Asthma control and management in 8,000 European patients: the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey

Experiences of Oral Corticosteroid Use and Adverse Effects: A National Cross-Sectional Survey of People with Asthma

Purpose

Oral corticosteroids (OCS) are an effective treatment for severe uncontrolled asthma or asthma exacerbations, but frequent bursts or long-term use carry serious and sometimes irreversible adverse effects, or complications such as adrenal insufficiency upon discontinuation. Our aim was to survey people with asthma on their experiences of, and attitudes towards, using OCS.

Patients and Methods

This study was a national descriptive cross-sectional survey of people with asthma in Australia. An anonymous survey was hosted online with invitations to participate distributed by national consumer peak bodies. Survey free-text responses were coded to the Theoretical Domains Framework (TDF) to elicit determinants of OCS use.

Results

1808 people with asthma participated between 3 and 16 May 2022. Most common reasons for using OCS were severe asthma symptoms (40%), doctor prescription (38%) or asthma action plan recommendations (20%). Approximately 55% of people had experienced adverse effects from OCS use. Commonly reported adverse effects were trouble sleeping (69%), weight gain (56%) and mood problems (41%). Of people who had OCS at home or an OCS script, 44% did not have an action plan that described when and how they should take them. People (33%) did not feel well informed about OCS adverse effects from their healthcare team. People had varied awareness (3-65%) of current available strategies to reduce OCS use. 'Knowledge', 'Environmental context and resources' and 'Social influences' were the most coded TDF domains influencing OCS use.

Conclusion

Adverse effects of OCS use are common. People with asthma are not adequately informed about optimal OCS use or strategies to reduce overuse. These findings can help guide the implementation of OCS stewardship initiatives.

Pediatric asthma inhaler technique: quality and content analysis of YouTube videos

BACKGROUND

Proper technique for using inhalers is crucial in treating pediatric asthma. YouTube offers a wide range of videos on pediatric inhaler technique, but there is a need to analyze the quality, reliability, and content of these resources.

AIMS

This study aims to analyze the quality, reliability, and content of YouTube videos on pediatric asthma inhaler techniques.

METHODS

The study has a descriptive, retrospective, and cross-sectional design. The research was conducted by searching YouTube using the "Pediatric Metered Dose Inhaler," "Pediatric Accuhaler," and "Pediatric Diskus." The video's popularity was measured using the Video Power Index. The quality and reliability of the videos were evaluated using the modified DISCERN and Global Quality Scale (GQS).

RESULTS

This study analyzed 55 YouTube videos on the pediatric inhaler technique. 19 of the videos were related to the pMDI inhaler with a spacer for tidal breathing, 14 pMDI inhaler with a spacer for single breath, and 22 diskus device. Findings show that videos demonstrating the use of pMDI devices for single breath have more reliable modified DISCERN scores. However, videos related to tidal breathing are more popular than those showing the use of diskus devices and single breath. Based on the checklist for videos on diskus devices, the steps with the highest error rates are 'Check dose counter' at 72.7% and 'Breathe out gently, away from the inhaler' at 63.6%. A moderate correlation was observed between the modified DISCERN score and the GQS.

CONCLUSIONS

While YouTube videos on the pMDI single-breath technique may be useful for pediatric patients and caregivers, it is crucial for them to receive inhaler technique education from their healthcare provider. This study's findings hold great significance for pediatric patients and caregivers, particularly those who rely on YouTube for health-related information.

Predictive parameters of uncontrolled asthma in the real world: a prospective study

BACKGROUND

The ultimate goal of asthma management is to have complete control of the condition, yet the number of patients with uncontrolled asthma continues to rise. This study aims to determine the prevalence of uncontrolled asthma, identify predictive parameters, and compare MART and non-MART treatment regimes.

METHODS

A prospective questionnaire was administered to 495 patients who signed the consent form. According to the scores obtained from the Asthma control test (ACT), patients were grouped into Group 1 (ACT score ≤ 19): Uncontrolled Asthma and Group 2 (ACT score > 19): Well-Controlled Asthma. Treatment adherence was evaluated by using the Morisky Medication Adherence Scale (MMAS).

RESULTS

The proportion of patients with uncontrolled asthma was found to be 54.9%. Effective predictors of uncontrolled asthma were female gender (OR = 1.7, 95% CI 1.1-2.7, p = 0.023), FEV1/FVC%<93% (OR = 2.5, 95% CI 1.5-4.1, p < 0.001), a history of visits to the emergency department during the previous year (OR = 2.7, 95% CI 1.7-4.3, p < 0.001), and receiving non-MART treatment (OR = 2.0, 95% CI 1.3-3.1, p = 0.001). MMAS was found to be higher, and medication adherence lower, in uncontrolled asthma patients (p = 0.040). The MART treatment regimen was preferred in 36% of cases. In the MART treatment group, as compared to the non-MART treatment group, uncontrolled asthma (43.8% vs. 61.2%) was observed according to ACT (p < 0.001).

CONCLUSION

The risk of uncontrolled asthma was found to be higher in female patients, or those who had visited the emergency department, had been hospitalized within the past year, had poor pulmonary function test results or low treatment compliance, and who were on non-MART treatment regimens.

A Retrospective Study Evaluating Asthma Control in Patients on Fluticasone Propionate/Salmeterol Proactive Regular Dosing with a History of Uncontrolled Asthma

INTRODUCTION

The MERIT study in Malaysia is a real-world retrospective, observational, multicenter study that evaluated asthma control in patients with uncontrolled asthma who were switched from as-needed (pro re nata [PRN]) budesonide/formoterol or inhaled corticosteroid (ICS) whenever a short-acting beta-agonist (SABA) was taken, to proactive regular dosing of fluticasone propionate/salmeterol (FP/SAL PRD).

METHODS

Data from the medical records of patients who were stepped up to FP/SAL PRD were extracted retrospectively at baseline and follow-up (between 3 and 6 months after stepping up to FP/SAL PRD). The primary endpoint was the percentage of patients with improvement in asthma control assessed via the Asthma Control Test (ACT). Secondary endpoints included safety and the percentage of patients with moderate and severe exacerbations. Additionally, patient-reported use of reliever medication, systemic corticosteroids, emergency department visits, or hospitalization was also analyzed.

RESULTS

One hundred twenty patients with uncontrolled asthma who were stepped up to FP/SAL PRD were enrolled in the study. Of these, 76 (63.3%) patients were on prior budesonide/formoterol PRN, and 44 (36.7%) were on prior ICS with SABA PRN treatment. After stepping up to FP/SAL PRD with a mean follow-up of 5.8 months, 110 (91.7%) patients achieved asthma control at the follow-up visit (p < 0.001). Similar improvements were observed regardless of prior PRN regimen. A statistically significant improvement was observed in the mean ACT score at the follow-up visit (p < 0.0001). The proportion of patients with moderate and severe exacerbations was also reduced after stepping up to FP/SAL PRD, with no adverse events reported. Over 80% of patients reported a decrease in the use of systemic corticosteroids, visits to the emergency department, or hospitalization.

CONCLUSION

This study highlights the effectiveness of the FP/SAL PRD treatment approach in patients with uncontrolled asthma on a PRN treatment regimen.

Unlocking Better Asthma Control: A Narrative Review of Adherence to Asthma Therapy and Innovative Monitoring Solutions

This review addresses the ongoing challenges in asthma management, particularly focusing on patient adherence to inhaler therapy. Asthma, a chronic condition characterized by variable respiratory symptoms and airflow obstruction, can lead to significant morbidity and mortality if not properly managed. Despite advances in inhaler technology and therapeutic options, non-adherence remains a significant barrier to optimal asthma control. This review explores both intentional and unintentional non-adherence, influenced by factors such as age, socioeconomic status, and the complexity of inhaler devices. The Global Initiative for Asthma (GINA) provides guidelines aimed at improving adherence through targeted interventions, and this review examines their application. Common inhaler technique errors, including incorrect inhalation speed, not exhaling before inhaling, and failure to hold breath post-inhalation, are identified as major contributors to inadequate asthma control. Furthermore, the review explores the emerging role of electronic monitoring devices (EMDs), such as CapMedic and DigiHaler, which offer real-time feedback to enhance inhaler technique and adherence. The role of biomarkers in assessing adherence and the potential of personalized treatment strategies, including biologic therapies, are also discussed. Overall, addressing adherence requires a comprehensive approach that integrates patient education, tailored interventions, and technological innovations to achieve better clinical outcomes in asthma management.

Asthma Control According to GINA 2023: Does Changing the Criteria Improve Asthma Control?

Background/Objectives: Achieving disease control is the main goal in asthmatic patients in order to prevent future risks and exacerbations. There are several clinical guidelines that set different definitions of asthma control, and these differences may affect management and treatment in many patients. Our aim was to describe asthma control patterns according to the Global Initiative for Asthma (GINA) 2023 in patients considered to have uncontrolled asthma as per previous GINA 2010 guidelines. Methods: A total of 1299 patients from the COAS study were analyzed. The COAS study was a cross-sectional multicenter study conducted in routine clinical practice that included patients with uncontrolled asthma according to GINA 2010. These patients were then re-classified using the now updated GINA 2023 asthma control criteria. Results: After applying GINA 2023 control criteria, previously uncontrolled patients were now classified as having controlled asthma in 24.3% of cases and partially controlled asthma in 16.3% of cases. Only 59.4% maintained their previous diagnosis of uncontrolled asthma. ACT in the uncontrolled patients remained similar after re-classification, as did the percentage of active smokers, respiratory allergy, rhinitis, and lung function. Conclusions: Changes in clinical guideline criteria affect the definition of asthma control. When excluding pulmonary function abnormalities in GINA 2023 asthma control criteria, the percentage of controlled patients greatly increased.

The need for implementing a standardized, evidence-based emergency department discharge plan for optimizing adult asthma patient outcomes in the UAE, expert meeting report

BACKGROUND

Asthma is a common chronic respiratory inflammatory disease that adversely affects patients' quality of life (QoL) and overall well-being. When asthma is not adequately controlled, there is a higher risk of exacerbations and hospitalizations, thereby increasing the direct and indirect costs associated with the treatment and productivity loss. Overreliance on SABA and underutilization of ICS in the management of asthma can result in suboptimal treatment and poor asthma control. Patients who visit the emergency department are more likely to have poorly controlled asthma. Ensuring that these patients are provided with an evidence-based treatment plan during discharge can help reduce the risk of future exacerbations and consequently reduce the burden on the UAE healthcare system.

METHODS

A joint task force comprising experts from the Emirates Society of Emergency Medicine (ESEM) and Emirates Thoracic Society (ETS) reviewed published evidence and updated guidelines in asthma management to optimize the post-discharge recommendations.

RESULTS

The ESEM-ETS experts' joint task force has developed a step-by-step plan for emergency department/hospital discharge, which is based on the GINA 2023 guideline recommendations and the medications available in the UAE. By adhering to this structured plan, emergency department physicians can play a crucial role in improving asthma care, long-term patient outcomes, and the utilization of healthcare resources.

CONCLUSIONS

Prioritizing patient education and ensuring patients are equipped with the best-suited asthma treatment plans prior to discharge can help ED physicians improve patient outcomes and reduce healthcare resource utilization in UAE hospitals.

Over-the-counter short-acting β2-agonist purchase and asthma-related health outcomes: a post hoc analysis of the SABINA III study

This post-hoc analysis of the SABINA III study evaluated the association of short-acting β2-agonist (SABA) prescriptions and self-reported over-the-counter (OTC) SABA purchase in the previous 12 months with asthma-related outcomes using multivariable regression models in 4556 patients (mean age, 48.9 years). Of the 2810 patients prescribed ≥3 SABA canisters, 776 (27.6%) also purchased ≥1 SABA OTC. This subset of 776 patients reported the highest disease burden; 73.2% had ≥1 severe exacerbation and 55.7% had uncontrolled asthma. Asthma-related outcomes worsened with any SABA OTC purchase, regardless of SABA prescriptions; disease burden was the highest in patients with ≥3 SABA prescriptions and ≥1 SABA OTC purchase vs 1-2 SABA prescriptions only (86% lower odds of having at least partly controlled asthma and 124% increased incidence of severe asthma (both P < 0.001). These findings emphasize the need to implement policy changes to restrict SABA purchase without prescriptions and ensure access to affordable asthma care.

An evaluation of Asthma control using the Asthma control test in patients at the University Hospital, Agadir, Morocco

Background

Asthma is a common chronic disease, and asthma control is the major therapeutic objective, thus ensuring a good health-related quality of life. This study aimed to evaluate the level of asthma control in a sample of asthmatic patients followed in allergology consultation during our training using the asthma control test (ACT) and its correlation with other parameters.

Methodology

This is a cross-sectional study of 66 asthmatic patients who were followed in pulmonology consultation at Agadir University Hospital after completing the asthma control test questionnaire over 6 months (June to December 2021).

Results

The age of the patients ranged from 17 to 76 years, with an average age of 41.36 +/- 13.31 years. There was a predominance of females in this sample, representing 54.5% of the patients against 45.5% of males. All patients were on inhaled corticosteroid therapy (ICS) (as monotherapy in 25.8% of cases and in combination with a long-acting beta-2 mimetic (LABA) in 74.2% of cases). 60.6% of the patients were from low socioeconomic levels, of which 28.8% were from rural areas. 22.7% of the participants were illiterate. Allergic rhinitis was found in 66.6% of patients and allergic conjunctivitis in 45.5%. Active smoking was found in 16.7% of cases. Obesity was found in 10 patients (15.2% of cases). According to the ACT, asthma was totally controlled in 37.9% of cases and partially controlled in 43.9% of patients.

Conclusion

The level of asthma control found in this study was lower compared to other populations. The study also showed that better ACT scores and asthma control correlated with higher socioeconomic levels.

Preclinical Evaluation of Electronic Health Records (EHRs) to Predict Poor Control of Chronic Respiratory Diseases in Primary Care: A Novel Approach to Focus Our Efforts

Background/Objectives: Managing chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) within the Spanish Sistema Nacional de Salud (SNS) presents significant challenges, particularly due to their high prevalence and poor disease control rates-approximately 45.1% for asthma and 63.2% for COPD. This study aims to develop a novel predictive model using electronic health records (EHRs) to estimate the likelihood of poor disease control in these patients, thereby enabling more efficient management in primary care settings. Methods: The Seleida project employed a bioinformatics approach to identify significant clinical variables from EHR data in primary care centers in Seville and Valencia. Statistically significant variables were incorporated into a logistic regression model to predict poor disease control in patients with asthma and COPD patients. Key variables included the number of short-acting β-agonist (SABA) and short-acting muscarinic antagonist (SAMA) canisters, prednisone courses, and antibiotic courses over the past year. Results: The developed model demonstrated high accuracy, sensitivity, and specificity in predicting poorly controlled disease in both asthma and COPD patients. These findings suggest that the model could serve as a valuable tool for the early identification of at-risk patients, allowing healthcare providers to prioritize and optimize resource allocation in primary care settings. Conclusions: Integrating this predictive model into primary care practice could enhance the proactive management of asthma and COPD, potentially improving patient outcomes and reducing the burden on healthcare systems. Further validation in diverse clinical settings is warranted to confirm the model's efficacy and generalizability.

MELTEMI and COLUMBA: 5-Year Comparative Safety Analysis of Benralizumab and Mepolizumab

BACKGROUND

Benralizumab and mepolizumab are interleukin (IL)-5Rα/interleukin-5-targeted monoclonal antibodies indicated as add-on treatments for patients with uncontrolled severe eosinophilic asthma (SEA).

OBJECTIVE

To evaluate and compare the safety of benralizumab and mepolizumab among patients with SEA treated in MELTEMI and COLUMBA open-label, long-term extension studies, respectively.

METHODS

MELTEMI was an extension study of benralizumab every 4 weeks (q4w) or every 8 weeks (q8w) for adults (aged 18-75 y) with SEA. MELTEMI participants transitioned from the BORA extension, preceded by participation in 1 of 3 placebo-controlled studies (SIROCCO, CALIMA, or ZONDA). COLUMBA was an extension study of mepolizumab for patients (aged ≥ 12 y) with SEA who transitioned from the dose-ranging DREAM study. Safety endpoints were presented as drug exposure patient-years (MELTEMI, q4w 784.28, q8w 797.03; COLUMBA 1,201) for nonserious adverse events, serious adverse events, and infections; malignancies were counted numerically.

RESULTS

This analysis included 446 MELTEMI patients (benralizumab q4w 220; benralizumab q8w 226) and 347 COLUMBA patients (mepolizumab q4w). Viral upper respiratory tract infection was the most common nonserious adverse event in both studies (MELTEMI q8w 46.5%; q4w 47.3%; COLUMBA, 48.7%). Asthma-related events were the most common serious adverse events in both studies: MELTEMI 8.0% (q8w) and 8.6% (q4w) and COLUMBA 9.5%. Serious infections included pneumonia (MELTEMI q8w, 2 [0.9%]; COLUMBA, 6 [1.7%]); cellulitis (MELTEMI q8w, 1 [0.4%]; COLUMBA, 2 [0.6%]); and respiratory tract infections (COLUMBA, 2 [0.6%]). COLUMBA reported 6 malignancies and MELTEMI reported 4 malignancies in each group.

CONCLUSIONS

This analysis demonstrated generally similar safety events between mepolizumab and benralizumab in patients with SEA.

Real-World Safety Profile of Biologic Drugs for Severe Uncontrolled Asthma: A Descriptive Analysis from the Spanish Pharmacovigilance Database

Background: The present investigation provides a thorough analysis of adverse drug reactions (ADRs) reported in the Database of the Spanish Pharmacovigilance System (FEDRA) for biologic medications primarily indicated for severe refractory asthma, including omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, and tezepelumab. Our main objective was to identify ADRs not documented in the drugs' Technical Sheets (summary of product characteristics, SmPC), potentially indicating unrecognized risks meriting pharmacovigilance attention. Methods: Data spanning from each drug's market introduction until 22 January 2024, were analyzed, sourced from direct submissions to the Spanish Pharmacovigilance System, industry communications, and literature reviews. We evaluated notifications impartially to ensure a comprehensive review of all the ADRs associated with these medications. Results: This investigation underlines the critical role of post-marketing surveillance in enhancing patient safety. It emphasizes the necessity for healthcare professionals to report ADRs comprehensively to foster a robust pharmacovigilance system. Furthermore, the study highlights gaps between the reported ADRs and the information provided in SmPCs, signaling potential areas for improvement in drug safety monitoring and regulatory oversight. Conclusions: Finally, these findings may contribute to informed decision making in clinical practice and regulatory policy, ultimately advancing patient care and safety in the management of severe uncontrolled asthma.

iPREDICT: Characterization of Asthma Triggers and Selection of Digital Technology to Predict Changes in Disease Control

Purpose

The iPREDICT program aimed to develop an integrated digital health solution capable of continuous data streaming, predicting changes in asthma control, and enabling early intervention.

Patients and Methods

As part of the iPREDICT program, asthma triggers were characterized by surveying 221 patients (aged ≥18 years) with self-reported asthma for a risk-benefit analysis of parameters predictive of changes in disease control. Seventeen healthy volunteers (age 25-65 years) tested 13 devices to measure these parameters and assessed their usability attributes.

Results

Patients identified irritants such as chemicals, allergens, weather changes, and physical activity as triggers that were the most relevant to deteriorating asthma control. Device testing in healthy volunteers revealed variable data formats/units and quality issues, such as missing data and low signal-to-noise ratio. Based on user preference and data capture validity, a spirometer, vital sign monitor, and sleep monitor formed the iPREDICT integrated system for continuous data streaming to develop a personalized/predictive algorithm for asthma control.

Conclusion

These findings emphasize the need to systematically compare devices based on several parameters, including usability and data quality, to develop integrated digital technology programs for asthma care.

Expert consensus on oral corticosteroids stewardship for the treatment of severe asthma in the Middle East and Africa

In the Middle East and Africa (MEA) region, overuse of oral corticosteroids (OCS) for asthma management, both as burst and maintenance therapy, poses a significant challenge. Gaps in knowledge regarding the need to taper OCS in patients with severe asthma and the use of OCS in comorbid conditions have been noted. OCS stewardship can help attain optimal and effective OCS tapering along with reducing OCS overuse and over-reliance. In this paper, we discuss current practices regarding the use of OCS in asthma, globally and in the MEA region. Expert recommendations for achieving OCS stewardship in the MEA region have also been presented. Regional experts recommend increasing awareness among patients about the consequences of OCS overuse, engaging community pharmacists, and educating primary healthcare professionals about the benefits of prompt appropriate referral. Innovative local referral tools like ReferID can be utilized to refer patients with asthma to specialist care. The experts also endorse a multidisciplinary team approach and accelerating access to newer medicines like biologics to implement OCS stewardship and optimize asthma care in the MEA region.

Rhinitis Control and Medication Use in a Real-World Sample of Patients With Persistent Rhinitis or Rhinosinusitis: A Community Pharmacy Study

BACKGROUND

Little is known about rhinitis control in real-life, nor about the contribution of treatment-related and patient-related factors.

OBJECTIVE

This study aimed to examine the level of rhinitis control and rhinitis medication utilization in patients with persistent rhinitis and to identify predictors of rhinitis control.

METHODS

A cross-sectional observational study was conducted in patients with persistent rhinitis recruited in community pharmacies. Participants completed the Rhinitis Control Assessment Test, a questionnaire on patient/rhinitis characteristics, and rhinitis medication use. A visual analog scale for nasal symptoms was also completed. Pharmacy dispensing data were used to calculate adherence to intranasal glucocorticoids. Nasal spray technique was evaluated using a standardized checklist. Predictors of rhinitis control were explored using a linear regression model.

RESULTS

A total of 1,514 patients, recruited in 215 pharmacies, participated in the study (mean age 48.7 y, 62% female). Almost 60% exhibited suboptimal rhinitis control (Rhinitis Control Assessment Test ≤ 21 of 30). A 50-mm cut-off on the visual analog scale yielded 78.1% sensitivity to identify suboptimal rhinitis control. Participants most frequently used intranasal glucocorticoids (55.6%) and intranasal decongestants (47.4%). Only 10.3% of current nasal spray users demonstrated perfect technique. More than half (54.8%) of glucocorticoid users were identified as underadherent. Female sex, self-reported nasal hyperreactivity, active asthma, and use of oral/intranasal decongestants or nasal saline were identified as predictors of worse rhinitis control.

CONCLUSIONS

Suboptimal rhinitis control was common in this real-life sample of persistent rhinitis patients. Improving use of rhinitis medication may be key to increase disease control.

Asthma management with triple ICS/LABA/LAMA combination to reduce the risk of exacerbation: an umbrella review compliant with the PRIOR statement

INTRODUCTION

According to Global Initiative for Asthma (GINA) guidelines, long-acting muscarinic antagonists (LAMAs) should be considered as add-on therapy in patients with asthma that remains uncontrolled, despite treatment with medium-dose (MD) or high-dose (HD) inhaled corticosteroids (ICS)/long-acting β2-agonist (LABA) combinations. In patients ≥ 18 years, LAMA may be added in triple combination with an ICS and a LABA. To date, the precise efficacy of triple ICS/LABA/LAMA combination remains uncertain concerning the impact on exacerbation risk in patients with uncontrolled asthma. Therefore, an umbrella review was performed to systematically summarize available data on the effect of triple ICS/LABA/LAMA combination on the risk of asthma exacerbation.

METHODS

An umbrella review has been performed according to the PRIOR statement.

RESULTS

The overall results obtained from 5 systematic reviews and meta-analyses suggest that triple ICS/LABA/LAMA combination reduces the risk of asthma exacerbation. HD-ICS showed a greater effect particularly in reducing severe asthma exacerbation, especially in patients with evidence of type 2 inflammation biomarkers.

CONCLUSIONS

The findings of this umbrella review suggest an optimization of ICS dose in triple ICS/LABA/LAMA combination, based on the severity of exacerbation and type 2 biomarkers expression.

The association between waist circumference and adult asthma attack using nationally representative samples

AIMS

This study aims to explore the relationship between waist circumference and asthma attack in adults.

METHODS

In this cross-sectional study, we analysed data from 5,530 U.S. adults diagnosed with asthma. Participants were categorized into two groups based on their experience of asthma attacks: with or without asthma attacks. We employed adjusted weighted logistic regression models, weighted restricted cubic splines, subgroup and sensitivity analyses to assess the association between waist circumference and asthma attack.

RESULTS

The median age of all participants was 43 years, and the median waist circumference was 98.9 cm, with a median BMI was 28.50 kg/m2. Participants in the asthma attack group had significantly higher waist circumferences than those in the non-attack group (P < 0.001). After full adjustment for body mass index-defined obesity, age, gender, race, education levels, poverty income ratio levels, smoking status, and metabolic syndrome, every 5 cm increase in waist circumference exhibited a 1.06 times higher likelihood of asthma attack probability. The weighted restricted cubic spline analysis demonstrated an increased risk of asthma attacks with rising waist circumference. Subgroup analyses confirmed this relationship across various groups differentiated by gender, age, and smoking status. When applying a stricter definition of asthma attack, the weighted logistic regression models showed robust association between waist circumference and asthma attack.

CONCLUSION

Waist circumference is an independent predictor of asthma attacks. Our findings underscore the importance of waist circumference measurement in evaluating the risk of asthma attacks.

The Asthma App as a New Way to Promote Responsible Short-Acting Beta2-Agonist Use in People With Asthma: Results of a Mixed Methods Pilot Study

BACKGROUND

Approximately 262 million people worldwide are affected by asthma, and the overuse of reliever medication-specifically, short-acting beta2-agonist (SABA) overuse-is common. This can lead to adverse health effects. A smartphone app, the Asthma app, was developed via a participatory design to help patients gain more insight into their SABA use through monitoring and psychoeducation.

OBJECTIVE

This pilot study aims to evaluate the feasibility and usability of the app. The preliminary effects of using the app after 3 months on decreasing asthma symptoms and improving quality of life were examined.

METHODS

A mixed methods study design was used. Quantitative data were collected using the app. Asthma symptoms (measured using the Control of Allergic Rhinitis and Asthma Test) and the triggers of these symptoms were collected weekly. Quality of life (36-Item Short-Form Health Survey) was assessed at baseline and after 3, 6, and 12 months. User experience (System Usability Scale) was measured at all time points, except for baseline. Furthermore, objective user data were collected, and qualitative interviews, focusing on feasibility and usability, were organized. The interview protocol was based on the Unified Theory of Acceptance and Use of Technology framework. Qualitative data were analyzed using the Framework Method.

RESULTS

The baseline questionnaire was completed by 373 participants. The majority were female (309/373, 82.8%), with a mean age of 46 (SD 15) years, and used, on average, 10 SABA inhalations per week. App usability was rated as good: 82.3 (SD 13.2; N=44) at 3 months. The Control of Allergic Rhinitis and Asthma Test score significantly improved at 3 months (18.5) compared with baseline (14.8; β=.189; SE 0.048; P<.001); however, the obtained score still indicated uncontrolled asthma. At 3 months, there was no significant difference in the quality of life. Owing to the high dropout rate, insufficient data were collected at 6 and 12 months and were, therefore, not further examined. User data showed that 335 users opened the app (250/335, 74.6%, were returning visitors), with an average session time of 1 minute, and SABA registration was most often used (7506/13,081, 57.38%). Qualitative data (from a total of 4 participants; n=2, 50% female) showed that the participants found the app acceptable and clear. Three participants stated that gaining insight into asthma and its triggers was helpful. Two participants no longer used the app because they perceived their asthma as controlled and, therefore, did not use SABA often or only used it regularly based on the advice of the pulmonologist.

CONCLUSIONS

The initial findings regarding the app's feasibility and usability are encouraging. However, the notable dropout rate underscores the need for a cautious interpretation of the results. Subsequent studies, particularly those focusing on implementation, should explore the potential integration of the app into standard treatment practices.

Predictors and components of inpatient asthma hospital cost: A retrospective cohort study. Analysis from a sample of 14 Belgian hospitals

Background

Addressing the challenges of asthma has involved various approaches, including the examination of costs associated with hospitalization. However, there is a limited number of studies that have investigated the actual expenses incurred by hospital settings in caring for asthma patients. This study aims to describe the costs, predictors, and breakdown of expenditures in different categories.

Design and methods

A retrospective cohort study was conducted, involving 314 hospital stays of patients over 12 years old who were admitted for asthma and classified under APR-DRG 141 (asthma). Univariate and multiple linear regression analyses were performed.

Results

The median cost, regardless of DRG severity, amounted to 2.314€ (1.550€-3.847€). Significant variations were observed when the sample was stratified based on the severity of DRG, revealing a cost gradient that increases with severity. The length of stay followed a similar trend. Six predictors were identified: age, admission to intensive care, asthma severity, severity level of the DRG, winter admission, and length of stay. The cost breakdown showed that 44% constituted direct costs, 25% were indirect costs, 26% were attributed to medical procedures performed outside the patient unit, and 5% were related to medication administration.

Conclusions

This study initiates a discussion on the role of reducing hospital costs in strategies aiming at controlling asthma-related costs. We argue that cost reduction cannot be achieved solely at the hospital level but must be approached from a public health perspective. This includes promoting high-quality outpatient care and addressing factors leading to poor adherence to the care plan.

Prospective direct comparison of biologic treatments for severe eosinophilic asthma: Findings from the PRISM study

BACKGROUND

Although various monoclonal antibodies have been used as add-on therapy for severe eosinophilic asthma (SEA), to the best of our knowledge, no direct head-to-head comparative study has evaluated their efficacy.

OBJECTIVE

To compare the efficacy of reslizumab, mepolizumab, and dupilumab in patients with SEA.

METHODS

This was a multicenter, prospective observational study in patients with SEA who had received 1 of these biologic agents for at least 6 months. Cox proportional hazard models were used to compare the risk of the first exacerbation event, adjusting for sputum or blood eosinophils and common asthma-related covariates. The annual exacerbation rate was analyzed using a negative binomial model, and a mixed-effect model was used to analyze changes in forced expiratory volume in 1 second and asthma control test score over time.

RESULTS

A total of 141 patients with SEA were included in the analysis; 71 (50%) received dupilumab; 40 (28%) received reslizumab, and 30 (21%) received mepolizumab. During the 12-month follow-up, 27.5%, 43.3%, and 38.0% of patients in the reslizumab, mepolizumab, and dupilumab groups, respectively, experienced at least 1 exacerbation. However, after adjusting for confounding factors, the dupilumab and mepolizumab groups showed similar outcomes in time-to-first exacerbation, exacerbation rate, forced expiratory volume in 1 second, and asthma control test score to those of the reslizumab group.

CONCLUSION

In patients with SEA, treatment with reslizumab, mepolizumab, and dupilumab resulted in comparable clinical outcomes within a 12-month period.

TRIAL REGISTRATION

The cohort protocol was sanctioned by the Institutional Review Board of each study center (clinicaltrial.gov identifier NCT05164939).

[Diagnosis and therapy of patients with asthma in Germany. Results of the care study RELEVANT]

BACKGROUND

Diagnostic and therapeutic options for asthma have improved with asthma control and remission being of central importance. The RELEVANT study aimed for a nationwide snapshot of current asthma diagnosis and treatment in general practice and specialty care for identification of further aspects for optimization.

METHOD

RELEVANT is a nationwide cross-sectional study using a structured questionnaire. This comprised 14 questions on asthma-related topics covering diagnostics and therapy. Participants were general practitioners/internal medicine specialists and pulmonologists.

RESULTS

A total of 1,558 persons took part in the survey. Regarding relevant specific diagnostic procedures for asthma, GPs/internists almost exclusively mentioned pulse oximetry. Among the pulmonologists, fractional exhaled nitric oxide (FeNO) measurement was mentioned, among others. FeNO and blood eosinophils were only mentioned by the pulmonologists as diagnostic and treatment-relevant markers. A total of more than 60% of the GPs/internists surveyed stated that only around 25% or fewer of their patients would voluntarily report restrictions in their everyday lives. Regarding drug treatment, the majority stated that they recognized differences between various ICS/LABA combination therapies.

CONCLUSIONS

The results indicate a need for optimization, particularly regarding asthma control. This involves both a better assessment by patients' everyday life restrictions and modern ways of assessing asthma control in cooperation between GPs/internal medicine specialists and pulmonologists. One fifth of respondents do not see any differences between various ICS/LABA combinations in daily practice, although there are pharmacodynamic and pharmacokinetic differences.

Psychometric assessment of the Adherence to Asthma Medication Questionnaire in asthma patients in China: a validation study

BACKGROUND

Patients' medication adherence plays a critical role in the treatment and rehabilitation of disease. However, few tools are currently available that can be used to identify the reasons for their nonadherence with their medication regimens. It is possible to evaluate both the level of medication adherence of a patient as well as the reasons for it using the Adherence to Asthma Medication Questionnaire (AAMQ). The purpose of this study was to adapt the AAMQ for use in Chinese patients and a variety of asthma patients.

METHODS

A total of 242 asthma patients were recruited from Jinzhou in China. The Adherence to Asthma Medication Questionnaire was translated and back-translated using the Brislin translation model. Test-retest reliability, internal consistency, and stability all play a large role in determining the reliability of a scale. Confirmatory factor analysis was used to examine the scale's construct validity, and expert consultation was used to verify the scale's content validity. Statistics were deemed significant at p < 0.05.

RESULTS

The Cronbach's α value of the Chinese version of the AAMQ was 0.866, and the coefficient values for the three domains ranged between 0.702 and 0.798. The split-half reliability and stability values were 0.794 and 0.772, respectively. The content validity index of the scale (S-CVI) was 0.923, and the content validity index of the level of scale entry was 0.857-1.000. According to the confirmatory factor analysis, the chi-square degreed of freedom were 1.484, and the model fitting indices were all within normal limits.

CONCLUSIONS

The AAMQ had good reliability and validity for asthmatic patients. The results of the scale's assessment can be used as a criterion for medication adherence among asthmatic patients and to understand the causes. This study provides a reference for solving the problem of medication adherence among asthma patients and implementing targeted nursing measures.

PATIENT OR PUBLIC CONTRIBUTION

Gratitude is extended to all individuals collaborating in completing the survey and to the author.

Pharmacological treatment of asthma in Sweden from 2005 to 2015

OBJECTIVE

Despite access to effective therapies many asthma patients still do not have well-controlled disease. This is possibly related to underuse of inhaled corticosteroids (ICS) and overuse of short-acting β2-agonists (SABA). Our aim was to investigate longitudinal trends and associated factors in asthma treatment.

METHODS

Two separate cohorts of adults with physician-diagnosed asthma were randomly selected from 14 hospitals and 56 primary health centers in Sweden in 2005 (n = 1182) and 2015 (n = 1225). Information about symptoms, maintenance treatment, and use of rescue medication was collected by questionnaires. Associations between treatment and sex, age, smoking, education, body mass index (BMI), physical activity, allergic asthma, and symptom control were analyzed using Pearson's chi2-test. Odds ratios (ORs) were calculated using logistic regression.

RESULTS

Maintenance treatment with ICS together with long-acting β2-agonists (LABA) and/or montelukast increased from 39.2% to 44.2% (p = 0.012). The use of ICS + LABA as-needed increased (11.1-18.9%, p < 0.001), while SABA use decreased (46.4- 41.8%, p = 0.023). Regular treatment with ICS did not change notably (54.2-57.2%, p = 0.14). Older age, former smoking, and poor symptom control were related to treatment with ICS + LABA/montelukast. In 2015, 22.7% reported daily use of SABA. A higher step of maintenance treatment, older age, obesity, shorter education, current smoking, allergic asthma, low or very high physical activity, and a history of exacerbations were associated with daily SABA use.

CONCLUSIONS

The use of ICS + LABA both for maintenance treatment and symptom relief has increased over time. Despite this, the problem of low use of ICS and high use of SABA remains.

Efficacy and safety of macrolide therapy for adult asthma: A systematic review and meta-analysis

BACKGROUND

The evidence for macrolide therapy in adult asthma is not properly established and remains controversial. We conducted a systematic review and meta-analysis to examine the efficacy and safety of macrolide therapy for adult asthma.

METHODS

We searched randomized controlled trials from MEDLINE via the PubMed, CENTRAL, and Ichushi Web databases. The primary outcome was asthma exacerbation. The secondary outcomes were serious adverse events (including mortality), asthma-related quality of life (symptom scales, Asthma Control Questionnaire, and Asthma Quality of Life Questionnaire), rescue medication (puffs/day), respiratory function (morning peak expiratory flow, evening peak flow, and forced expiratory volume in 1 s), bronchial hyperresponsiveness, and minimum oral corticosteroid dose. Of the 805 studies, we selected seven studies for the meta-analysis, which was conducted using a random-effects model.

SYSTEMATIC REVIEW REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (UMIN000050824).

RESULTS

No significant difference between macrolide and placebo for asthma exacerbations was observed (risk ratio 0.71, 95 % confidence interval [CI] 0.46-1.09; p = 0.12). Macrolide therapy for adult asthma showed a significant improvement in rescue medication with short-acting beta-agonists (mean difference -0.41, 95 % CI -0.78 to -0.04; p = 0.03). Macrolide therapy did not show more serious adverse events (odd ratio 0.61, 95 % CI 0.34-1.10; p = 0.10) than those with placebo. The other secondary outcomes were not significantly different between the macrolide and placebo groups.

CONCLUSIONS

Macrolide therapy for adult asthma may be more effective than placebo and could be a treatment option.

Individualized aerosol medicine: Integrating device into the patient

Pulmonary drug delivery is complex due to several challenges including disease-, patient-, and clinicians-related factors. Although many inhaled medications are available in aerosol medicine, delivering aerosolized medications to patients requires effective disease management. There is a large gap in the knowledge of clinicians who select and provide instructions for the correct use of aerosol devices. Since improper device selection, incorrect inhaler technique, and poor patient adherence to prescribed medications may result in inadequate disease control, individualized aerosol medicine is essential for effective disease management and control. The components of individualized aerosol medicine include: (1) Selecting the right device, (2) Selecting the right interface, (3) Educating the patient effectively, and (4) Increasing patient adherence to therapy. This paper reviews each of these components and provides recommendations to integrate the device and interface into the patient for better clinical outcomes.

Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe-Based envirONmental cost of treatment (CARBON) study

BACKGROUND

Poorly controlled asthma is associated with increased morbidity and healthcare resource utilisation (HCRU). Therefore, to quantify the environmental impact of asthma care, this retrospective, cohort, healthCARe-Based envirONmental cost of treatment (CARBON) study estimated greenhouse gas (GHG) emissions in the UK associated with the management of well-controlled versus poorly controlled asthma.

METHODS

Patients with current asthma (aged ≥12 years) registered with the Clinical Practice Research Datalink (2008‒2019) were included. GHG emissions, measured as carbon dioxide equivalent (CO2e), were estimated for asthma-related medication use, HCRU and exacerbations during follow-up of patients with asthma classified at baseline as well-controlled (<3 short-acting β2-agonist (SABA) canisters/year and no exacerbations) or poorly controlled (≥3 SABA canisters/year or ≥1 exacerbation). Excess GHG emissions due to suboptimal asthma control included ≥3 SABA canister prescriptions/year, exacerbations and any general practitioner and outpatient visits within 10 days of hospitalisation or an emergency department visit.

RESULTS

Of the 236 506 patients analysed, 47.3% had poorly controlled asthma at baseline. Scaled to the national level, the overall carbon footprint of asthma care in the UK was 750 540 tonnes CO2e/year, with poorly controlled asthma contributing excess GHG emissions of 303 874 tonnes CO2e/year, which is equivalent to emissions from >124 000 houses in the UK. Poorly controlled versus well-controlled asthma generated 3.1-fold higher overall and 8.1-fold higher excess per capita carbon footprint, largely SABA-induced, with smaller contributions from HCRU.

CONCLUSIONS

These findings suggest that addressing the high burden of poorly controlled asthma, including curbing high SABA use and its associated risk of exacerbations, may significantly alleviate asthma care-related carbon emissions.

Short-acting β2-agonist prescriptions in patients with asthma: findings from the South Korean cohort of SABINA III

BACKGROUND/AIMS

Despite short-acting β2-agonist (SABA) overuse being associated with poor asthma outcomes, data on SABA use in South Korea is scarce. Herein, we describe prescription patterns of SABA and other asthma medications in patients from the South Korean cohort of the SABA use IN Asthma (SABINA) III study.

METHODS

This study included patients with asthma aged ≥ 12 years, who had ≥ 3 consultations with the same healthcare provider, and medical records containing data for ≥ 12 months prior to the study visit. Patients were classified by investigator-defined asthma severity (per 2017 Global Initiative for Asthma recommendations) and practice type (primary or specialist care). Data on disease characteristics, asthma treatments, and clinical outcomes in the 12 months before the study visit were collected using electronic case report forms.

RESULTS

Data from 476 patients (mean age, 55.4 years; female, 63.0%) were analyzed. Most patients were treated by specialists (83.7%) and had moderate-to-severe asthma (91.0%). Overall, 7.6% of patients were prescribed ≥ 3 SABA canisters (defined as over-prescription). In patients prescribed SABA in addition to maintenance therapy, 47.4% were over-prescribed SABA. Most patients (95.4%) were prescribed a fixed-dose combination of an inhaled corticosteroid and a long-acting β2-agonist as maintenance therapy. Although asthma was well-controlled/partly-controlled in 91.6% of patients, 29.6% experienced ≥ 1 severe asthma exacerbation.

CONCLUSION

SABA over-prescription was reported in nearly 50% of patients prescribed SABA in addition to maintenance therapy, underscoring the need to align clinical practices with the latest evidence-based recommendations and educate physicians and patients on appropriate SABA use.

Exploring the feasibility, acceptability, usability and safety of a digitally supported self-management intervention for uncontrolled asthma: A pre-post pilot study in secondary care

Introduction

Asthma control is often suboptimal, which is associated with incorrect medication use and poor asthma management by patients. Astmakompas, a digital self-management intervention, comprises a mobile app for patients, a web portal for healthcare professionals (HCP), and a wireless spirometer. Together, these components are intended to facilitate symptom monitoring, patient-HCP communication and assist in asthma-related self-management.

Objective

The pilot study primarily aims to assess the feasibility, acceptability, usability and safety of Astmakompas from patient and HCP perspectives, and secondarily to explore potential effects on asthma control, medication use, Quality of Life, self-efficacy and (in)direct costs.

Methods

A mixed-method, multi-center, pre-post study design was conducted in two Dutch hospitals, involving patients with uncontrolled asthma and four HCPs. Primary outcomes were assessed post-intervention using questionnaires and in-depth interviews. Secondary outcomes were assessed at baseline and post-intervention using questionnaires, and post-intervention using in-depth interviews.

Results

In general, the data show that Astmakompas was considered feasible, acceptable, usable and safe by both patients (n = 14) and HCPs (n = 4). Furthermore, qualitative data of 11 patients and all HCPs showed the importance of guidance from HCPs and tailoring of Astmakompas to care needs. Astmakompas helped patients recognise symptoms and provided valuable insights into asthma control while being easy to use. Asthma control improved from baseline (M = 2.1, SD = 1.3) to post-intervention (M = 1.3, SD = 1.0, t(13) = 2.61; p = .02).

Conclusion

Astmakompas shows promise for further implementation and research. Future randomized studies with longer evaluation periods are crucial to assess the tool's impact on asthma outcomes and workload. It is important that HCPs guide and tailor interventions to meet the patient's individual needs and circumstances.

Mild asthma is not mild: risk factors and predictive biomarkers for severe acute exacerbations and progression in mild asthma

INTRODUCTION

Asthma is a common chronic respiratory disease characterized by chronic airway inflammation, airway hyperresponsiveness, reversible airflow limitation, and airway remodeling. Mild asthma is the most common type of asthma, but it is the most neglected. Sometimes mild asthma can lead to acute severe exacerbations or even death.

AREAS COVERED

This article reviews the epidemiology, risk factors, and possible predictors of acute severe exacerbations and disease progression in mild asthma to improve the understanding of mild asthma and its severe acute exacerbations and progression.

EXPERT OPINION

There is a necessity to improve asthma patient categorization and redefine mild asthma's concept to heighten patient and physician attention. Identifying mild asthma patients that are highly vulnerable to severe acute exacerbations and researching the mechanisms are future prioritizations.

Short-acting β2-agonist Prescription Patterns in Patients with Asthma in the Philippines: Results from SABINA III

Objective

As asthma is a chronic inflammatory disease of the airways, anti-inflammatory treatment should be positioned at the forefront of guideline-directed asthma care. However, patients tend to rely on short-acting β2-agonists (SABAs) for rapid-onset symptom relief. The impact of SABA overuse and associated clinical outcomes have been investigated extensively in Europe and North America. Limited data are available from countries in Asia, Africa, Latin America, and the Middle East. The SABA use IN Asthma (SABINA) III program, a large multicountry, observational study, was undertaken to describe the global extent of SABA use and its potential contribution to suboptimal disease control. As part of the SABINA III study, we aimed to characterize SABA prescription collection and asthma-related clinical outcomes among patients in the Philippines.

Methods

This nationwide, observational, cross-sectional, SABINA III study included patients (aged ≥12 years) with a documented asthma diagnosis recruited between May 2019 and January 2020 from 10 sites in the Philippines. Demographics, disease characteristics and prescribed asthma treatments, including SABA and inhaled corticosteroids (ICS) in the 12 months preceding study start, were recorded during a single visit, and transcribed onto an electronic case report form (eCRF). Patients were classified by investigator-defined asthma severity, guided by the 2017 Global Initiative for Asthma (GINA) report and practice type, either primary or pulmonary medicine specialist care.

Results

Of 245 patients analyzed, 63.3% were classified as having moderate-to-severe asthma (GINA steps 3-5), and most patients (63.3%) were enrolled by pulmonary medicine specialists. Overall, 33.1% (n=81) of patients had experienced ≥1 severe exacerbation in the previous 12 months and 18.4% (n=45) of patients had uncontrolled asthma. With respect to asthma treatments, a total of 6.5% (n=16), 40.4% (n=99), and 2.4% (n=6) of patients were prescribed SABA monotherapy, SABA in addition to maintenance therapy, and ICS, respectively, in the 12 months prior to their study visit. Most patients (n=156 [63.7%]) received prescriptions of fixed-dose combinations of ICS and long-acting β2-agonists. SABA over-prescription, defined as ≥3 SABA canister prescriptions per year, was observed in 10.6% (n=21) of patients. Additionally, 25.6% (n=23) of patients classified as having mild asthma were prescribed either nebulized SABA (n=17) or oral SABA (n=6). Nearly one-third of patients (n=75 [30.6%]) had purchased over-the-counter (OTC) SABA, and 46.9% (n=115) were prescribed antibiotics.

Conclusion

In this SABINA III Philippines study cohort, more than 10% of patients were over-prescribed SABA canisters. Additionally, prescriptions for oral or nebulized SABA, the purchase of non-prescription (OTC) SABA, and the high percentage of prescriptions for antibiotics warrant country-wide improvements in asthma care and management.

The emerging role of digital health in the management of asthma

The most common reasons seen for lack of asthma control include misconceptions about disease control, low controller treatment adherence, poor inhaler technique, and the resulting underuse of controllers and overuse of short-acting beta2 agonists (SABAs). Narrowing these care gaps may be achieved through well-designed patient education that considers the patient's motivation, beliefs, and capabilities regarding their asthma and its management and empowers the patient to become an active participant in treatment decisions. Digital health technologies (DHTs) and digital therapeutic (DT) devices provide new opportunities to monitor treatment behaviors, improve communication between healthcare providers and patients, and generate data that inform educational interactions. DHT and DT have been proven effective in enhancing patient self-management in other chronic conditions, particularly diabetes. Accelerated integration of DHT and DT into the management of asthma patients is facilitated by the use of digital inhalers that employ sensor technology ("smart" inhalers). These devices efficiently provide real-time feedback on controller adherence, SABA use, and inhaler technique that have the strong potential to optimize asthma control.

The Design of a Persuasive Game to Motivate People with Asthma in Adherence to Their Maintenance Medication

Objective

This study aimed to design a persuasive game, using objective adherence data, to motivate people with asthma to adhere to their medication regimen.

Methods

A participatory user-centered design approach was employed, involving end-users and other stakeholders throughout the study. The approach consisted of four phases. Semi-structured interviews and a survey were conducted to understand user needs and reasons for poor adherence (Phase 1: define). Key themes were identified, leading to the formulation of behavior change strategies and design and game requirements. Several design directions were ideated, resulting in a concept for a serious game (Phase 2: ideate). Two rounds of user-tests were performed to evaluate a prototype of the serious game in terms of usability, perceived impact on medication adherence and motivation (Phase 3: prototype and Phase 4: evaluate).

Results

Findings from semi-structured interviews (n = 6) and the online survey (n = 20) revealed that people's non-adherence was often attributed to the perception of asthma as an episodic condition, the delayed experienced effect of maintenance inhalers, and lack of knowledge regarding difference of effect between maintenance and reliever inhalers. The study used behavior change strategies to translate these insights into design requirements for the development of the narrative-based persuasive game Ademgenoot. This six-week challenge-based game combines various behavior change strategies, including personal goal setting and continuous visual feedback, as well as persuasive game design elements, such as a narrative and rewards, with the aim of enhancing motivation to adhere to their medication regimen. User-testing (n = 8; round 1 and 2) showed that Ademgenoot is feasible in clinical practice and has the potential to support people with mild asthma in adherence to their maintenance medication.

Discussion

Future efforts should be directed towards a larger evaluation to assess the impact on motivation and inhaler use behaviour.

Greenhouse Gas Emissions from Respiratory Treatments: Results from the SABA CARBON International Study

INTRODUCTION

Healthcare systems are looking to reduce their carbon impact. Short-acting β2-agonist (SABA) overuse (≥ 3 canisters/year) is common in asthma and linked to poor outcomes; however, its environmental impact remains unknown. As part of the CARBON programme, this study retrospectively quantified the carbon footprint of SABA and controller inhalers across all respiratory indications and SABA overuse in asthma in lower-middle-income countries (LMICs), upper-middle-income countries and high-income countries across Africa, Asia Pacific, Latin America and the Middle East.

METHODS

Two data sources were utilised to evaluate the carbon contribution of inhalers to respiratory care. To quantify greenhouse gas (GHG) emissions associated with total inhaler use across all respiratory indications, inhaler sales data were obtained from IQVIA MIDAS® (Q4/2018-Q3/2019) and compared by dose to prevent confounding from differences in canister actuation counts. GHG emissions associated with SABA overuse in asthma were evaluated using prescription and self-reported over-the-counter purchase data from the SABA use IN Asthma (SABINA) III study (2019-2020). Inhaler-related GHG emissions were quantified using published data and product life cycle assessments.

RESULTS

SABA accounted for > 50% of total inhaler use and inhaler-related emissions in most countries analysed. The total SABA-related emissions were estimated at 2.7 million tonnes carbon dioxide equivalents, accounting for 70% of total inhaler-related emissions. Among the countries, regions and economies analysed, per capita SABA use and associated emissions were higher in Australia, the Middle East and high-income countries. Most SABA prescriptions for asthma (> 90%) were given to patients already overusing SABA.

CONCLUSIONS

Globally, SABA use/overuse is widespread and is the greatest contributor to the carbon footprint of respiratory treatment, regardless of the economic status of countries. Implementing evidence-based treatment recommendations, personalising treatment and reducing healthcare inequities, especially in LMICs, may improve disease control and patient outcomes, thereby reducing SABA overuse and associated carbon emissions beyond SABA use alone.

Tezepelumab reduces exacerbations across all seasons in patients with severe, uncontrolled asthma (NAVIGATOR)

BACKGROUND

Asthma exacerbation frequencies vary throughout the year owing to seasonal triggers. Tezepelumab is a human monoclonal antibody that targets thymic stromal lymphopoietin. In the phase 3 NAVIGATOR study (NCT03347279), tezepelumab significantly reduced the annualized asthma exacerbation rate (AAER) vs placebo in patients with severe, uncontrolled asthma.

OBJECTIVE

To evaluate the effect of tezepelumab on asthma exacerbations across all seasons in NAVIGATOR patients (post hoc).

METHODS

NAVIGATOR was a multicenter, randomized, double-blind, placebo-controlled study. Patients (12-80 years old) were randomized 1:1 to tezepelumab 210 mg or placebo subcutaneously every 4 weeks for 52 weeks. AAER over 52 weeks was assessed by season. Data from patients in the Southern Hemisphere were transformed to align with Northern Hemisphere seasons.

RESULTS

Tezepelumab reduced the AAER vs placebo by 63% (95% confidence interval [CI], 52-72) in winter, 46% (95% CI, 26-61) in spring, 62% (95% CI, 48-73) in summer, and 54% (95% CI, 41-64) in fall. In matched climates, during the spring allergy season (March 1 to June 15) and ragweed allergy season (September), tezepelumab reduced the AAER vs placebo in patients with seasonal allergy by 59% (95% CI, 29-77) and 70% (95% CI, 33-87), respectively. In patients with perennial allergy and in those with seasonal allergy, tezepelumab reduced the AAER vs placebo across all seasons.

CONCLUSION

Tezepelumab reduced exacerbations across all seasons vs placebo in patients with severe, uncontrolled asthma, including patients with seasonal and perennial allergies. These data further support the efficacy of tezepelumab in a broad population of patients with severe, uncontrolled asthma.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03347279 (https://clinicaltrials.gov/ct2/show/NCT03347279).

Research progress on the mechanism of astragaloside IV in the treatment of asthma

Asthma is a common chronic respiratory disease, and its treatment is a core problem and challenge in clinical practice. Glucocorticoids (GCs) are the first-line therapy for the treatment of asthma. Local and systemic adverse reactions caused by GCs create obstacles to the treatment of asthma. Therefore, the research target is to find a new, safe, and effective therapeutic medicine at present. Natural products are an important source for treating asthma with low cost and low toxicity. Astragaloside IV (AS-IV) is an active ingredient of traditional Chinese medicine Astragalus mongholicus Bunge. Previous studies have indicated that AS-IV plays a therapeutic role in the treatment of asthma by inhibiting airway inflammation and remodeling the airway, and by regulating immunity and neuroendocrine function (Fig. 1) . It has a variety of biological characteristics such as multi-target intervention, high safety, and good curative effect. This article reviews the specific mechanism of AS-IV for the treatment of asthma to provide references for subsequent research.

Addressing therapeutic inertia for asthma biologics: Lessons from the KOFU study

Despite evidence-based guidelines and the availability of five biologics in Japan to treat severe asthma, approximately one-third of patients with severe asthma continue to have uncontrolled disease. This lack of appropriate evidence-based treatment is a complex issue resulting from therapeutic inertia, a lack of treatment intensification according to evidence-based guidelines for patients who are considered eligible but not receiving therapy, and is often driven by complex factors involving patients, physicians, and healthcare systems. The KOFU study, the largest cross-sectional Internet Survey for severe asthma in Japan, addressed potential barriers to starting biologic treatment and sought a solution for therapeutic inertia regarding asthma biologics. Although the burden of high medical costs is the largest barrier to initiating biologic treatment for patients, other important barriers were also revealed, including an incorrect perception of asthma severity or a poor recognition of the need for treatment intensification, a lack of proper communication with patients or a lack of confidence in the physicians, initiating biologics together with the complicated process of the insurance systems to ease the burden of high medical costs or strict criteria for the approval of biologics for health care insurance systems. Increased awareness and understanding of these barriers to biologic treatment may facilitate an optimal recommendation process to individualize treatment in patients with severe asthma.

Clinical inertia in asthma

Despite advances in pharmaceutical treatment in recent years, a relatively high proportion of patients with asthma do not have adequate asthma control, causing chronic disability, poor quality of life, and multiple emergency department visits and hospitalizations. A multifaceted approach is needed to overcome the problems with managing asthma, and clinical inertia (CI) is a crucial concept to assist with this approach. It divides clinical inertia into three main categories, which include healthcare provider-related, patient-related, and healthcare system-related CI. The strategies to overcome these CI are complex, and the M-GAP approach, which combines a multidisciplinary approach, dissemination of guidelines, utilization of applications, and development and promotion of low-cost prescriptions, will help clinicians.

Evaluation of short-acting Beta-2-agonist prescriptions and associated clinical outcomes: Findings from the SABA use IN Asthma (SABINA) study in Asia

Background

The extent of short-acting Beta-2-agonist (β2-agonist) (SABA) use across Asian countries is not well documented. As part of the SABA use IN Asthma (SABINA) III study, we assessed SABA prescriptions and clinical outcomes in patients with asthma from Asia.

Methods

This cross-sectional study recruited patients (aged ≥12 years) with asthma from 8 Asian countries. Data on disease characteristics and asthma treatments were collected using electronic case report forms. Patients were classified by practice type (primary or specialist care) and investigator-defined asthma severity (per Global Initiative for Asthma [GINA] 2017 recommendations). The association of SABA prescriptions with clinical outcomes was analyzed using multivariable regression models.

Results

Overall, 3066 patients were analyzed, with a mean (standard deviation) age of 51.8 (16.7) years; of these patients, 2116 (69%) were female, 2517 (82.1%) had moderate-to-severe asthma and 2498 (81.5%) and 559 (18.2%) were treated in specialist and primary care, respectively. In total, 1423 (46.4%) patients had partly controlled/uncontrolled asthma, with 1149 (37.5%) patients experiencing ≥1 severe asthma exacerbation in the previous year. Overall, 800 (26.7%) patients were prescribed ≥3 SABA canisters in the previous year, which is regarded as overprescription and was associated with a significantly decreased odds of at least partly controlled asthma and increased incidence rates of severe exacerbations (P < 0.01 for both associations).

Conclusion

The findings from this cohort of predominantly specialist-treated patients with asthma indicate SABA overprescription in at least 1 in every 4 patients, and this overprescription is associated with poor clinical outcomes. These data highlight the need for adherence to recently updated asthma treatment recommendations in Asia.

European Respiratory Society short guidelines for the use of as-needed ICS/formoterol in mild asthma

Recent clinical trials of as-needed fixed-dose combination of inhaled corticosteroid (ICS)/formoterol have provided new evidence that may warrant a reconsideration of current practice. A Task Force was set up by the European Respiratory Society to provide evidence-based recommendations on the use of as-needed ICS/formoterol as treatment for mild asthma. The Task Force defined two questions that were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. The Task Force utilised the outcomes to develop recommendations for a pragmatic guideline for everyday clinical practice. The Task Force suggests that adults with mild asthma use as-needed ICS/formoterol instead of regular ICS maintenance treatment plus as-needed short-acting β2-antagonist (SABA) and that adolescents with mild asthma use either as-needed ICS/formoterol or ICS maintenance treatment plus as-needed SABA (conditional recommendation; low certainty of evidence). The recommendation for adults places a relatively higher value on the reduction of systemic corticosteroid use and the outcomes related to exacerbations, and a relatively lower value on the small differences in asthma control. Either treatment option is suggested for adolescent patients as the balance is very close and data more limited. The Task Force recommends that adult and adolescent patients with mild asthma use as-needed ICS/formoterol instead of as-needed SABA (strong recommendation; low certainty of evidence). This recommendation is based on the benefit of as-needed ICS/formoterol in mild asthma on several outcomes and the risks related to as-needed SABA in the absence of anti-inflammatory treatment. The implementation of this recommendation is hampered in countries (including European Union countries) where as-needed ICS/formoterol is not approved for mild asthma.

Genomics of Treatable Traits in Asthma

The astounding number of genetic variants revealed in the 15 years of genome-wide association studies of asthma has not kept pace with the goals of translational genomics. Moving asthma diagnosis from a nonspecific umbrella term to specific phenotypes/endotypes and related traits may provide insights into features that may be prevented or alleviated by therapeutical intervention. This review provides an overview of the different asthma endotypes and phenotypes and the genomic findings from asthma studies using patient stratification strategies and asthma-related traits. Asthma genomic research for treatable traits has uncovered novel and previously reported asthma loci, primarily through studies in Europeans. Novel genomic findings for asthma phenotypes and related traits may arise from multi-trait and specific phenotyping strategies in diverse populations.

Assessing the Effects of Changing Patterns of Inhaled Corticosteroid Dosing and Adherence with Fluticasone Furoate and Budesonide on Asthma Management

INTRODUCTION

Pharmacological asthma management focuses on the use of inhaled corticosteroid (ICS)-containing therapies, which reduce airway inflammation and provide bronchoprotection, improving symptom control and reducing exacerbation risk. ICS underuse due to poor adherence is common, leading to poor clinical outcomes including increased risk of mortality. This article reviews efficacy versus systemic activity profiles for various adherence patterns and dosing regimens of fluticasone furoate (FF)-containing and budesonide (BUD)-containing asthma therapies in clinical trials and real-world studies.

METHODS

We performed a structured literature review (1 January 2000-3 March 2022) and mathematical modelling analysis of FF-containing and BUD-containing regular daily dosing in patients with mild-to-severe asthma, as-needed BUD/formoterol (FOR) in mild asthma, and BUD/FOR maintenance and reliever therapy (MART) dosing in moderate-to-severe asthma, to assess efficacy (bronchoprotection) and systemic activity (cortisol suppression) profiles of dosing patterns of ICS use in multiple adherence scenarios.

RESULTS

A total of 22 manuscripts were included in full-text review and 18 in the model simulations. Focusing on FF-containing or BUD-containing treatments at comparable adherence rates, regular daily FF or FF/vilanterol (VI) dosing provided more prolonged bronchoprotection and fewer systemic effects than daily BUD, daily BUD/FOR, or BUD/FOR MART dosing, especially in low adherence scenarios. In model simulations and the real-world setting, FF/VI generally provided longer bronchoprotection, lower systemic activity, and greater clinical benefits over BUD/FOR as well as consistently higher adherence.

CONCLUSION

In this literature review and modelling analysis, FF/VI was found to show clinical advantages on asthma control over BUD/FOR. These findings have implications for helping clinicians select the most suitable inhaled therapy for their patients with asthma.

Quality indicators in the rational management of severe asthma: A Spanish multidisciplinary consensus

AIM

Severe asthma is a complex, heterogeneous condition that can be difficult to control despite currently available treatments. Multidisciplinary severe asthma units (SAU) improve control in these patients and are cost-effective in our setting; however, their implementation and development can represent an organizational challenge. The aim of this study was to validate a set of quality care indicators in severe asthma for SAU in Spain.

METHODS

The Carabela initiative, sponsored by SEPAR, SEAIC, SECA and SEDISA and implemented by leading specialists, analyzed the care processes followed in 6 pilot centers in Spain to describe the ideal care pathway for severe asthma. This analysis, together with clinical guidelines and SEPAR and SEAIC accreditation criteria for asthma units, were used to draw up a set of 11 quality of care indicators, which were validated by a panel of 60 experts (pulmonologists, allergologists, and health-policy decision-makers) using a modified Delphi method.

RESULTS

All 11 indicators achieved a high level of consensus after just one Delphi round.

CONCLUSIONS

Experts in severe asthma agree on a series of minimum requirements for the future optimization, standardization, and excellence of current SAUs in Spain. This proposal is well grounded on evidence and professional experience, but the validity of these consensus indicators must be evaluated in clinical practice.

Impact of asthma in Europe: A comparison of web search data in 21 European countries

Background

Asthma is a chronic inflammatory disorder of the airways and one of the most important non-communicable diseases worldwide. Analyzing crowdsourced data can help understand public interest and unmet needs as well as potential factors influencing search behavior.

Objective

The study aimed to investigate asthma-related web search data in Europe to identify possible regional and seasonal variations and to assess public interest.

Methods

Google Ads Keyword Planner was used to measure search volume for search terms related to asthma, allergic asthma, and bronchial asthma in 21 European countries between January 2018 and December 2021. The top 10 keywords of each country were categorized qualitatively. Search volume per 100 000 inhabitants was descriptively assessed in terms of regional and seasonal trends. Spearman correlations between search volume and pollen concentration as well as coronavirus disease (COVID-19) cases were investigated.

Results

The median search volume per 100 000 inhabitants for asthma and allergic asthma was highest in Northern and Western Europe, while the highest search volume for bronchial asthma was observed in Western and Eastern regions. A seasonal trend was identified for all search terms and in all regions. Correlations were found between search frequency and pollen load and search behavior and COVID-19 cases. Overall, Europeans were most interested in the diseases in general, their treatment options, and symptoms.

Conclusion

These results highlighted the need for reliable and region-specific information about the disease and for public campaigns to improve asthma control. The study also emphasizes the importance of using crowdsourced data for a more encompassing overview beyond conventional healthcare data.

SABAs as Reliever Medications in Asthma Management: Evidence-Based Science

The role of as-needed inhaled short-acting β2-agonists (SABAs) in the management of asthma has become a subject of debate due to differing opinions in the professional community relating to the use of SABAs. In this article, we summarize the current position of SABAs when used as reliever medications and examine the challenges to appropriate use including a critique of the data that have led to the condemnation of SABA used as a reliever. We consider the evidence for the appropriate use of SABA as a reliever together with practical solutions to ensure such use, including identifying patients at risk of misusing their SABA relievers and managing issues of inhaler technique and treatment adherence. We conclude that inhaled corticosteroid (ICS)-based maintenance treatment with SABA used as-needed as a reliever is an effective and safe treatment for patients with asthma, with no scientific evidence of a causal link between SABA use as a reliever and mortality or serious adverse events (including exacerbations). Increased SABA use warns of a deterioration in asthma control, and patients at risk of misusing their ICS and SABA medication should be rapidly identified to ensure they are receiving adequate ICS-based controller therapy. Appropriate use of ICS-based controller therapy and as-needed SABA should be encouraged and promoted with educational activities.

Economic evaluation of biological treatments in patients with severe asthma: a systematic review

BACKGROUND

Asthma is a highly prevalent disease, one of the chronic diseases with the highest economic costs; thus, it imposes a high economic burden on society, the healthcare system, patients, and third-party payers. Contrary to this study, until now, systematic reviews of economic evaluations (EEs) of treatments for severe asthma have not been exclusively focused on biological treatments, and have included a small number of studies and only model-based EEs.

METHODS

This study systematically reviews EEs of biological therapies for severe asthma published until December 2022 using PRISMA guidelines. The review analyzes the cost-effectiveness of biologicals in comparison to SOC, or SOC plus OCS. The quality of the EEs is assessed using Consensus on Health Economics Checklist extended (CHEC-extended).

RESULTS

Thirty-nine studies were eligible: 15 based on a Markov model, and 19 trial-based; eight adopting societal and NHS perspectives, and seven the payer's perspective. The reviewed EEs addressed cost-effectiveness, cost-utility, and incremental costs and outcomes comparison. Their findings were mainly expressed through ICER-incremental cost-effectiveness ratio (24 studies: 13 concluded that biological were cost-effective) and cost comparison analysis (14 studies: 6 concluded that biological were cost-effective), and were sensitive to a wide variety of factors (e.g. medication cost, treatment response, time horizon, utility benefits, mortality, exacerbation rate, discount rate, etc.).

CONCLUSIONS

There has been some ambiguity concerning the EE of biological therapies due to variation in choice of study design and contradictory results. Nevertheless, it can be concluded that biological treatments improve health outcomes, in many contexts at a high cost.

Mild asthma: Lessons learned and remaining questions

Patients living with mild disease represent the largest proportion of asthma patients. There are significant challenges in proposing a definition that would best describe these patients, while also accurately identifying at-risk individuals. Current literature suggests considerable inflammatory and clinical heterogeneity within this group. Research has shown that these patients are at risk of poor control, exacerbations, lung function decline, and death. Despite conflicting data on its prevalence, eosinophilic inflammation appears to be a predictor of poorer outcomes in mild asthma. There is an immediate need to better understand phenotypic clusters in mild asthma. It is also important to understand factors that influence disease progression and remission, as it is evident that both vary in mild asthma. Guided by robust literature that supports inhaled corticosteroid-based strategies over short-acting beta-agonist (SABA) reliant regimens, the management of these patients has evolved considerably. Unfortunately, SABA use remains high in clinical practice despite strong advocacy from the Global Initiative for Asthma. Future mild asthma research should explore the role of biomarkers, develop prediction tools based on composite risk scores, and explore targeted therapies at least for at-risk individuals.

WITHDRAWN: Prospective direct comparison of biological treatments on severe eosinophilic asthma: Findings from the PRISM study

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