Regular versus as-needed budesonide and formoterol combination treatment for moderate asthma: a non-inferiority, randomised, double-blind clinical trial

START CARE: a protocol for a randomised controlled trial of step-wise budesonide-formoterol reliever-based treatment in children

Background

Asthma is the most common chronic childhood respiratory condition globally. Inhaled corticosteroid (ICS)-formoterol reliever-based regimens reduce the risk of asthma exacerbations compared with conventional short-acting β2-agonist (SABA) reliever-based regimens in adults and adolescents. The current limited evidence for anti-inflammatory reliever therapy in children means it is unknown whether these findings are also applicable to children. High-quality randomised controlled trials (RCTs) are needed.

Objective

The study aim is to determine the efficacy and safety of budesonide-formoterol reliever alone or maintenance and reliever therapy (MART) compared with standard therapy: budesonide or budesonide-formoterol maintenance, both with terbutaline reliever, in children aged 5 to 11 years with mild, moderate and severe asthma.

Methods

A 52-week, multicentre, open-label, parallel group, phase III, two-sided superiority RCT will recruit 400 children aged 5 to 11 years with asthma. Participants will be randomised 1:1 to either budesonide-formoterol 100/6 µg Turbuhaler reliever alone or MART; or budesonide or budesonide-formoterol Turbuhaler maintenance, with terbutaline Turbuhaler reliever. The primary outcome is moderate and severe asthma exacerbations as rate per participant per year. Secondary outcomes are asthma control, lung function, exhaled nitric oxide and treatment step change. Assessment of Turbuhaler technique and cost-effectiveness analysis are also planned.

Conclusion

This will be the first RCT to compare the efficacy and safety of a step-wise budesonide-formoterol reliever alone or MART regimen with conventional inhaled ICS or ICS-long-acting β-agonist maintenance plus SABA reliever in children. The results will provide a much-needed evidence base for the treatment of asthma in children.

Systematic literature review of traits and outcomes reported in randomised controlled trials of asthma with regular dosing of inhaled corticosteroids with short-acting β2-agonist reliever, as-needed ICS/formoterol, or ICS/formoterol maintenance and reliever therapy

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.

Single inhaler triple therapy (SITT) in asthma: Systematic review and practice implications

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.

Evaluation of Budesonide-Formoterol for Maintenance and Reliever Therapy Among Patients With Poorly Controlled Asthma: A Systematic Review and Meta-analysis

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.

Long-term effects of asthma medication on asthma symptoms: an application of the targeted maximum likelihood estimation

Background

Long-term effectiveness of asthma control medication has been shown in clinical trials but results from observational studies with children and adolescents are lacking. Marginal structural models estimated using targeted maximum likelihood methods are a novel statistiscal approach for such studies as it allows to account for time-varying confounders and time-varying treatment. Therefore, we aimed to calculate the long-term risk of reporting asthma symptoms in relation to control medication use in a real-life setting from childhood to adulthood applying targeted maximum likelihood estimation.

Methods

In the prospective cohort study SOLAR (Study on Occupational Allergy Risks) we followed a German subsample of 121 asthmatic children (9–11 years old) of the ISAAC II cohort (International Study of Asthma and Allergies in Childhood) until the age of 19 to 24. We obtained self-reported questionnaire data on asthma control medication use at baseline (1995–1996) and first follow-up (2002–2003) as well as self-reported asthma symptoms at baseline, first and second follow-up (2007–2009). Three hypothetical treatment scenarios were defined: early sustained intervention, early unsustained intervention and no treatment at all. We performed longitudinal targeted maximum likelihood estimation combined with Super Learner algorithm to estimate the relative risk (RR) to report asthma symptoms at SOLAR I and SOLAR II in relation to the different hypothetical scenarios.

Results

A hypothetical intervention of early sustained treatment was associated with a statistically significant risk increment of asthma symptoms at second follow-up when compared to no treatment at all (RR: 1.51, 95% CI: 1.19–1.83) or early unsustained intervention (RR:1.38, 95% CI: 1.11–1.65).

Conclusions

While we could confirm the tagerted maximum likelihood estimation to be a usable and robust statistical tool, we did not observe a beneficial effect of asthma control medication on asthma symptoms. Because of potential due to the small sample size, lack of data on disease severity and reverse causation our results should, however, be interpreted with caution.

SMART and as-needed therapies in mild-to-severe asthma: a network meta-analysis

To date, there are no network meta-analyses comparing the impact of as-needed treatments in asthma, including the single maintenance and reliever therapy (known as "SMART" or "MART"; for simplicity, SMART will be used hereafter) and the use of inhaled corticosteroid (ICS)/long-acting β₂-agonist (LABA) combination exclusively on an as-needed basis. Therefore, we performed a systematic review and network meta-analysis concerning the efficacy and safety of SMART and as-needed therapies in asthma. Data from 32 096 asthmatic patients were extracted from 21 studies, lasting from 6 to 12 months. In adult mild-to-moderate asthmatic patients low-dose SMART and as-needed low-dose ICS/LABA combination were significantly (relative effect <0.78; p<0.05) more effective than the other as-needed therapies in reducing the risk of exacerbation, and both were ranked as the first treatment option reaching the first quartile of the surface under the cumulative ranking curve analysis (SUCRA). In adult moderate-to-severe asthmatic patients, low-dose to medium-dose SMART and high-dose ICS/LABA+as-needed short-acting β₂-agonist were equally effective in reducing the risk of severe asthma exacerbation (p>0.05), although only low- to medium-dose SMART was ranked as the first treatment option (first SUCRA quartile). Overall, these treatments were well tolerated, and effective also on lung function and disease control. This study supports SMART and as-needed therapies as a suitable therapeutic option for asthma, by providing the most effective positioning of each specific treatment according to the disease severity.

Repeated Herbal Acupoint Sticking Relieved the Recurrence of Allergic Asthma by Regulating the Th1/Th2 Cell Balance in the Peripheral Blood

Allergic asthma is an inflammatory disease involving the Th1/Th2 cell imbalance in the peripheral blood. Repeated herbal acupoint sticking (RHAS) has been used for hundreds of years in China to relieve the recurrence of allergic asthma, and it is still practiced today. Thus, we explored the effect on allergic asthma relapse and the underlying immunoregulatory mechanism in this study. Here, we enrolled 50 allergic asthma participants, and 38 of them completed the treatment and follow-up (the allergic asthma group). In addition, 13 healthy participants (the control group) were enrolled. The recurrence number of allergic asthma participants and asthma control test (ACT) were used to evaluate the effect of treatment on relieving allergic asthma recurrence. Flow cytometry was performed to analyze the levels of Th1 and Th2 cells in the peripheral blood. The serum levels of IgE, IFN-γ, and IL-4 were detected by ELISA. (1) In the allergic asthma group, compared to before the first treatment, the recurrence number of allergic asthma participants decreased and the ACT score increased at end of the last treatment, 18 and 30 weeks of the trial (P < 0.05). At 18 and 30 weeks of the trial, the recurrence number of allergic asthma participants was less and the ACT score was higher than the ones from the same period last year in the allergic asthma group (P < 0.05). Compared to before the first treatment, the percentage of Th1 cell did not change significantly, the percentage of Th2 cell decreased, and the Th1/Th2 cell ratio increased in the allergic asthma group by the end of the last treatment (P < 0.05). Meanwhile, the release of IgE and IL-4 reduced (P < 0.05), and the release of IFN-γ did not significantly change in the allergic asthma group. (2) Compared with the control group, the serum levels of IgE and IL-4 and the percentage of Th2 cell were higher, and the Th1/Th2 cell ratio was lower in the allergic asthma group (P < 0.05). There was no significant difference between Th1 cell and IFN-γ before the first treatment. (3) Compared with the control group, the IgE levels and the percentage of Th2 cell were higher in the allergic asthma group (P < 0.01). Simultaneously, there was no significant difference between Th1 cell, the Th1/Th2 cell ratio, and the serum levels of IFN-γ and IL-4 by the end of the last treatment. The data suggested that RHAS reduced the amount of Th2 cell and elevated the Th1/Th2 cell ratio, thereby alleviating the inflammatory responses in the allergic asthma participants.

Dose-response relationship of ICS/fast-onset LABA as reliever therapy in asthma

Background and objective

The dose-response relationship of inhaled corticosteroid (ICS)/fast-onset long acting beta agonist (LABA) reliever therapy has not been formally addressed. The objective of this retrospective analysis is to ascertain from the available evidence whether ICS/fast-onset LABA administered as reliever therapy has a different dose-response relationship than maintenance fixed dose ICS/fast-onset LABA therapy in reducing risk of severe exacerbations.

Methods

A systematic literature review was undertaken to identify randomised controlled trials (RCTs) in which randomised treatments included either i) budesonide/formoterol reliever monotherapy versus budesonide/formoterol fixed dose maintenance with short acting beta agonist (SABA) reliever therapy, or ii) budesonide/formoterol reliever therapy in addition to budesonide/formoterol maintenance versus higher fixed dose maintenance budesonide/formoterol with SABA as reliever therapy. Eligible studies were reviewed to allow determination of the relative potency and efficacy of the comparator regimens to reduce the risk of a severe exacerbation.

Results

The one RCT of budesonide/formoterol reliever monotherapy showed a 4.6-fold (95% CI 2.9 to 7.3) greater potency than budesonide/formoterol fixed dose maintenance plus SABA reliever therapy in reducing the risk of severe exacerbations. In the one RCT that compared budesonide/formoterol maintenance and reliever therapy with higher fixed dose maintenance budesonide/formoterol plus SABA reliever therapy, there was an additional 26% (95% CI 4 to 42%) reduction in severe exacerbation risk with the addition of budesonide/formoterol reliever therapy to maintenance budesonide/formoterol, despite a 25% lower total budesonide/formoterol dose.

Conclusion

The limited available evidence suggests that budesonide/formoterol reliever therapy has greater potency and efficacy than budesonide/formoterol fixed dose maintenance plus SABA reliever therapy in reducing the risk of a severe exacerbation. This is an important concept which has the potential to guide clinical practice in asthma, although the small number of studies available highlights the need for further research to better define these pharmacological properties.

[New approaches of inhaled steroid asthma management in mild to moderate asthma]

Inhaled corticosteroids (ICS) are the cornerstone of the management of asthma. Daily use allows to reduce mortality, intensity and frequency of exacerbations, to increase the control of symptoms of asthma and the quality of life of asthmatics patients and to reduce the decline of the lung function. A daily use of a weak dose of ICS allows to control the symptoms of asthma of the vast majority of mild to moderate asthmatics patients who account for about 75-80 % of the French asthmatic patients. An add-on strategy with a combination by ICS/LABA allows to decrease by 20 % the risk of an exacerbation compared with a treatment by CSI in monotherapy. "SMART" which consists in using a fixed ICS/LABA combination as a maintenance and reliever therapy had showed better results in the prevention of exacerbations that the use of the same combination associated with a SABA as a reliever therapy. This strategy is recommended by GINA at the same level of proof as the classical treatment. An "on-demand" use of a ICS/LABA combination according to symptoms is clearly less efficacious in terms of control of the symptoms than the classical strategy by ICS/LABA; but both strategies are identical in terms of prevention of exacerbations. The daily dose of ICS is 4 to 5 times less than in the daily ICS group. The clinical effectiveness and cost-effectiveness of a standard asthma self-management plan that advises patients to temporarily quadrupling the dose of ICS in case of asthma worsening can be an alternative and allow to reduce 20 % of clinically important asthma exacerbations.

Prevalence of Small-Airway Dysfunction among COPD Patients with Different GOLD Stages and Its Role in the Impact of Disease

BACKGROUND

In chronic obstructive pulmonary disease (COPD) patients, small-airway dysfunction (SAD) is considered a functional hallmark of disease. However, the exact role of SAD in the clinical presentation of COPD is not yet completely understood; moreover, it is not known whether SAD may have a relationship with the impact of disease.

OBJECTIVES

To evaluate the prevalence of SAD among COPD patients categorized by the old and the new GOLD classification and to ascertain whether there is a relationship between SAD and impact of disease measured by the COPD Assessment Test (CAT) questionnaire.

METHODS

We prospectively enrolled COPD outpatients from the University Hospital of Parma. Using the impulse oscillometry system (IOS), we assessed the fall in resistance from 5 to 20 Hz (R5-R20), reactance at 5 Hz (X5), and resonant frequency (FRes) as markers of peripheral airway dysfunction. According to R5-R20 ≥0.07 or <0.07, the cohort was also categorized in patients with and without SAD, respectively.

RESULTS

We studied 202 patients. In both GOLD classifications, a progressive increasing distribution of R5-R20 and FRes was reported with a decreasing of X5. Moreover, there was a significant correlation between R5-R20 and CAT (r = 0.527, p < 0.001). Finally, the presence of SAD (OR 11.96; 95% CI 4.53-31.58; p < 0.001) and use of ICS + LABA + LAMA (OR 5.31; 95% CI 1.88-15.02; p = 0.002) were independent predictors of higher impact (CAT score ≥10).

CONCLUSION

In COPD patients, the presence of SAD, as assessed by IOS, progressively increases with GOLD classifications and it is closely related to the high impact of disease on health status.

The frequency of, and adherence to, single maintenance and reliever therapy instructions in asthma: a descriptive analysis

Inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) fixed-dose combinations are recommended regular maintenance options for asthma. ICS/LABAs containing formoterol may also be indicated for single maintenance and reliever therapy (SMART). This analysis evaluated the frequency of SMART dosing of budesonide/formoterol fixed-dose combination (BFC) in the United Kingdom. Secondary objectives were to assess adherence and use of short-acting ß₂-agonists (SABAs). This was a descriptive analysis of treatment patterns using the UK Clinical Practice Research Datalink-GP OnLine Database data (2009–2013). SMART dosing was determined when prescription instructions contained guidance for daily dosing plus ‘and when required’. Treatment and prescription refill patterns of BFC and SABA were described in the year following the index date to identify adherence and SMART dosing instructions versus other dosing regimens. Of 14,818 patients identified, 173 (1.2%) had evidence of prescriptions for SMART dosing at their index BFC prescription. Despite being prescribed SMART dosing, 91 of 173 patients (53%) were additionally dispensed SABA in the year following the index date. The mean number of BFC inhalers used was less than required for daily treatment for SMART and non-SMART dosing groups (4.7 and 4.8, respectively).This analysis suggests that SMART dosing is infrequent when examining dosing instructions. Therefore, results of randomised clinical trials using SMART dosing may not translate to clinical practice in the United Kingdom because of the low level of SMART prescription, concurrent use of SABA, and inadequate refill persistence observed. Further research is needed to understand SMART dosing in real-world clinical practice.