Asthma & Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Kathryn V. Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children’s Health, Jacksonville, Florida
| | | | - Helen K. Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia
| | - Leonard B. Bacharier
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne E. Dixon
- Division of Pulmonary Critical Care, Department of Medicine, University of Vermont, Burlington, Vermont
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Lynn B. Gerald
- Population Health Sciences Program, University of Illinois Chicago, Chicago, Illinois
| | - Ross C. Brownson
- Department of Surgery, School of Medicine, and
- Prevention Research Center, Brown School, Washington University in Saint Louis, St. Louis, Missouri
| | - Stephen D. Persell
- Division of General Internal Medicine, Department of Medicine, and
- Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Katherine M. Hiller
- Department of Emergency Medicine, School of Medicine, Indiana University, Bloomington, Indiana; and
| | - Mario Castro
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Kansas, Kansas City, Kansas
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18
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Nanda A, Siles R, Park H, Louisias M, Ariue B, Castillo M, Anand MP, Nguyen AP, Jean T, Lopez M, Altisheh R, Pappalardo AA. Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee. J Allergy Clin Immunol 2023; 151:869-880. [PMID: 36720288 DOI: 10.1016/j.jaci.2023.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/08/2023] [Accepted: 01/19/2023] [Indexed: 01/29/2023]
Abstract
The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.
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Affiliation(s)
- Anil Nanda
- Asthma and Allergy Center, Lewisville-Flower Mound; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Roxana Siles
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland
| | - Henna Park
- Department of Pediatrics, University of Illinois Hospital, Chicago
| | - Margee Louisias
- Department of Medicine, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Cleveland; Department of Immunology, Boston Children's Hospital, Boston; Harvard Medical School, Boston
| | - Barbara Ariue
- Department of Pediatrics, Division of Allergy/Immunology, Loma Linda Children's Hospital, Loma Linda
| | - Maria Castillo
- Department of Medical Education at Driscoll Children's Hospital, Corpus Christi
| | - Mahesh Padukudru Anand
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysore
| | - Anh P Nguyen
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, School of Medicine, University of California Davis, Sacramento
| | - Tiffany Jean
- Division of Basic and Clinical Immunology, Department of Medicine, University of California Irvine, Orange
| | - Michael Lopez
- Division of Basic and Clinical Immunology, Department of Medicine, University of California Irvine, Orange
| | - Roula Altisheh
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland
| | - Andrea A Pappalardo
- Department of Pediatrics, Department of Medicine, University of Illinois at Chicago, Chicago
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19
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Brattsand R, Selroos O. May a different kinetic mode explain the high efficacy/safety profile of inhaled budesonide? Pulm Pharmacol Ther 2022; 77:102167. [PMID: 36180011 DOI: 10.1016/j.pupt.2022.102167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022]
Abstract
The claimed functional basis for ICSs in asthma and COPD is airway selectivity, attained by inhaling a potent, lipophilic compound with long local dissolution/absorption time. The development has been empirically based, resulting in five widely used ICSs. Among them, budesonide (BUD) deviates by being less lipophilic, leading to a more rapid systemic uptake with plasma peaks with some systemic anti-inflammatory activity. By this, BUD fits less well into the current pharmacological dogma of optimal ICS profile. In this review we compared the physicochemical, pharmacological and clinical properties of BUD, fluticasone propionate (FP) and fluticasone furoate (FF), representing different levels of lipophilicity, airway and systemic kinetics, focusing on their long-acting β2-agonist (LABA) combinations, in line with current GINA and GOLD recommendations. We are aware of the differences between formoterol (FORM) and the not rapid acting LABAs such as e.g. salmeterol and vilanterol but our comparisons are based on currently available combination products. A beclomethasone dipropionate (BDP)/FORM combination is also commented upon. Based on clinical comparisons in asthma and COPD, we conclude that the BUD/formoterol (BUD/FORM) combination is as effective and safe as the FP and FF combinations, and is in some cases even better as it can be used as "maintenance plus reliever therapy" (MART) in asthma and as maintenance in COPD. This is difficult to explain by current views of required ICS's/LABAs pharmacokinetic profiles. We propose that BUD achieves its efficacy by a combination of airway and systemic activity. The airway activity is dominating. The systemic activity contributes by plasma peaks, which are high enough for supportive anti-inflammatory actions at the blood and bone marrow levels but not sufficiently long to trigger a similar level of systemic adverse effects. This may be due to BUD's capacity to exploit a systemic differentiation mechanism as programmed for cortisol's various actions. This differentiation prospect can be reached only for an ICS with short plasma half-life. Here we present an alternative mode for an ICS to reach combined efficacy and safety, based on a poorly investigated and exploited physiological mechanism. A preference of this mode is broader versatility, due to that its straighter dose-response should allow a better adaptation to disease fluctuations, and that its rapid activity enables use as "anti-inflammatory reliever".
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Affiliation(s)
- Ralph Brattsand
- Experimental Pharmacology, Budera Company, Kristinehamn, Sweden.
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20
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Imam SF, Zafar S, Oppenheimer J. SMART in treatment of asthma exacerbations. Ann Allergy Asthma Immunol 2022; 129:703-708. [PMID: 35914659 DOI: 10.1016/j.anai.2022.07.024] [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: 06/06/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this review is to evaluate the effectiveness and practicality of SMART (single maintenance and reliever therapy) in the treatment of asthma exacerbation. DATA SOURCES PubMed, MEDLINE, Cochrane, and Clinical Trial databases using the keywords SMART therapy, maintenance and reliever therapy, and budesonide and formoterol. STUDY SELECTION Articles were selected based on their relevance and applicability to this topic. RESULTS Multiple studies have evaluated the efficacy of SMART in reducing asthma exacerbations in comparison to standard inhaled corticosteroid (ICS) maintenance and short-acting beta-agonist (SABA) rescue therapy. Most of the randomized trials demonstrated a reduction in asthma exacerbation with open-label studies revealing similar effectiveness in reducing asthma exacerbation. Previously, concerns have been raised regarding the administration of increased doses of long-acting beta-agonist that may potentially mask symptoms and delay appropriate medical attention. However, studies have not demonstrated an increase in morbidity or mortality. The primary concern regarding many of these trials is that they have been sponsored by pharmaceutical companies. CONCLUSION Although not all studies demonstrated the effectiveness of SMART, the majority revealed a significant reduction in asthma exacerbation frequency and severity.
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Affiliation(s)
- Syed Fahmeed Imam
- Division of Allergy/Immunology, Rheumatology, & Pulmonology, Department of Medicine, Rutgers New Jersey Medical School.
| | - Saira Zafar
- Division of Allergy/Immunology, Rheumatology, & Pulmonology, Department of Medicine, Rutgers New Jersey Medical School
| | - John Oppenheimer
- Division of Allergy/Immunology, Rheumatology, & Pulmonology, Department of Medicine, Rutgers New Jersey Medical School
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21
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Collinsworth AW, Masica AL, Kudyakov R, Bayer V, Millard MW, Shaikh A. Retrospective observational study of asthma and chronic obstructive pulmonary disease prevalence and associated healthcare resource utilization in a large, integrated healthcare system. Proc (Bayl Univ Med Cent) 2022; 35:737-745. [PMID: 36304620 PMCID: PMC9586654 DOI: 10.1080/08998280.2022.2096370] [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] [Indexed: 11/15/2022] Open
Abstract
Limited data exist on asthma and chronic obstructive pulmonary disease (COPD) management—major drivers of healthcare resource utilization (HCRU) in the USA. We describe prevalence and exacerbation rates, therapeutic interventions, and HCRU for asthma and/or COPD within a large, integrated healthcare system. Patients with asthma, COPD, and asthma + COPD were identified from retrospective electronic health record data (2016–2018) of >1.7 million patients. Descriptive analysis of disease prevalence and exacerbation frequencies, pharmacotherapies, and HCRU was performed. Time-to-event analysis of time to first exacerbation was performed in patients with asthma and/or COPD. Exacerbation rates, pharmacotherapies, and HCRU were examined by exploratory analysis in an outpatient subset. Overall, 149,086 unique patients (8.6%) had encounters for asthma, COPD, or asthma + COPD. Acute care utilization was high, including emergency department visits (asthma, 52.9%; COPD, 35.1%) and hospitalizations (asthma, 26.7%; COPD, 65.7%). Many patients were prescribed short-acting therapies (asthma, 45.3%; COPD, 40.0%; asthma + COPD, 54.7%). Prescription rates for maintenance therapies were low (17.1%, 20.8%, 31.7%) and annual exacerbation rates were 0.65, 0.80, and 1.33. This analysis showed a substantive prevalence of pulmonary disease, variability between documented prescriptions and pharmacotherapy guidelines, and high HCRU. Appropriate tailoring of pharmacotherapies and management of asthma and COPD over a continuum are opportunities to improve patient care.
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Affiliation(s)
| | - Andrew L. Masica
- Baylor Scott & White Health, Dallas, Texas
- Texas Health Resources, Arlington, Texas
| | | | - Valentina Bayer
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | | | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
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22
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Lee DL, Baptist AP. Understanding the Updates in the Asthma Guidelines. Semin Respir Crit Care Med 2022; 43:595-612. [PMID: 35728605 DOI: 10.1055/s-0042-1745747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma is a chronic inflammatory lung disease that affects millions of Americans, with variable symptoms of bronchospasm and obstruction among individuals over time. The National Heart, Lung, and Blood Institute (NHLBI) published the 2020 Focused Updates to the Asthma Management Guidelines based on the latest research since the 2007 Expert Panel Report-3 (EPR-3). The following article reviews the 21 new recommendations on the six core topics in asthma: use of intermittent inhaled corticosteroids, long-acting muscarinic antagonist therapy, use of the fractional exhaled nitric oxide test in asthma diagnosis and monitoring, indoor allergen mitigation, immunotherapy, and bronchial thermoplasty. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to rate recommendations as strong or conditional based on the evidence. The recommendations were based on systematic reviews of the literature and focused on patient-centered critical outcomes of asthma exacerbations, asthma control, and asthma-related quality of life. Understanding the recommendations with consideration of individual values through shared decision-making may improve asthma outcomes.
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Affiliation(s)
- Deborah L Lee
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI
| | - Alan P Baptist
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI
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23
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Adejumo I, Patel M, McKeever TM, Shaw DE. Does inhaler technology improve adherence and asthma control? A pilot randomized controlled trial. Ann Allergy Asthma Immunol 2022; 128:727-729. [PMID: 35257874 DOI: 10.1016/j.anai.2022.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Ireti Adejumo
- NIHR Nottingham Respiratory Biomedical Research Centre, Department of Respiratory Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Mitesh Patel
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Tricia M McKeever
- NIHR Nottingham Respiratory Biomedical Research Centre, Department of Respiratory Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Dominick E Shaw
- NIHR Nottingham Respiratory Biomedical Research Centre, Department of Respiratory Medicine, University of Nottingham, Nottingham, United Kingdom
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24
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Singh D, Garcia G, Maneechotesuwan K, Daley-Yates P, Irusen E, Aggarwal B, Boucot I, Berend N. New Versus Old: The Impact of Changing Patterns of Inhaled Corticosteroid Prescribing and Dosing Regimens in Asthma Management. Adv Ther 2022; 39:1895-1914. [PMID: 35284999 PMCID: PMC9056489 DOI: 10.1007/s12325-022-02092-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
Abstract
Inhaled corticosteroid (ICS)-containing therapies are the mainstay of pharmacological management of asthma. They can be administered alone or in combination with a long-acting bronchodilator, depending on asthma severity, and may also be supplemented with short-acting bronchodilators for as-needed rescue medication. Adherence to asthma therapies is generally poor and characterized by underuse of ICS therapies and over-reliance on short-acting bronchodilators, which leads to poor clinical outcomes. This article reviews efficacy versus systemic activity profiles for various dosing regimens of budesonide (BUD) and fluticasone propionate (FP). We performed a structured literature review of BUD and FP regular daily dosing, and BUD/formoterol (FOR) as-needed dosing, to explore the relationship between various dosing patterns of ICS regimens and the risk–benefit profile in terms of the extent of bronchoprotection and cortisol suppression. In addition, we explored how adherence could potentially affect the risk–benefit profile, in patients with mild, moderate, and moderate-to-severe asthma. With a specific focus on BUD or FP-containing treatments, we found that regular daily ICS and ICS/long-acting β2-agonist (LABA) dosing had a greater degree of bronchoprotection than as-needed BUD/FOR dosing or BUD/FOR maintenance and reliever therapy (MART) dosing, and still maintained low systemic activity. We also found that the benefits of regular daily ICS dosing regimens were diminished when adherence was low (50%); the shorter duration of bronchoprotection observed was similar to that seen with typical as-needed BUD/FOR usage. These findings have implications for aiding clinicians with selecting the most suitable treatment option for asthma management, and subsequent implications for the advice clinicians give their patients. Inhaled corticosteroid (ICS)-containing therapies can be administered in a variety of ways depending on a patient’s asthma severity. Patients with mild asthma tend to experience symptom relief with as-needed or regular daily use of an ICS alone, whereas patients with more severe asthma may require regular daily use of an ICS plus a long-acting β2-agonist (LABA) to experience sufficient asthma control. However, failure to correctly adhere to ICS-containing therapies or an over-reliance on short-acting bronchodilators for symptom relief hinders optimal asthma management, thus negatively affecting overall patient health and wellbeing. Understanding how different dosing regimens affect the degree of bronchoprotection (efficacy) and cortisol suppression (systemic activity) of ICS treatments would benefit physicians by helping them to prescribe the most appropriate treatment for their patient’s asthma. We performed a structured literature review of two ICS molecules—budesonide (BUD) (alone and combined with formoterol [FOR]) and fluticasone propionate (FP)—to explore the relationship between various ICS dosing regimens, and then used these findings to construct models for ICS risk–benefit profiles. Our models factored in different ICS dosing regimens—as-needed, regular daily dosing, and maintenance and reliever therapy (MART)—and various degrees of treatment adherence. We found that regular daily ICS and ICS/LABA dosing provided better bronchoprotection than as-needed BUD/FOR dosing or BUD/FOR MART dosing, but this benefit was diminished with low adherence. Regular daily dosing maintained low cortisol suppression, which indicated a fairly low risk of negative side effects. Our findings have subsequent implications for optimizing treatment in patients with asthma.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Gabriel Garcia
- Pulmonary Chest Services, Hospital R Rossi, La Plata, Argentina
| | - Kittipong Maneechotesuwan
- Division of Respiratory Disease and Tuberculosis, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Peter Daley-Yates
- Clinical Pharmacology and Experimental Medicine, GlaxoSmithKline plc., Research and Development, Uxbridge, UK.
| | - Elvis Irusen
- Division of Pulmonology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- GlaxoSmithKline plc., Johannesburg, South Africa
| | - Bhumika Aggarwal
- Regional Respiratory Medical Affairs, GlaxoSmithKline plc., Singapore, 139234, Singapore
| | - Isabelle Boucot
- Regional Medical Affairs, GlaxoSmithKline plc., Brentford, UK
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Comparative efficacy of inhalers in mild-to-moderate asthma: systematic review and network meta-analysis. Sci Rep 2022; 12:5949. [PMID: 35396495 PMCID: PMC8993836 DOI: 10.1038/s41598-022-09941-z] [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: 09/17/2021] [Accepted: 03/24/2022] [Indexed: 12/03/2022] Open
Abstract
The comparative effectiveness of different inhaler therapies in mild-to-moderate asthma remains unclear. To assess this, we performed a systematic review and network meta-analysis of randomized controlled trials on the use of inhalers for mild-to-moderate asthma by searching PubMed, Cochrane, and Embase. A total of 29 trials including 43,515 patients and 12 types of inhaler therapies were included. For the prevention of severe and moderate-to-severe exacerbations, inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) as maintenance and reliever (SMART) showed the highest rank for effectiveness. As-needed ICS/LABA or short-acting β2-agonist (SABA) was similar to low-dose ICS and superior to as-needed SABA or LABA for the prevention of severe and moderate-severe exacerbations. As for lung function (FEV1), low-dose ICS/LABA had the highest rank; as-needed ICS/LABA was inferior to regular low-dose ICS but superior to placebo. Higher-dose ICS had a superior effect on the Asthma Control Questionnaire (ACQ) scores, and as-needed ICS/LABA and as-needed SABA or LABA had lower ranks in p-rankogram than did the regular use of low-dose ICS. As-needed ICS with LABA or SABA was more effective than a similar dose of regular ICS for preventing exacerbation in mild-to-moderate asthma. As-needed ICS showed some weakness in improving lung function and controlling asthma symptoms.
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26
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Agusti A, Fabbri L, Lahousse L, Singh D, Papi A. Single inhaler triple therapy (SITT) in asthma: Systematic review and practice implications. Allergy 2022; 77:1105-1113. [PMID: 34478578 PMCID: PMC9290056 DOI: 10.1111/all.15076] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
A significant number of patients with asthma remain uncontrolled despite treatment with inhaled corticosteroids (ICS) and long-acting β2 adrenergic bronchodilators (LABA). The addition of long-acting antimuscarinic agents (LAMA) can improve the management of asthma in these patients. Recently, three novel triple therapy (ICS/LABA/LAMA) formulations in a single-inhaler device (SITT) have been investigated in patients with uncontrolled asthma despite ICS/LABA treatment. Here, we review systematically the evidence available to date in relation to SITT in patients with uncontrolled asthma despite ICS-LABA treatment and conclude that SITT is a safe and effective therapeutic alternative in these patients. We also discuss how to position this new therapeutic alternative in their practical clinical management as well as the opportunities and challenges that it may generate for patients, physicians, and payers.
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Affiliation(s)
- Alvar Agusti
- Respiratory Institute IDIBAPS CIBERES Hospital ClinicUniv. Barcelona Barcelona Spain
| | - Leonardo Fabbri
- Section of Respiratory Medicine Department of Morphology, Surgery and Experimental Medicine University of Ferrara Ferrara Italy
| | - Lies Lahousse
- Department of Bioanalysis Ghent University Ghent Belgium
| | - Dave Singh
- Medicines Evaluation Unit University of ManchesterManchester University NHS Foundation Trust Manchester UK
| | - Alberto Papi
- Emergency Department, Respiratory Medicine University of FerraraUniversity Hospital S. Anna Ferrara Italy
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27
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Beasley R, Harrison T, Peterson S, Gustafson P, Hamblin A, Bengtsson T, Fagerås M. Evaluation of Budesonide-Formoterol for Maintenance and Reliever Therapy Among Patients With Poorly Controlled Asthma: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e220615. [PMID: 35230437 PMCID: PMC8889464 DOI: 10.1001/jamanetworkopen.2022.0615] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE The Global Initiative for Asthma (GINA) recommends 2 alternative treatments for patients receiving treatment at steps 3 to 5: single inhaler combination inhaled corticosteroid-formoterol as both maintenance and reliever (SMART) or inhaled corticosteroid-long-acting β2-agonist as maintenance plus short-acting β2-agonist as reliever. OBJECTIVE To assess whether switching to SMART is associated with longer time to first severe asthma exacerbation compared with a step up or continuation of GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever among patients with poorly controlled asthma. DATA SOURCES For this systematic review and meta-analysis, the literature, internal study databases at AstraZeneca and the Medical Research Institute of New Zealand, and references from a previous systematic review and meta-analysis on SMART were searched to identify randomized clinical trials published from January 1990 to February 2018, that compared budesonide-formoterol by SMART with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever. STUDY SELECTION Trials of at least 24 weeks' duration were included if they reported baseline data on GINA treatment step, asthma control status, and efficacy measures of severe exacerbations. Included patients were adults and adolescents with asthma and baseline Asthma Control Questionnaire 5-item version scores of 1.5 or higher. DATA EXTRACTION AND SYNTHESIS Patient-level data were identified by independent extraction, and analyses were performed using a fixed-effect model. Data analysis was performed from August 2018 to November 2021. MAIN OUTCOMES AND MEASURES The primary outcome was time to first severe asthma exacerbation associated with each treatment, analyzed by Cox proportional hazards regression. RESULTS Overall, 4863 patients were included (3034 [62.4%] female; mean [SD] age, 39.8 [16.3] years). Switching patients with uncontrolled asthma at GINA step 3 (n = 1950) to SMART at either step 3 or 4 was associated with a prolonged time to first severe asthma exacerbation, with a 29% reduced risk compared with stepping up to step 4 inhaled corticosteroid-long-acting β2-agonist maintenance plus short-acting β2-agonist reliever (hazard ratio, 0.71; 95% CI, 0.52-0.97). For patients with uncontrolled asthma at step 3 and step 4 (n = 2913), switching to SMART was associated with a prolonged time to first severe asthma exacerbation and a 30% reduced risk compared with remaining at the same treatment step (hazard ratio, 0.70; 95% CI, 0.58-0.85). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, for patients with poorly controlled asthma, SMART was associated with longer time to first severe asthma exacerbation compared with a step up or continuation of GINA step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever. These findings suggest that if an adult or adolescent receiving treatment at GINA step 3 or 4 has poorly controlled asthma, it is preferable to switch to the SMART regimen rather than to step up or continue the GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever therapy.
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Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
- Victoria University Wellington, Wellington, New Zealand
| | - Tim Harrison
- Nottingham National Institute for Health Research Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom
- Digital Health Research & Development, AstraZeneca, Cambridge, United Kingdom
| | | | - Per Gustafson
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Angus Hamblin
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom
| | | | - Malin Fagerås
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
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SMART - is it practical in the United States? Curr Opin Pulm Med 2022; 28:245-250. [PMID: 35131990 DOI: 10.1097/mcp.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The 2020 focused updates to the asthma management guidelines by the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group advocate for inhaled corticosteroid (ICS)-formoterol combinations as single maintenance and reliever therapy (SMART) for patients with persistent asthma. We review the rationale, the evidence supporting SMART use in asthma, and barriers limiting its wide adoption in the United States. RECENT FINDINGS A growing body of evidence supports the use of SMART over the conventional use of controller medicaments with an as-needed short-acting β2 agonist for rescue therapy for the purpose of reducing the risk of asthma exacerbation and maintaining asthma control in adolescents and adults with persistent disease. Lack of US Food and Drug Administration approval, inconsistent insurance coverage, and limited options of ICS-formoterol combination available for use as SMART represent obstacles to wider integration of SMART in clinical practice. SUMMARY SMART represents a paradigm shift in asthma management. By identifying and addressing the current and anticipated barriers to implementing SMART, its adoption by providers is likely to increase in the United States.
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma Strategy 2021. Executive Summary and Rationale for Key Changes. Arch Bronconeumol 2022; 58:35-51. [DOI: 10.1016/j.arbres.2021.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022]
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Bao W, Zhang Y, Hang J, Guo Y, Tang W, Yun C, Deng J, Jin M, Lai K, Yu H, Beekman M, Zhou X, Zhang M. Short-acting beta-2 agonist prescription patterns and clinical outcomes in Chinese patients with asthma: an observational study in mainland China for the SABINA programme. Ther Adv Respir Dis 2022; 16:17534666221115054. [PMID: 36065527 PMCID: PMC9449520 DOI: 10.1177/17534666221115054] [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] [Indexed: 11/18/2022] Open
Abstract
Objectives: The SABINA CHINA study aimed to determine prescription data for asthma
medication with a focus on SABA and ICS in a representative population of
patients with asthma in China. Methods: SABINA China was a multicentre, observational, cross-sectional study with
data collected retrospectively from a convenience sample of 25 tertiary
centres across China. Patients (age ⩾ 12 years) with ⩾3 consultations/year
were enrolled. Data were collected on clinical characteristics, asthma
severity, and symptom control (as per GINA 2017), treatment and history of
severe exacerbations over the past year. SABA over-prescription was defined
as ⩾3 SABA canisters/year. Descriptive statistics are presented. Results: Between March and August 2020, 498 patients were included in the outcome
analysis. Mean (SD) age was 48.7 (15.0) years, 57.9% were female and 91% had
moderate-to-severe asthma (n = 453). Overall, 12.5%
(n = 62) and 26.4% (n = 131) of
patients had uncontrolled and partly controlled asthma, respectively. SABA
add-on was prescribed to 20.3% (n = 101) of patients; one
patient with moderate-to-severe asthma was prescribed SABA-alone. SABA
over-prescription in the overall population was 4.0%
(n = 20; all with moderate-to-severe asthma) and 19.8%
(20/101) among those prescribed SABA add-on. In the mild asthma group, 50%
(n = 22) were prescribed ICS/LABA and 43.2%
(n = 19) were prescribed LTRA. Among those with
moderate-to-severe asthma, 97.4% (n = 441) were prescribed
ICS/LABA and 55.0% (n = 249) were prescribed LTRA.
Approximately 30% of patients (n = 149) experienced ⩾1% and
6.6% (n = 33) ⩾3 severe exacerbations in the preceding
year; mean annual number of severe exacerbation/patient was 0.6 (1.2). Among
those prescribed SABA add-on, ICS/LABA and LTRA (non-mutually exclusive
groups due to overlapping prescriptions), 54.5%, 29.9%, and 35.3% had ⩾1
severe exacerbations, respectively. Conclusion: Among patients with predominantly moderate-to-severe asthma managed in
tertiary care and were prescribed SABA, 1 in 5 received ⩾3 canisters/year.
Fewer patients who received ICS/LABA prescriptions experienced annual
exacerbations than those prescribed SABA add-on.
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Affiliation(s)
- Wuping Bao
- Department of Pulmonary and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yingying Zhang
- Department of Pulmonary and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingqing Hang
- Department of Pulmonary and Critical Care Medicine, Shanghai Putuo District People's Hospital, Shanghai, China
| | - Yubiao Guo
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Tang
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chunmei Yun
- Department of Pulmonary and Critical Care Medicine, Inner Mongolia Autonomous Region People's Hospital, Hohhot, China
| | - Jingmin Deng
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Meiling Jin
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kefang Lai
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Huapeng Yu
- Department of Pulmonary and Critical Care Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Maarten Beekman
- International Medical Respiratory & Immunology, AstraZeneca Netherlands, The Hague, The Netherlands
| | - Xin Zhou
- Department of Pulmonary and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, No. 100, Haining Road, Shanghai 200080, China
| | - Min Zhang
- Department of Pulmonary and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, No. 100, Haining Road, Shanghai 200080, China
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Modification of Apremilast from Pills to Aerosol a Future Concept. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111590. [PMID: 34770103 PMCID: PMC8582726 DOI: 10.3390/ijerph182111590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/22/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022]
Abstract
Background: Inhaled drugs have been available in the market for several years and for several diseases. Drugs for chronic obstructive pulmonary disease, cystic fibrosis, and diabetes have been used for several years. In the field of drug modification, these drugs range from tablets to aerosol. Methods: Milling as used to break down the tablets to powder and nebulisers are used to produce aerosol droplets. A mastersizer was used to measure the mass median aerodynamic diameter of the aerosol droplets. Results: Apremilast produced mmad diameters (2.43 μm) without any statistical difference between the different jet-nebulizers. The residual cup B contributed to greater mmad diameters as the 95% interval of mean values, based on those the ANOVA mean square clearly indicated, followed by cups C and F. The previous interval plot is much better clarified when the interaction means between drug and residual cap are plotted. The residual cups B, C and F produce mmad between (2.0–3.2). Conclusion: In the current research study we demonstrated our methodology to create apremilast powder and produce apremilast aerosol droplets with different nebulisers and residual cups.
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Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:S1-S18. [PMID: 34718211 DOI: 10.1016/j.jaip.2021.10.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. Eur Respir J 2021; 59:13993003.02730-2021. [PMID: 34667060 PMCID: PMC8719459 DOI: 10.1183/13993003.02730-2021] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes.GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as- needed combination ICS-formoterol reduces severe exacerbations by >60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA.Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4.Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia.
| | - Leonard B Bacharier
- Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Guy G Brusselle
- Ghent University Hospital, Ghent, Belgium and Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Liesbeth Duijts
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Fanny W Ko
- The Chinese University of Hong Kong, Hong Kong
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, USA
| | | | - Jiangtao Lin
- China-Japan Friendship Hospital, Peking University, Beijing, China
| | | | | | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, United Kingdom
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. Respirology 2021; 27:14-35. [PMID: 34668278 DOI: 10.1111/resp.14174] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as- needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia
| | - Leonard B Bacharier
- Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Guy G Brusselle
- Ghent University Hospital, Ghent, Belgium and Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Liesbeth Duijts
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Fanny W Ko
- The Chinese University of Hong Kong, Hong Kong
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, USA
| | | | - Jiangtao Lin
- China-Japan Friendship Hospital, Peking University, Beijing, China
| | | | | | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, United Kingdom
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive Summary and Rationale for Key Changes. Am J Respir Crit Care Med 2021; 205:17-35. [PMID: 34658302 PMCID: PMC8865583 DOI: 10.1164/rccm.202109-2205pp] [Citation(s) in RCA: 162] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults/adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Affiliation(s)
- Helen K Reddel
- The University of Sydney, 4334, Woolcock Institute of Medical Research,, Sydney, New South Wales, Australia;
| | - Leonard B Bacharier
- Vanderbilt University Medical Center, 12328, Monroe Carell Jr Children's Hospital , Nashville, Tennessee, United States
| | - Eric D Bateman
- University of Cape Town Department of Medicine, 71984, Observatory, Western Cape, South Africa
| | - Christopher E Brightling
- NIHR Leicester Biomedical Research Centre, 573772, Leicester, United Kingdom of Great Britain and Northern Ireland
| | - Guy G Brusselle
- University Hospital Ghent, 60200, Ghent, Belgium and Erasmus MC University Medical Center, Rotterdam, Belgium
| | - Roland Buhl
- Mainz University Hospital, Pulmonary Department, Mainz, Germany
| | - Alvaro A Cruz
- Universidade Federal da Bahia, 28111, ProAR-Center of Excellence in Asthma, Salvador, Brazil
| | - Liesbeth Duijts
- Erasmus MC, 6993, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - J Mark FitzGerald
- The University of British Columbia, 8166, Vancouver, British Columbia, Canada
| | - Louise J Fleming
- Imperial College London, 4615, London, United Kingdom of Great Britain and Northern Ireland
| | | | - Fanny W Ko
- The Chinese University of Hong Kong, 26451, Hong Kong, Hong Kong
| | - Jerry A Krishnan
- University of Illinois at Chicago, 14681, Breathe Chicago Center, Chicago, Illinois, United States
| | - Mark L Levy
- Locum GP, London, United Kingdom of Great Britain and Northern Ireland
| | - Jiangtao Lin
- Peking University, 12465, China-Japan Friendship Hospital, Beijing, China
| | - Kevin Mortimer
- Liverpool School of Tropical Medicine, 9655, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Paulo M Pitrez
- Hospital Moinhos de Vento, 156417, Porto Alegre, Rio Grande do Sul, Brazil
| | - Aziz Sheikh
- The University of Edinburgh, 3124, Usher Institute, Edinburgh, United Kingdom of Great Britain and Northern Ireland
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Reddel HK, Bateman ED, Schatz M, Krishnan JA, Cloutier MM. A Practical Guide to Implementing SMART in asthma management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:S31-S38. [PMID: 34666208 DOI: 10.1016/j.jaip.2021.10.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022]
Abstract
The use of a single inhaler containing the combination of an inhaled corticosteroid (ICS) and formoterol, a specific long-acting bronchodilator, for both maintenance and quick relief therapy (single maintenance and reliever therapy [SMART or MART]) is recommended by both the Global Initiative for Asthma and the National Asthma Education and Prevention Program Coordinating Committee in steps 3 and 4 of asthma management. This article provides practical advice about implementing SMART in clinical practice based on evidence and clinical experience. Fundamental to SMART is that ICS-formoterol provides quick relief of asthma symptoms similar to that of short-acting β2-agonists such as albuterol, while reducing the risk for severe asthma exacerbations and at an overall lower ICS exposure. Most SMART clinical trials were in adults and adolescents (aged ≥12 years), using budesonide-formoterol 160/4.5 μg (delivered dose), one inhalation once or twice daily (step 3) and two inhalations twice daily (step 4). For both steps 3 and 4, patients take additional inhalations of budesonide-formoterol 160/4.5 μg, one inhalation whenever needed for symptom relief, up to a maximum for adults and adolescents of 12 total inhalations in any single day (delivering 54 μg formoterol). The efficacy and safety of SMART with budesonide-formoterol and beclometasone-formoterol have been confirmed, but other ICS-long-acting bronchodilator combinations have not been studied. The SMART regimen should be introduced with a careful explanation of its role in self-management, preferably with a customized written asthma action plan. The cost to patients and the availability of SMART treatment will depend on the prescribed dose and national or local payer agreements.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research and University of Sydney, Sydney, Australia.
| | - Eric D Bateman
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Care Program, San Diego, Calif
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, Ill
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O'Carroll O, McCarthy C, Butler MW. Treatments for poorly controlled asthma. BMJ 2021; 375:n2355. [PMID: 34607802 DOI: 10.1136/bmj.n2355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Orla O'Carroll
- Department of Respiratory and Sleep Medicine, St Vincent's University Hospital, Dublin, Republic of Ireland
| | - Cormac McCarthy
- Department of Respiratory and Sleep Medicine, St Vincent's University Hospital, Dublin, Republic of Ireland
- School of Medicine, University College Dublin, Dublin, Republic of Ireland
| | - Marcus W Butler
- Department of Respiratory and Sleep Medicine, St Vincent's University Hospital, Dublin, Republic of Ireland
- School of Medicine, University College Dublin, Dublin, Republic of Ireland
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Canonica GW, Paggiaro P, Blasi F, Musarra A, Richeldi L, Rossi A, Papi A. Manifesto on the overuse of SABA in the management of asthma: new approaches and new strategies. Ther Adv Respir Dis 2021; 15:17534666211042534. [PMID: 34587829 PMCID: PMC8488406 DOI: 10.1177/17534666211042534] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The risks of overusing short-acting β2-agonists (SABA), including an
increase in asthma-related deaths, are many and well known. The Global
Initiative on Asthma (GINA) 2019 and 2020 updates recommend as-needed inhaled
corticosteroid (ICS)/formoterol as the preferred rescue medication in mild
asthma as monotherapy and also in moderate to severe asthma when the maintenance
and reliever therapy (MART) strategy is used. Using SABA for symptom relief,
however, was the standard of treatment for many years, and consequently this
practice persists, particularly in patients not taking ICS regularly. Here, we
examine the rationale for this shift from a long-standing recommendation for
as-needed SABA treatment to the use of as-needed ICS/formoterol and consider
clinical evidence on strategies for asthma treatment and patient management.
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Affiliation(s)
- Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Personalized Medicine, Asthma and Allergy, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Italy
| | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Rossi
- Pulmonary Unit, Azienda Ospedaliera Universitaria Integrata and University of Verona, Verona, Italy
| | - Alberto Papi
- Research Center on Asthma and COPD, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Rogliani P, Beasley R, Cazzola M, Calzetta L. SMART for the treatment of asthma: A network meta-analysis of real-world evidence. Respir Med 2021; 188:106611. [PMID: 34536699 DOI: 10.1016/j.rmed.2021.106611] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/04/2021] [Indexed: 11/17/2022]
Abstract
A large proportion of asthmatic patients are treated with protocols resulting from data obtained by randomized controlled trials (RCTs) for which they would not have been eligible. Therefore, the aim of this study was to undertake a quantitative synthesis on real-world evidence comparing single inhaled corticosteroid (ICS)/formoterol maintenance and reliever therapy (SMART) and maintenance ICS/long-acting β2-adrenoceptor agonist (LABA) + as-needed short-acting β2-adrenoceptor agonist (SABA). A network meta-analysis of real-world studies was performed to compare SMART with ICS/LABA + as-needed SABA therapies in asthmatic patients. The surface under the cumulative ranking curve analysis was used to rank efficacy. The posterior probability distribution was reported as 95% credible interval (95%CrI). Data of 11,360 asthmatic patients were extracted from 6 studies. SMART including an ICS at medium-dose (MD) was more effective than MD ICS/LABA FDC + as-needed SABA (RR 0.54 95%CrI 0.42-0.69; P < 0.001) and low-dose (LD) SMART (RR 0.82 95%CrI 0.70-0.95; P < 0.05) against severe asthma exacerbation. MD SMART improved the Asthma Control Questionnaire score more than MD ICS/LABA FDC + as-needed SABA (delta effect -0.33 95%CrI -0.62 to -0.01; P < 0.05). The efficacy rank was: MD SMART > LD SMART > ICS + LABA free combination + as-needed SABA > ICS/LABA FDC + as-needed SABA > MD ICS/LABA FDC + as-needed SABA. The findings of this network meta-analysis of real-world evidence, and concordance with the effect estimates resulting from previous meta-analyses of RCTs, suggest that SMART may represent the preferred therapeutic option to reduce the risk of severe exacerbation in adults with moderate to severe asthma.
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Affiliation(s)
- Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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How I do it. Work-up of severe asthma. Chest 2021; 160:2019-2029. [PMID: 34265308 DOI: 10.1016/j.chest.2021.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 11/22/2022] Open
Abstract
CASE EXAMPLE A 56-year-old gentleman has difficult to control asthma and a history of four exacerbations in the prior 12 months despite high-dose inhaled corticosteroids (ICS) and additional controller therapies. Is he suitable for more advanced therapeutic options? SCOPE OF REVIEW We herein review the clinical assessment of a patient with suspected severe asthma, discuss factors contributing to poor asthma control and how biomarkers assist in disease investigation and stratification. HOW I DO IT The key components of our multidisciplinary approach are to confirm an asthma diagnosis and adherence to treatment, to assess any contributing comorbidities or confounding factors, and to stratify what type of asthma our patient has. The combination of spirometry and repeated measures of key biomarkers of type-2 airway inflammation - the blood eosinophil count and fractional exhaled nitric oxide - identifies whether poor disease control is driven by uncontrolled, ICS-resistant type-2 airway inflammation or ongoing airflow obstruction. A failure to elicit evidence of either suggests an alternative driver for the patient's symptoms including chronic airway infection and non-asthma causes. Each phenotype represents a treatable trait that requires a specific targeted approach. Critically, steroids can cause harm and their use should be guided by objective evidence of inflammation rather than symptoms alone. CASE CONCLUSION After assessment of treatment adherence and exclusion of relevant comorbidities, the patient was found to have severe asthma with ICS-resistant type-2 airway inflammation. We will consider additional treatment options at our next appointment (Part 2/2 of this How I Do It series).
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Tong X, Liu T, Li Z, Liu S, Fan H. Is It Really Feasible to Use Budesonide-Formoterol as Needed for Mild Persistent Asthma? A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:644629. [PMID: 34149408 PMCID: PMC8213339 DOI: 10.3389/fphar.2021.644629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/19/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Previous studies suggest that inhaled budesonide-formoterol used as needed could effectively reduce the severe exacerbation of mild persistent asthma. However, there are some differences between these studies, so we conducted a meta-analysis. Methods: We searched PubMed, Ovid MEDLINE, Cochrane Library and several web search engines to screen the literature until March 25, 2020 and used risk ratios (RR), odds ratios, hazard ratios (HR) and weighted mean differences with 95% confidence intervals (CI) to evaluate the pooled effects. Adolescent/adult patients with mild persistent asthma who used budesonide-formoterol as needed were included in this study. The primary outcome was to investigate the superiority of budesonide-formoterol as needed in reducing severe exacerbations in patients with mild persistent asthma. STATA 12.0 software was used for statistical analysis. Results: Across all 4 articles, 4,023 patients used budesonide-formoterol as needed (budesonide-formoterol group), 4,042 patients used budesonide maintenance plus short-acting β2-agonist (SABA) as needed (budesonide group), and 1,500 patients used SABA as needed (SABA group). The results showed that the incidence of severe exacerbations and the time to first severe exacerbation in the budesonide-formoterol group were significantly different from those for the SABA group (RR = 0.46, 95% CI = 0.36-0.59, p < 0.001; HR = 0.43, 95% CI = 0.33-0.56, p < 0.001; respectively), but there was no difference between the budesonide-formoterol group and budesonide group (RR = 0.86, 95% CI = 0.62-1.04, p = 0.093; HR = 0.77, 95% CI = 0.57-1.03, p = 0.079; respectively). There were statistically significant differences in the forced expiratory volume in 1 second and in the responses to the Asthma Control Questionnaire-5 between the budesonide-formoterol group and the SABA group, but the differences were not clinically significant. In addition, the daily dose of budesonide in the budesonide-formoterol group was significantly lower than that in the budesonide group, and there was no difference in the incidence of adverse events among the three groups. Conclusion: In summary, budesonide-formoterol used as needed may reduce severe exacerbation in adolescent/adult patients with mild persistent asthma.
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Affiliation(s)
- Xiang Tong
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Tao Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Zhenzhen Li
- Health Management Center, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Sitong Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
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Hendeles L, Blake KV, Galbreath A. A Single Inhaler Combining a Corticosteroid and Long-Acting Beta-2 Agonist for Maintenance with Additional Doses for Reliever Therapy (SMART): Obstacles for Asthma Patients in the USA. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2021; 34:73-75. [PMID: 34143685 DOI: 10.1089/ped.2021.0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Leslie Hendeles
- College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Kathryn V Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health, Jacksonville, Florida, USA
| | - Ashley Galbreath
- College of Pharmacy, University of Florida College of Pharmacy, Gainesville, Florida, USA
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Crossingham I, Turner S, Ramakrishnan S, Fries A, Gowell M, Yasmin F, Richardson R, Webb P, O'Boyle E, Hinks TS. Combination fixed-dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database Syst Rev 2021; 5:CD013518. [PMID: 33945639 PMCID: PMC8096360 DOI: 10.1002/14651858.cd013518.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Asthma affects 350 million people worldwide including 45% to 70% with mild disease. Treatment is mainly with inhalers containing beta₂-agonists, typically taken as required to relieve bronchospasm, and inhaled corticosteroids (ICS) as regular preventive therapy. Poor adherence to regular therapy is common and increases the risk of exacerbations, morbidity and mortality. Fixed-dose combination inhalers containing both a steroid and a fast-acting beta₂-agonist (FABA) in the same device simplify inhalers regimens and ensure symptomatic relief is accompanied by preventative therapy. Their use is established in moderate asthma, but they may also have potential utility in mild asthma. OBJECTIVES To evaluate the efficacy and safety of single combined (fast-onset beta₂-agonist plus an inhaled corticosteroid (ICS)) inhaler only used as needed in people with mild asthma. SEARCH METHODS We searched the Cochrane Airways Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase, ClinicalTrials.gov and the World Health Organization (WHO) trials portal. We contacted trial authors for further information and requested details regarding the possibility of unpublished trials. The most recent search was conducted on 19 March 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cross-over trials with at least one week washout period. We included studies of a single fixed-dose FABA/ICS inhaler used as required compared with no treatment, placebo, short-acting beta agonist (SABA) as required, regular ICS with SABA as required, regular fixed-dose combination ICS/long-acting beta agonist (LABA), or regular fixed-dose combination ICS/FABA with as required ICS/FABA. We planned to include cluster-randomised trials if the data had been or could be adjusted for clustering. We excluded trials shorter than 12 weeks. We included full texts, abstracts and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We analysed dichotomous data as odds ratios (OR) or rate ratios (RR) and continuous data as mean difference (MD). We reported 95% confidence intervals (CIs). We used Cochrane's standard methodological procedures of meta-analysis. We applied the GRADE approach to summarise results and to assess the overall certainty of evidence. Primary outcomes were exacerbations requiring systemic steroids, hospital admissions/emergency department or urgent care visits for asthma, and measures of asthma control. MAIN RESULTS We included six studies of which five contributed results to the meta-analyses. All five used budesonide 200 μg and formoterol 6 μg in a dry powder formulation as the combination inhaler. Comparator fast-acting bronchodilators included terbutaline and formoterol. Two studies included children aged 12+ and adults; two studies were open-label. A total of 9657 participants were included, with a mean age of 36 to 43 years. 2.3% to 11% were current smokers. FABA / ICS as required versus FABA as required Compared with as-required FABA alone, as-required FABA/ICS reduced exacerbations requiring systemic steroids (OR 0.45, 95% CI 0.34 to 0.60, 2 RCTs, 2997 participants, high-certainty evidence), equivalent to 109 people out of 1000 in the FABA alone group experiencing an exacerbation requiring systemic steroids, compared to 52 (95% CI 40 to 68) out of 1000 in the FABA/ICS as-required group. FABA/ICS as required may also reduce the odds of an asthma-related hospital admission or emergency department or urgent care visit (OR 0.35, 95% CI 0.20 to 0.60, 2 RCTs, 2997 participants, low-certainty evidence). Compared with as-required FABA alone, any changes in asthma control or spirometry, though favouring as-required FABA/ICS, were small and less than the minimal clinically-important differences. We did not find evidence of differences in asthma-associated quality of life or mortality. For other secondary outcomes FABA/ICS as required was associated with reductions in fractional exhaled nitric oxide, probably reduces the odds of an adverse event (OR 0.82, 95% CI 0.71 to 0.95, 2 RCTs, 3002 participants, moderate-certainty evidence) and may reduce total systemic steroid dose (MD -9.90, 95% CI -19.38 to -0.42, 1 RCT, 443 participants, low-certainty evidence), and with an increase in the daily inhaled steroid dose (MD 77 μg beclomethasone equiv./day, 95% CI 69 to 84, 2 RCTs, 2554 participants, moderate-certainty evidence). FABA/ICS as required versus regular ICS plus FABA as required There may be little or no difference in the number of people with asthma exacerbations requiring systemic steroid with FABA/ICS as required compared with regular ICS (OR 0.79, 95% CI 0.59 to 1.07, 4 RCTs, 8065 participants, low-certainty evidence), equivalent to 81 people out of 1000 in the regular ICS plus FABA group experiencing an exacerbation requiring systemic steroids, compared to 65 (95% CI 49 to 86) out of 1000 FABA/ICS as required group. The odds of an asthma-related hospital admission or emergency department or urgent care visit may be reduced in those taking FABA/ICS as required (OR 0.63, 95% CI 0.44 to 0.91, 4 RCTs, 8065 participants, low-certainty evidence). Compared with regular ICS, any changes in asthma control, spirometry, peak flow rates (PFR), or asthma-associated quality of life, though favouring regular ICS, were small and less than the minimal clinically important differences (MCID). Adverse events, serious adverse events, total systemic corticosteroid dose and mortality were similar between groups, although deaths were rare, so confidence intervals for this analysis were wide. We found moderate-certainty evidence from four trials involving 7180 participants that FABA/ICS as required was likely associated with less average daily exposure to inhaled corticosteroids than those on regular ICS (MD -154.51 μg/day, 95% CI -207.94 to -101.09). AUTHORS' CONCLUSIONS We found FABA/ICS as required is clinically effective in adults and adolescents with mild asthma. Their use instead of FABA as required alone reduced exacerbations, hospital admissions or unscheduled healthcare visits and exposure to systemic corticosteroids and probably reduces adverse events. FABA/ICS as required is as effective as regular ICS and reduced asthma-related hospital admissions or unscheduled healthcare visits, and average exposure to ICS, and is unlikely to be associated with an increase in adverse events. Further research is needed to explore use of FABA/ICS as required in children under 12 years of age, use of other FABA/ICS preparations, and long-term outcomes beyond 52 weeks.
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Affiliation(s)
| | - Sally Turner
- East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Sanjay Ramakrishnan
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Anastasia Fries
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Matthew Gowell
- New College, University of Oxford Medical School, Oxford, UK
| | | | | | - Philip Webb
- East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Emily O'Boyle
- New College, University of Oxford Medical School, Oxford, UK
| | - Timothy Sc Hinks
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Aisanov ZR, Avdeev SN, Arkhipov VV, Belevsky AS, Voznesenskiy NA. Peculiarities of Mild Asthma in Russia: the Results of SYGMA2 Study. TERAPEVT ARKH 2021; 93:449-455. [DOI: 10.26442/00403660.2021.04.200812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
Aim. Patients with mild asthma may experience severe exacerbations. This analysis was conducted to investigate regional peculiarities of mild asthma population in Russia.
Materials and methods. The SYGMA2 is a double-blind multinational study involving adult patients with mild asthma (n=4176). We conducted an open-label descriptive analysis of the baseline characteristics of the Russian group (n=579) of SYGMA2 trial comparing to SYGMA2 population from other countries. The subanalysis was descriptive only, and no hypothesis were tested.
Results. The Russian population of patients with mild asthma was comparable to the rest of countries in terms of demographic characteristics, smoking status and duration of asthma. The spirometric parameters in the Russian group was slightly worse than in the other population. At the study entry 48% of Russian patients had symptom control on maintenance therapy, but 52% were uncontrolled on short-acting bronchodilators. While in other countries this ratio was inverse (55/45%). More patients with mild asthma in the Russian group had at least one severe exacerbation in the previous year (30.1% vs 20.7% in other countries).
Conclusion. We revealed a delayed prescription of controller therapy and overuse of short-acting bronchodilators in the Russian group of mild asthma patients, that may increase risk of asthma non-control and severe exacerbation.
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Aisanov Z, Avdeev S, Arkhipov V, Belevsky A. SYmbicort given as needed in mild asthma (SYGMA study): a retrospective subanalysis of the Russian population. J Asthma 2021; 59:989-997. [PMID: 33600729 DOI: 10.1080/02770903.2021.1892753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION While mild asthma is generally better controlled than more severe disease, patients with mild asthma may experience severe exacerbations. Definite differences between countries in terms of asthma severity and control were described previously. Since SYGMA was a global study, this sub-analysis was conducted in geographic region to investigate potential regional specificities. METHODS The SYGMA2 trial is double-blind multicenter study involving patients ≥12 years of age with mild asthma (n = 4176), eligible for regular treatment with inhaled corticosteroid (ICS). We conducted an open-label descriptive subanalysis of the baseline characteristics of the Russian population (n = 579) comparing to rest of participants of SYGMA2 trial from other 24 countries. The subanalysis is solely descriptive and will be used for hypothesis generation. RESULTS The Russian population of patients with mild asthma hardly differs from the population in other countries in terms of baseline demographic and anthropometric characteristics, smoking status, and duration of asthma. At the study entry few patients from Russia received maintenance therapy with ICS and had symptom control, but the majority was uncontrolled on short-acting bronchodilators, thus the uncontrolled/controlled ratio was 52%/48% vs 45%/55% in other countries. More patients with mild asthma in the Russian group had faced at least one severe exacerbation in the previous year (30.1% vs 20.7%). CONCLUSIONS The subanalysis revealed a delayed prescription of controller (ICS) therapy and overuse of short-acting bronchodilators in the Russian population with mild asthma. These factors can lead to insufficient symptom control and higher risk of severe exacerbation in the Russian population with mild asthma.
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Affiliation(s)
- Zaurbek Aisanov
- Pulmonology Department, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Sergey Avdeev
- Pulmonology Department, I M Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Vladimir Arkhipov
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuing Professional Education, Moscow, Russian Federation
| | - Andrey Belevsky
- Pulmonology Department, Pirogov Russian National Research Medical University, Moscow, Russian Federation
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Lugogo N, Gilbert I, Tkacz J, Gandhi H, Goshi N, Lanz MJ. Real-world patterns and implications of short-acting β 2-agonist use in patients with asthma in the United States. Ann Allergy Asthma Immunol 2021; 126:681-689.e1. [PMID: 33515710 DOI: 10.1016/j.anai.2021.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/18/2020] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Short-acting β2-agonist (SABA) use is one measure reflecting asthma control. OBJECTIVE To evaluate the associations between real-world SABA use and severe asthma exacerbations in the United States. METHODS Patients with asthma 12 years of age or older receiving SABA in the IBM MarketScan research databases of US administrative claims from September 30, 2014, to September 30, 2016, were evaluated. Patients with 12 months' continuous eligibility before and after their first SABA claim (index SABA), an asthma diagnosis before through 60 days postindex, and either one additional SABA or at least 1 maintenance fill(s) were included. SABA claims postindex (including index fill) were grouped as follows: low: index only; medium: 2 to 3 canisters per year; and high: 4 or more canisters per year. Differences in SABA exposure with respect to disease severity groups and severe asthma exacerbations (hospitalizations, emergency visits, or outpatient systemic corticosteroids) were analyzed by analysis of variance and χ2 (significance, P ≤ .05). RESULTS A total of 135,540 patients were included: 62.8% women; mean (SD) age, 40.9 (18.3) years; SABA fills per 12-months postindex: 3.0(2.7). Furthermore, 28% of patients filled 1 SABA, 47% 2 to 3, and 25% 4 or more canisters per year. Despite higher maintenance medication possession ratio with increasing SABA (low, 0.53 (0.37); medium, 0.59 (0.35); high, 0.66 (0.32)), annual exacerbation rate per person per year and percent of patients within each SABA group having at least 1 exacerbation rose as SABA fills increased (low, 1.00 (1.45), 45.8%; medium, 1.20 (1.62), 54.3%; high, 1.50 (1.94), 58.7%). Mean SABA fills differed between patients with 0 exacerbation, 2.8 (2.6); 1 exacerbation, 2.9 (2.5); and 2 or more exacerbations, 3.3 (2.9). CONCLUSION Exacerbation risk increased with increasing SABA fills. Management strategies ensuring adequate anti-inflammatory therapy delivered to the airways when symptoms occur may be needed to mitigate asthma morbidity.
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Affiliation(s)
- Njira Lugogo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ileen Gilbert
- BioPharmaceuticals Medical - USA, AstraZeneca, Wilmington, Delaware.
| | - Joseph Tkacz
- Life Sciences, IBM Watson Health, Cambridge, Massachusetts
| | - Hitesh Gandhi
- BioPharmaceuticals Medical - USA, AstraZeneca, Wilmington, Delaware
| | - Nadia Goshi
- BioPharmaceuticals Global Medicines Development - US, AstraZeneca, Wilmington, DE
| | - Miguel J Lanz
- Allergy and Asthma, AAADRS Clinical Research Center, Coral Gables, Florida
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Fukahori S, Kawano T, Obase Y, Iriki J, Tsuchida-Yabe T, Tomari S, Fukushima C, Matsuse H, Mukae H. Comparison of 12-Week Additional Effect Features of Formoterol Co-Inhalation and Tulobuterol Patch on Budesonide Inhalation in Elderly Patients With Asthma. ALLERGY & RHINOLOGY 2020; 11:2152656720980416. [PMID: 33403154 PMCID: PMC7739199 DOI: 10.1177/2152656720980416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background For asthma strategy, to avoid the aggravation of bronchial inflammation and contraction, the long acting beta agonist (LABA) addition on inhaled corticosteroids (ICS) has been recommended. Objectives To know whether there is any clinical difference between the additional efficacies of Formoterol (FOR) and Tulobuterol (TUL) onto Budesonide (BUD) may be useful for the elderly patients' asthma treatment strategy. Methods Eighteen outpatients with mild to moderate bronchial asthma with FEV1.0% < 80% treated by intermediate ICS dosages visited Respiratory Division of Nagasaki University Hospital or Isahaya General Hospital, Japan Community Health care Organization were subjected, and were randomly assigned (9 cases per group) to either the FBC group (BUD/FOR 160/4.5 µg, 2 inhalations twice daily) or BUD + TUL group (BUD 200 mcg: 2 inhalations twice daily + TUL 2 mg daily) and were compared in parallel with 2 arms for 12 weeks prospectively. Peak expiratory flow, forced expiratory volume in 1 second, impulse oscillometry (IOS), fractional exhaled nitric oxide (FeNO), Asthma Control Questionnaire, mini-Asthma Quality of Life Questionnaire (mini-AQLQ), and occurrence of adverse reactions were compared. Results The "Fres" of IOS was improved in FBC group (p = 0.03). The "emotion" domain of mini-AQLQ was improved in BUD + TUL group (p = 0.03). Conclusion By changing the drug formulation, the patch was superior in terms of satisfaction, but it was thought that the inhaled combination was superior in improving the respiratory function itself. It is necessary to pay attention to the characteristics of the patient when selecting treatment.
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Affiliation(s)
- Susumu Fukahori
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Tetsuya Kawano
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Jun Iriki
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Tomoko Tsuchida-Yabe
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinya Tomari
- Department of Respiratory Medicine, Isahaya General Hospital, Japan Community Health Care Organization, Isahaya, Japan
| | - Chizu Fukushima
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroto Matsuse
- Division of Respiratory Medicine, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
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Cloutier MM, Dixon AE, Krishnan JA, Lemanske RF, Pace W, Schatz M. Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program. JAMA 2020; 324:2301-2317. [PMID: 33270095 DOI: 10.1001/jama.2020.21974] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Asthma is a major public health problem worldwide and is associated with excess morbidity, mortality, and economic costs associated with lost productivity. The National Asthma Education and Prevention Program has released the 2020 Asthma Guideline Update with updated evidence-based recommendations for treatment of patients with asthma. OBJECTIVE To report updated recommendations for 6 topics for clinical management of adolescents and adults with asthma: (1) intermittent inhaled corticosteroids (ICSs); (2) add-on long-acting muscarinic antagonists; (3) fractional exhaled nitric oxide; (4) indoor allergen mitigation; (5) immunotherapy; and (6) bronchial thermoplasty. EVIDENCE REVIEW The National Heart, Lung, and Blood Advisory Council chose 6 topics to update the 2007 asthma guidelines based on results from a 2014 needs assessment. The Agency for Healthcare Research and Quality conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by an expert panel (n = 19) that included asthma content experts, primary care clinicians, dissemination and implementation experts, and health policy experts to develop 19 new recommendations using the GRADE method. The 17 recommendations for individuals aged 12 years or older are reported in this Special Communication. FINDINGS From 20 572 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort. CONCLUSIONS AND RELEVANCE Asthma is a common disease with substantial human and economic costs globally. Although there is no cure or established means of prevention, effective treatment is available. Use of the recommendations in the 2020 Asthma Guideline Update should improve the health of individuals with asthma.
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Affiliation(s)
| | | | - Jerry A Krishnan
- University of Illinois Hospital and Health Sciences System, Chicago
| | - Robert F Lemanske
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Wilson Pace
- University of Colorado School of Medicine, Aurora
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, California
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Manangama G, Gramond C, Audignon-Durand S, Baldi I, Fabro-Peray P, Gilg Soit Ilg A, Guénel P, Lebailly P, Luce D, Stücker I, Brochard P, Lacourt A. Occupational exposure to unintentionally emitted nanoscale particles and risk of cancer: From lung to central nervous system - Results from three French case-control studies. ENVIRONMENTAL RESEARCH 2020; 191:110024. [PMID: 32777272 DOI: 10.1016/j.envres.2020.110024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Nanoscale particles (1-100 nm) can be of natural origin, and either intentionally or unintentionally produced by human activities. Toxicological data have suggested a possible carcinogenic effect of such particles. The aim of this study was to estimate the association between occupational exposure to nanoscale particles and risk of lung cancer, pleural mesothelioma and brain tumors in adults. METHODS Three French population-based case-control studies were analyzed: 1) the ICARE study including 2029 lung cancer cases and 2591 controls; 2) the PNSM study including 371 pleural mesothelioma cases and 730 controls and 3) the CERENAT study including 257 brain tumor cases and 511 controls. Occupational exposure to unintentionally emitted nanoscale particles (UNPs) was retrospectively assessed by a job exposure matrix providing a probability and a frequency of exposure. RESULTS In adjusted analyses among men, significant associations between occupational exposure to UNPs and lung cancer (OR = 1.51; 95% CI: 1.22-1.86 and brain tumors (OR = 1.69; 95% CI: 1.17-2.44) were observed. No increased OR was observed for pleural mesothelioma (OR = 0.78; 95% CI: 0.46-1.33). CONCLUSION This is the first study showing positive associations between occupational exposure to UNPs and increased risk of lung cancer and brain tumors. These preliminary results should encourage further epidemiological research.
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Affiliation(s)
- Guyguy Manangama
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene Team, UMR 1219, F-33000, Bordeaux, France
| | - Céline Gramond
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene Team, UMR 1219, F-33000, Bordeaux, France
| | - Sabyne Audignon-Durand
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene Team, UMR 1219, F-33000, Bordeaux, France
| | - Isabelle Baldi
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene Team, UMR 1219, F-33000, Bordeaux, France
| | | | | | - Pascal Guénel
- Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Cancer and Environment Team, Université Paris-Sud, Université Paris-Saclay, F-94800, Villejuif, France
| | - Pierre Lebailly
- ANTICIPE, U1086 INSERM, Université de Caen Normandie, And Centre de Lutte Contre le Cancer François Baclesse, F-14000, Caen, France
| | - Danièle Luce
- Université de Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S, 1085, Pointe-à-Pitre, France
| | - Isabelle Stücker
- Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Cancer and Environment Team, Université Paris-Sud, Université Paris-Saclay, F-94800, Villejuif, France
| | - Patrick Brochard
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene Team, UMR 1219, F-33000, Bordeaux, France
| | - Aude Lacourt
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene Team, UMR 1219, F-33000, Bordeaux, France.
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50
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Cloutier MM, Baptist AP, Blake KV, Brooks EG, Bryant-Stephens T, DiMango E, Dixon AE, Elward KS, Hartert T, Krishnan JA, Lemanske RF, Ouellette DR, Pace WD, Schatz M, Skolnik NS, Stout JW, Teach SJ, Umscheid CA, Walsh CG. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 2020; 146:1217-1270. [PMID: 33280709 PMCID: PMC7924476 DOI: 10.1016/j.jaci.2020.10.003] [Citation(s) in RCA: 399] [Impact Index Per Article: 99.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/22/2022]
Abstract
The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders:A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality's (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.
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Affiliation(s)
- Michelle M Cloutier
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Alan P Baptist
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Kathryn V Blake
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Edward G Brooks
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Tyra Bryant-Stephens
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Emily DiMango
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Anne E Dixon
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Kurtis S Elward
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Tina Hartert
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Jerry A Krishnan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Robert F Lemanske
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Daniel R Ouellette
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Wilson D Pace
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Michael Schatz
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Neil S Skolnik
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - James W Stout
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Stephen J Teach
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Craig A Umscheid
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Colin G Walsh
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
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