The use of β2-agonist therapy before hospital attendance for severe asthma exacerbations: a post-hoc analysis

National expert consensus on short-acting beta2-agonist overreliance in asthma care in Malaysia

OBJECTIVE

Inappropriate use of short-acting beta2-agonists (SABA) in asthma has been associated with undesired outcomes. This national expert consensus was developed to spread awareness of SABA overuse and provide recommendations on the ways to eliminate SABA overprescription and overreliance in asthma care in Malaysia.

DATA SOURCES

This expert consensus was developed by searching the PubMed database, using index terms to identify SABA overuse-related burden and recommendations made in asthma guidelines. Consensus recommendations were made via the Delphi method, involving a Malaysian expert committee comprising 13 healthcare professionals (five pulmonologists, four family medicine specialists, two emergency medicine physicians and two pharmacists).

STUDY SELECTIONS

The articles reviewed include randomized controlled trials, systematic reviews, meta-analyses, observational studies, guidelines, and surveys, with abstracts in English and published up until June 2023. Relevant recommendations were also sourced from the verified websites of medical organizations and societies.

RESULTS

Eleven consensus statements were developed, each statement achieving a priori agreement level of at least 70%. The statements reflect SABA overreliance in asthma care, as well as recommendations to eliminate SABA overprescription and overreliance in Malaysia. Supporting evidence in literature as well as expert committee discussions leading to the development of the finalized statements were elaborated.

CONCLUSION

This national expert consensus discussed the burden of SABA overreliance and made specific recommendations to eliminate SABA overprescription and overreliance in the Malaysian context. This consensus document is anticipated to impart better awareness among Malaysian healthcare providers and contribute to the continuous improvement of asthma care in the country.

Budesonide/formoterol maintenance and reliever therapy in childhood asthma: Real-world effectiveness and economic assessment

INTRODUCTION

The study aims to compare the real-world effectiveness and economy of the budesonide/formoterol reliever and maintenance therapy (SMART) with fixed-dose inhaled corticosteroids (ICS)/long-acting b-agonist (LABA) or ICS alone plus as-needed, short-acting β2 agonists (SABA) in pediatric patients.

METHODS

The outpatient data warehouse of a hospital in China was used. A total of 103 patients under 18 years old in the SMART group and 63 patients in the control group were included from January 1, 2020 to December 31, 2021. The effectiveness was assessed using asthma attacks and lung function at baseline, 6 months and 12 months follow-up. Cost-effectiveness analysis was performed with a three-state Markov model from the healthcare system perspective. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to check the robustness of the results.

RESULTS

The SMART regimen was more effective than other strategies in reducing the risk of mild and severe attacks in the real-life management of childhood asthma. Patients in both groups showed significant improvement in lung function at 6 and 12 months in contrast to baseline. Compared with other strategies, the forced expiratory volume in 1 s (FEV1 ) level in the SMART group was markedly improved at 6 months. The total cost of outpatient service using the SMART regimen was lower than that of other strategies, while the drug costs were similar in different groups. Incremental cost-effectiveness analysis results showed that using the SMART regimen reduced the total cost by approximately CNY 10,516.11 per year with a 0.12 quality-adjusted life year (QALYs) increase. Sensitive analyses supported that the SMART regimen was the dominant choice at the willingness-to-pay threshold of CNY 85,698, per capita GDP in China.

CONCLUSIONS

Collectively, our findings indicate that the real-world effectiveness and economy of the SMART regimen are superior to the traditional strategies in pediatric asthma patients.

Predictors of excessive short-acting β2-agonist use and asthma exacerbations: a retrospective analysis of a Polish prescription database

Introduction

Despite being linked to unfavourable outcomes, short-acting β2-agonists (SABAs) are still overused by a substantial proportion of patients with asthma.

Aim

To analyse the prevalence and predictors of SABA overuse and exacerbations in patients with asthma in a nationwide database of prescription purchase records.

Material and methods

The prevalence of excessive SABA use (≥ 12 canisters) and overuse (≥ 3 canisters) was analysed among patients aged 18-64 years who purchased asthma medications in 2018. Predictors of excessive SABA use and SABA overuse were examined by quasi-Poisson regression. Negative binomial regression was used to study the association of excessive SABA use or overuse to the risk of asthma exacerbation defined as a prescription for oral corticosteroids.

Results

Of 91,763 patients with asthma, 42,189 (46%) were SABA users (mean age, 47 years; 58% female). Among them, 34% purchased ≥ 3 SABA canisters, and 6% purchased ≥ 12 canisters. The risk (risk ratio, 95% CI) of excessive SABA use was lower in patients with concomitant prescriptions for inhaled corticosteroids (0.41, 0.34-0.48) or inhaled corticosteroids and long-acting β2-agonists (0.52, 0.47-0.56), women (0.63, 0.58-0.68), and those in secondary care (0.60, 0.44-0.66); older age was associated with a higher risk of excessive SABA use (1.06, 1.03-1.10). Excessive SABA use was the strongest predictor of asthma exacerbations among all patients (3.24, 2.84-3.70) and in those with ≥ 1 exacerbation (1.60, 1.50-1.71).

Conclusions

Excessive SABA use is highly prevalent in asthma management, is associated with lack of prescriptions for inhaled corticosteroids, and substantially increases the exacerbation risk.

Patterns of rescue and maintenance therapy claims surrounding a clinical encounter for an asthma exacerbation

BACKGROUND

A "window of opportunity" has been proposed where anti-inflammatory therapy administration in response to symptoms could prevent exacerbation.

OBJECTIVE

To evaluate rescue and maintenance therapy claims surrounding a severe asthma exacerbation serious enough to require a face-to-face clinical encounter.

METHODS

Merative MarketScan research databases (US administrative claims 2011 to 2017) were analyzed for patients aged ≥4 years, with an asthma diagnosis code, who filled short-acting β2-agonist (SABA) and Global Initiative for Asthma Steps 3 to 5 maintenance therapies. Patients were indexed on a random SABA claim and had 12 months' continuous health plan eligibility pre- and post-index. Serious exacerbations were severe exacerbations requiring systemic corticosteroids prescribed from an outpatient clinic, urgent care or emergency department, or hospitalization for asthma. SABA and maintenance claims 30 days pre- and post-event were analyzed.

RESULTS

Of 319,342 patients (30% children 4 to 11 years; 70% adults or adolescents ≥12 years), 27.2% of children and 16.8% of adolescents or adults experienced ≥ 1 serious exacerbation (unadjusted odds ratio [OR], 1.85 [95% confidence interval, 1.81-1.88]). In the 30 days pre-event, 42.6% filled ≥1 SABA (children: 44.3%; adolescents or adults: 41.5%; OR, 1.12 [1.09-1.16]) and 57.4% filled maintenance (children: 59.0%; adolescents or adults: 56.3%; OR, 1.12 [1.08-1.15]). In the 30 days post-event, 61.4% filled SABA (children: 69.7%; adolescents or adults: 55.6%; OR, 1.84 [1.78-1.90]) and 94.8% filled maintenance (children: 98.6%; adolescents or adults: 92.2%; OR, 6.09 [5.45-6.81]).

CONCLUSION

Many patients treated as having moderate-to-severe asthma escalate SABA claims before a serious exacerbation, but approximately 40% have no anti-inflammatory maintenance fill, highlighting a "window of opportunity" to prevent exacerbations using inhaled corticosteroids concomitantly with SABA as rescue.

Real-world evaluation of asthma reliever therapy among continuous users of asthma maintenance medication in Japan: A retrospective cohort study using a claims database

BACKGROUND

The decrease in mortality rate owing to asthma has slowed in recent years. A large proportion of patients with asthma remain uncontrolled in Japan. This study aimed to determine the prevalence of short-acting beta 2 agonists (SABA) overuse and its associated factors.

METHODS

This large-scale retrospective cohort study analyzed continuously treated patients with asthma aged 15-74 years between January 2017 and December 2017 using a Japanese insurance claims database. Characteristics, disease information, and prescribed drugs were extracted from the database, and treatment steps were defined according to drug combinations based on the criteria of the Japanese asthma guidelines. SABA overuse was defined as ≥3 canisters per year. Factors associated with SABA overuse were estimated using multivariable logistic regression.

RESULTS

Among 7,483 patients with mild-to-moderate asthma, 7,001 (93.6%) and 482 (6.4%) had low and high SABA use, respectively. Inhaled corticosteroids (ICS)/long-acting β-agonists (LABA) were the main asthma control treatments. The proportions of patients who overused SABA were 347 (9.9%) and 1,201 (5.6%) in the ICS and ICS/LABA groups, respectively. The factors associated with SABA overuse were male sex, ICS monotherapy, higher treatment steps, no history of allergic rhinitis, no history of chronic sinusitis, and no asthma management.

CONCLUSIONS

There is a relatively low prevalence of SABA overuse among asthmatic patients in Japan. ICS/LABA therapy, treatment steps, allergic rhinitis, chronic sinusitis, and asthma management are associated with a decreased risk of SABA overuse. Further studies are needed to investigate the association between SABA overuse and asthma exacerbation and mortality.

Landscape of short-acting beta-agonists (SABA) overuse in Europe

This review article provides an overview of short-acting beta-agonist (SABA) use and prescribing trends in Europe, summarizing updated data on the results from the industry-funded SABINA program (SABA use IN asthma) and other studies on this matter. SABA use continues to increase worldwide. Overuse has been defined as ≥3 canisters/year. Almost a third of European patients with asthma, at all severity levels, overuse SABA. Guidelines recommend close monitoring of patients who overuse SABA and avoiding over-reliance on SABA monotherapy. SABA overuse is associated with increased risk of asthma exacerbations and mortality, increased use of health services and negative physical and mental health outcomes. Reliance on SABA monotherapy can be unsafe and therefore it is necessary to change asthma treatment approaches and policies. Changes in physician and patient behaviours towards SABA use are required to ensure that patients with asthma are not over-reliant on SABA monotherapy. Notwithstanding, the limitations of the studies on the use of SABA should be considered, taking into account that the prescription/purchase of medication canisters does not always represent the actual use of the medication and that associations between SABA overuse and poor asthma outcomes may not be directly causal. National health systems and asthma guidelines must align asthma management with global recommendations and adjust them to local needs.

Electronic Inhaler Monitoring for Chronic Airway Disease: Development and Application of a Multidimensional Efficacy Framework

Inhaled therapy is the cornerstone of chronic airway disease therapy, but poor adherence to controller inhalers worsens clinical outcomes and increases cost. Monitoring of controller use is needed to improve adherence, and monitoring of reliever use can predict impending exacerbations. Both can be accurately achieved by electronic inhaler monitoring (EIM). However, evidence for EIM use in clinical practice is limited and varied, and knowledge gaps remain across different outcomes and health settings. We aimed to develop a framework to assess EIM systematically across all aspects of efficacy, apply this framework to the current literature, and identify gaps in efficacy to inform future development in the field. We adapted an existing framework for diagnostic tests, consisting of six levels of efficacy with ascending clinical relevance: technical, diagnostic accuracy, diagnostic thinking, therapeutic, patient outcome, and societal efficacy. Tailoring this framework to EIM, we incorporated expert feedback and applied it to the EIM efficacy literature. We found that EIM has good diagnostic accuracy, diagnostic thinking, and therapeutic efficacies, but evidence is lacking for specific aspects of technical, patient outcome, and societal efficacies. Further development of EIM requires improved reliability, usability, and data security for patients, and optimal integration with electronic medical records and overall patient care. Defining appropriate target patient groups and pairing EIM data with effective interventions, in conjunction with reducing costs through technological innovation and economies of scale, will enhance patient and societal outcome efficacies.

Short-acting β2-agonist prescriptions are associated with poor clinical outcomes of asthma: the multi-country, cross-sectional SABINA III study

Background

To gain a global perspective on short-acting β₂-agonist (SABA) prescriptions and associated asthma-related clinical outcomes in patients with asthma, we assessed primary health data across 24 countries in five continents.

Methods

SABINA III was a cross-sectional study that employed electronic case report forms at a study visit (in primary or specialist care) to record prescribed medication(s), over-the-counter (OTC) SABA purchases and clinical outcomes in asthma patients (≥12 years old) during the past 12 months. In patients with ≥1 SABA prescriptions, associations of SABA with asthma symptom control and severe exacerbations were analysed using multivariable regression models.

Results

Of 8351 patients recruited (n=6872, specialists; n=1440, primary care), 76.5% had moderate-to-severe asthma and 45.4% experienced ≥1 severe exacerbations in the past 12 months. 38% of patients were prescribed ≥3 SABA canisters; 18.0% purchased OTC SABA, of whom 76.8% also received SABA prescriptions. Prescriptions of 3–5, 6–9, 10–12 and ≥13 SABA canisters (versus 1–2) were associated with increasingly lower odds of controlled or partly controlled asthma (adjusted OR 0.64 (95% CI 0.53–0.78), 0.49 (95% CI 0.39–0.61), 0.42 (95% CI 0.34–0.51) and 0.33 (95% CI 0.25–0.45), respectively; n=4597) and higher severe exacerbation rates (adjusted incidence rate ratio 1.40 (95% CI 1.24–1.58), 1.52 (95% CI 1.33–1.74), 1.78 (95% CI 1.57–2.02) and 1.92 (95% CI 1.61–2.29), respectively; n=4612).

Conclusions

This study indicates an association between high SABA prescriptions and poor clinical outcomes across a broad range of countries, healthcare settings and asthma severities, providing support for initiatives to improve asthma morbidity by reducing SABA overreliance.

Findings from SABINA III, which included 8351 patients from 24 countries, indicate that across treatment steps and clinical care settings, high SABA prescriptions were associated with higher rates of severe exacerbations and poorer asthma controlhttps://bit.ly/2VHBISg

[What not to do in the therapeutic management of bronchial asthma. Delphi consensus recommendations for physicians who treat asthma]

Asthma is one of the most prevalent diseases in Spain, yet despite the great diagnostic and therapeutic advances made in this field, health outcomes suggest that up to 80% of patients do not have their asthma well controlled. Although the causes of this situation are diverse, there are some practices among the professionals who treat asthma that are not conducive to improving health outcomes in this disease. Our working group has prepared this document in order to remind clinicians of a series of basic guidelines, aligned with current guidelines and recent literature, and agreed by a multidisciplinary expert panel using Delphi methodology. These recommendations about what not to do in the management of asthma in the adult patient are structured into four areas: diagnosis, monitoring, treatment and prevention of exacerbations.

Impact of COVID-19 pandemic on asthma symptoms and management: A prospective analysis of asthmatic children in Ecuador

Background

Asthma affects up to 33% of children in Latin American settings. The ongoing COVID-19 pandemic has had a significant impact on access to and use of health services. We aimed to evaluate the impact of the COVID-19 lockdown on asthma exacerbations, medical facility visits, and use of asthma medications in children.

Methods

We used data from a prospective cohort of 213 children aged 5–17 years in 3 Ecuadorian cities and analysed the impact of the COVID-19 lockdown on asthma. Outcomes (asthma exacerbations, emergency room [ER] visits, planned and unplanned outpatient visits, and use of inhaled corticosteroids and Beta-2 agonists) were analysed using repeated Poisson counts (ie, number of events per participant before and during the COVID-19 lockdown).

Results

During compared to before lockdown: a) the number of asthma exacerbations remained constant (IRR, 0.87; 95% CI: 0.72–1.05; p = 0.152); b) outpatient visits (IRR 0.26, 95% CI 0.14–0.47, p < 0.001) declined 74% while ER visits declined 89% (IRR 0.11, 95% CI 0.04–0.32, p < 0.001); and c) there was no change in inhaled corticosteroids use (IRR 1.03, 95% CI 0.90–1.16, P = 0.699) while Beta-2 agonist use increased (IRR 1.32, 95% CI 1.10–1.58, P = 0.003).

Conclusions

In a cohort of Ecuadorian children with asthma, health services attendance decreased dramatically after COVID-19 lockdown, but asthma exacerbations and use of inhaled corticosteroids were unchanged. Future analyses will address the question of the effect of SARS-CoV-2 infection on asthma exacerbations and control in this paediatric population.

Self-titration of inhaled corticosteroid and β2-agonist in response to symptoms in mild asthma: a pre-specified analysis from the PRACTICAL randomised controlled trial

INTRODUCTION

In mild asthma, as-needed budesonide-formoterol is superior or noninferior to maintenance budesonide plus as-needed short-acting β₂-agonist in reducing severe exacerbations. In this pre-specified analysis, we investigated patterns of inhaled corticosteroid (ICS) and β₂-agonist use in PRACTICAL, a randomised controlled trial.

METHODS

Participants were randomised 1:1 to as-needed budesonide-formoterol (200/6 μg Turbuhaler, one actuation) or maintenance budesonide (200 μg Turbuhaler, one actuation twice a day) with as-needed terbutaline (250 μg, two actuations) for 52 weeks. 110 participants had electronic monitors attached to their study inhalers which captured the time and date of every actuation. Key outcome measures were patterns of ICS and β₂-agonist use. One actuation of budesonide-formoterol was considered to be an equivalent bronchodilator dose as two actuations of terbutaline.

RESULTS

Participants randomised to as-needed budesonide-formoterol had more days with no ICS use compared with maintenance budesonide (median total days of no use 156 versus 22 days, respectively), lower median daily budesonide dose (164 versus 328 μg, respectively) and a greater median number of days of ≥4 budesonide actuations (4 versus 1 days, respectively). Participants randomised to as-needed budesonide-formoterol took higher equivalent doses of β₂-agonist both overall (median number of actuations 0.8 versus 0.3 per day, respectively) and in response to worsening asthma (total number of "overuse days" of >8 or >16 actuations of budesonide-formoterol or terbutaline 33 versus 10 days, respectively).

CONCLUSIONS

The timing of ICS dose when self-titrated to β₂-agonist use is more important than total ICS dose in reducing severe exacerbation risk in mild asthma, when associated with greater overall use of as-needed β₂-agonist.

Towards a personalised treatment approach for asthma attacks

Asthma attacks (exacerbations) are common, accounting for over 90 000 UK hospital admissions per annum. They kill nearly 1500 people per year in the UK, have significant associated direct and indirect costs and lead to accelerated and permanent loss of lung function. The recognition of asthma as a heterogeneous condition with multiple phenotypes has revolutionised the approach to the long-term management of the condition, with greater emphasis on personalised treatment and the introduction of the treatable traits concept. In contrast asthma attacks are poorly defined and understood and our treatment approach consists of bronchodilators and systemic corticosteroids. This review aims to explore the current limitations in the description, assessment and management of asthma attacks. We will outline the risk factors for attacks, strategies to modify this risk and describe the recognised characteristics of attacks as a first step towards the development of an approach for phenotyping and personalising the treatment of these critically important events. By doing this, we hope to gradually improve asthma attack treatment and reduce the adverse effects associated with recurrent courses of corticosteroids.

Detecting asthma exacerbations using daily home monitoring and machine learning

OBJECTIVE

Acute exacerbations contribute significantly to the morbidity of asthma. Recent studies have shown that early detection and treatment of asthma exacerbations leads to improved outcomes. We aimed to develop a machine learning algorithm to detect severe asthma exacerbations using easily available daily monitoring data.

METHODS

We analyzed daily peak expiratory flow and symptom scores recorded by participants in the SAKURA study (NCT00839800), an international multicentre randomized controlled trial comparing budesonide/formoterol as maintenance and reliever therapy versus budesonide/formoterol maintenance plus terbutaline as reliever, in adults with persistent asthma. The dataset consisted of 728,535 records of daily monitoring data in 2010 patients, with 576 severe exacerbation events. Data post-processing techniques included normalization, standardization, calculation of differences or slopes over time and the use of smoothing filters. Principal components analysis was used to reduce the large number of derived variables to a smaller number of linearly independent components. Logistic regression, decision tree, naïve Bayes, and perceptron algorithms were evaluated. Model accuracy was assessed using stratified cross-validation. The primary outcome was the detection of exacerbations on the same day or up to three days in the future.

RESULTS

The best model used logistic regression with input variables derived from post-processed data using principal components analysis. This had an area under the receiver operating characteristic curve of 0.85, with a sensitivity of 90% and specificity of 83% for severe asthma exacerbations.

CONCLUSION

Asthma exacerbations may be detected using machine learning algorithms applied to daily self-monitoring of peak expiratory flow and asthma symptoms.

SABA Reliance Questionnaire (SRQ): Identifying Patient Beliefs Underpinning Reliever Overreliance in Asthma

BACKGROUND

Patient overreliance on short-acting beta₂ agonists (SABA), with concomitant underuse of inhaled corticosteroids (ICS), is associated with poor asthma control and increased risk of asthma attacks.

OBJECTIVE

To develop and validate a brief questionnaire to elicit patients' perceptions of SABA (eg, belief that asthma is best managed by SABA alone) that could lead them to be overly reliant on SABA.

METHODS

The 5-item SABA Reliance Questionnaire (SRQ) was adapted from the well-validated Beliefs about Medicines Questionnaire assessing patient perceptions of the importance of, and necessity for, SABA in managing their asthma. The psychometric properties of the questionnaire were studied using Amazon Mechanical Turk, an online survey platform, in 446 people with self-reported asthma. Internal reliability and criterion-related validity were assessed on the basis of relationships between SRQ scores and other variables, including self-reported adherence to ICSs and perceived importance of reliever inhalers.

RESULTS

Internal reliability was good with Cronbach α = 0.74. Criterion-related validity was demonstrated by an inverse correlation between SRQ scores and self-reported adherence to ICSs (r = -0.291; P < .0001), and significant correlation between SRQ scores and perceived reliever importance (r = 0.216; P < .0001), as well as by significant differences in SRQ scores between those with high and those with low self-reported ICS adherence (adherence to ICS t = 4.825; P < .0001).

CONCLUSIONS

The SRQ demonstrated acceptable internal reliability, and criterion validity, supporting its potential use as a pragmatic tool for identifying patients whose beliefs are indicative of overreliance on SABA for asthma.

Patient preferences for symptom-driven or regular preventer treatment in mild to moderate asthma: findings from the PRACTICAL study, a randomised clinical trial

Symptom-driven low-dose inhaled corticosteroid-formoterol is safe and effective in mild asthma and has been recommended as one of the preferred treatment regimens at steps 1 and 2 in the 2019 update of the Global Initiative for Asthma. However, there are no data on patient preferences for this regimen.A subgroup of participants in the PRACTICAL study (ACTRN12616000377437), a randomised controlled trial comparing symptom-driven budesonide-formoterol with maintenance budesonide plus as-needed terbutaline completed a survey on treatment preferences, satisfaction, beliefs and experience at their final study visit.306 (75%) out of 407 eligible participants completed the survey. Regimen preference was strongly associated with randomised treatment, as were preferences for and beliefs about preventer inhaler use. Combination preventer and reliever as-needed therapy was preferred by 135 (90%, 95% CI 85.2-94.8%) out of 150 who were randomised to as-needed budesonide-formoterol, and by 63 (40%, 95% CI 32.7-48.1%) out of 156 who were randomised to maintenance budesonide. By contrast, twice-daily preventer inhaler with a reliever inhaler as required was preferred by 15 (10%) out of 150 of those randomised to as-needed budesonide-formoterol and 93 (60%) out of 156 of those randomised to maintenance budesonide. Satisfaction with all study inhalers was high. Of patients randomised to as-needed budesonide-formoterol 92% (n=138) were confident using it as a reliever at the end of the study.Although most participants preferred the regimen to which they had been randomised, this association was much stronger for those randomised to budesonide-formoterol as needed, indicating that most patients preferred as-needed corticosteroid-formoterol therapy if they had experienced it.

[The management of asthma as a chronic inflammatory disease and global health problem: A position paper from the scientific societies]

Asthma is the most prevalent respiratory disease worldwide and it can affect people of all ages and is potentially fatal. Today, maintenance treatments are available that are effective in most patients, yet a significant proportion have poorly controlled disease, despite the resources on offer. This document, endorsed by members of the Spanish medical societies involved in the treatment of asthma, is intended to draw the attention of society and professionals to this problem in Spain. It focuses on the clinical, diagnostic and therapeutic aspects of asthma, and proposes some actions for improvement as regards patients and healthcare professionals which, in view of the current results arising from inadequate asthma control, might be beneficial to improve outcomes for both patients and public health.

Challenges in the treatment of asthma in children and adolescents

OBJECTIVE

Despite the availability of effective treatments, asthma control in children and adolescents remains inadequate and rates of health care use are high. This follow-up to a recent review (O'Byrne et al, Eur Respir J. 2017;50[3]) examines a number of challenges in current pediatric asthma management compared with that of an adult perspective and discusses possible alternative strategies that might improve pediatric asthma management and control.

DATA SOURCES

The evidence base for this review is limited because, historically, much of the research has been performed in adults.

STUDY SELECTIONS

Not applicable.

RESULTS

Pediatric asthma management is complicated by variability in asthma severity and control and difficulty in measuring pulmonary function and airway inflammation. Current challenges in pediatric asthma management include the recommended initial therapy treating only the symptoms rather than the underlying inflammation and switching to controller therapy only when asthma subsequently worsens.

CONCLUSION

Alternative strategies that might improve pediatric asthma management and control include replacement of short-acting β₂-agonist relievers by an inhaled corticosteroid plus a fast-acting β₂-agonist (short-acting β₂-agonist or fast- and long-acting β₂-agonist) combination at Global Initiative for Asthma step 1 or 2 to ensure that patients receive an inhaled corticosteroid whenever they feel the need for symptomatic relief. Such an approach could eliminate the problem of learned overuse or over-reliance on short-acting β₂-agonist reliever medication and address the other challenges in current pediatric asthma management. Clinical studies in pediatric patients or large studies involving a proportion of pediatric patients are required to provide the supporting evidence needed to help advance such new approaches and improve asthma control from a pediatric perspective.

The Asthma Controller Step-down Yardstick

Asthma guidelines recommend a control-based approach to disease management in which the assessment of impairment and risk is linked to step-based therapy. Using this model, controller treatment is adjusted-upward or downward-according to a patient's level of asthma control over time. Strategies for stepping up controller therapy are well described, and the adult and pediatric Asthma Yardsticks provide operational recommendations based on patient profiles. Strategies for stepping down controller treatment are less clear, although stepping down to the minimum effective therapy is important and should be considered when a patient's asthma has been well controlled for an adequate period as defined by risk and impairment. This Yardstick presents recommendations for when and how to step down asthma controller therapy according to guideline-defined control levels. The objective is to provide clinicians who treat patients with asthma with a practical and clinically relevant framework for implementing a step-down in controller therapy.

As-Needed Budesonide-Formoterol versus Maintenance Budesonide in Mild Asthma

BACKGROUND

Patients with mild asthma often rely on inhaled short-acting β₂-agonists for symptom relief and have poor adherence to maintenance therapy. Another approach might be for patients to receive a fast-acting reliever plus an inhaled glucocorticoid component on an as-needed basis to address symptoms and exacerbation risk.

METHODS

We conducted a 52-week, double-blind, multicenter trial involving patients 12 years of age or older who had mild asthma and were eligible for treatment with regular inhaled glucocorticoids. Patients were randomly assigned to receive twice-daily placebo plus budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol) used as needed or budesonide maintenance therapy with twice-daily budesonide (200 μg) plus terbutaline (0.5 mg) used as needed. The primary analysis compared budesonide-formoterol used as needed with budesonide maintenance therapy with regard to the annualized rate of severe exacerbations, with a prespecified noninferiority limit of 1.2. Symptoms were assessed according to scores on the Asthma Control Questionnaire-5 (ACQ-5) on a scale from 0 (no impairment) to 6 (maximum impairment).

RESULTS

A total of 4215 patients underwent randomization, and 4176 (2089 in the budesonide-formoterol group and 2087 in the budesonide maintenance group) were included in the full analysis set. Budesonide-formoterol used as needed was noninferior to budesonide maintenance therapy for severe exacerbations; the annualized rate of severe exacerbations was 0.11 (95% confidence interval [CI], 0.10 to 0.13) and 0.12 (95% CI, 0.10 to 0.14), respectively (rate ratio, 0.97; upper one-sided 95% confidence limit, 1.16). The median daily metered dose of inhaled glucocorticoid was lower in the budesonide-formoterol group (66 μg) than in the budesonide maintenance group (267 μg). The time to the first exacerbation was similar in the two groups (hazard ratio, 0.96; 95% CI, 0.78 to 1.17). The change in ACQ-5 score showed a difference of 0.11 units (95% CI, 0.07 to 0.15) in favor of budesonide maintenance therapy.

CONCLUSIONS

In patients with mild asthma, budesonide-formoterol used as needed was noninferior to twice-daily budesonide with respect to the rate of severe asthma exacerbations during 52 weeks of treatment but was inferior in controlling symptoms. Patients in the budesonide-formoterol group had approximately one quarter of the inhaled glucocorticoid exposure of those in the budesonide maintenance group. (Funded by AstraZeneca; SYGMA 2 ClinicalTrials.gov number, NCT02224157 .).

Identification of patterns of factors preceding severe or life-threatening asthma exacerbations in a nationwide study

BACKGROUND

Reducing near-fatal asthma exacerbations is a critical problem in asthma management.

OBJECTIVES

To determine patterns of factors preceding asthma exacerbations in a real-world setting.

METHODS

In a nationwide prospective study of 190 patients who had experienced near-fatal asthma exacerbation, cluster analysis was performed using asthma symptoms over the 2-week period before admission.

RESULTS

Three distinct clusters of symptoms were defined employing the self-reporting of a visual analogue scale. Cluster A (42.1%): rapid worsening within 7.4 hours from moderate attack to admission, young to middle-aged patients with low Body mass index and tendency to depression who had stopped anti-asthma medications, smoked, and hypersensitive to environmental triggers and furred pets. Cluster B (40.0%): fairly rapid worsening within 48 hours, mostly middle-aged and older, relatively good inhaled corticosteroid (ICS) or ICS/long-acting beta-agonist (LABA) compliance, and low perception of dyspnea. Cluster C (17.9%): slow worsening over 10 days before admission, high perception of dyspnea, smokers, and chronic daily mild-moderate symptoms. There were no differences in overuse of short-acting beta-agonists, baseline asthma severity, or outcomes after admission for patients in these 3 clusters.

CONCLUSION

To reduce severe or life-threatening asthma exacerbation, personalized asthma management plans should be considered for each cluster. Improvement of ICS and ICS/LABA compliance and cessation of smoking are important in cluster A. To compensate for low perception of dyspnea, asthma monitoring of peak expiratory flow rate and/or exhaled nitric oxide would be useful for patients in cluster B. Avoidance of environmental triggers, increase usual therapy, or new anti-type 2 response-targeted therapies should be considered for cluster C.

Symbicort® Maintenance and Reliever Therapy (SMART) and the evolution of asthma management within the GINA guidelines

INTRODUCTION

The Global Initiative for Asthma (GINA) annual report summarizes the latest evidence for asthma management. GINA recommends stepwise pharmacological treatment, advocating inhaled corticosteroids (ICS) plus rapid, long-acting β₂-agonists (LABA) delivered in a single inhaler for maintenance and relief at Steps 3 (moderate persistent asthma requiring 1-2 controllers plus as-needed reliever), 4 (severe persistent asthma requiring ≥2 controllers plus as-needed reliever), and 5 (higher level care and/or add-on treatment). Areas covered: Randomized controlled trials and real-world evidence demonstrate that flexibly dosed budesonide/formoterol for maintenance and relief (Symbicort® Maintenance And Reliever Therapy [SMART]) is associated with reductions in severe exacerbations, prolongs time to first exacerbation, and provides fast symptom relief. Expert commentary: SMART provides greater or equal levels of sustained asthma control than similar or higher fixed doses of ICS/LABA plus short-acting β₂-agonist (SABA) as needed or higher ICS plus SABA as needed, with lower overall ICS doses and cost. The simplified dosing strategy may improve adherence and overall asthma control but relies on patient education. Budesonide/formoterol as needed in mild asthma (patients qualifying for regular low-dose ICS) is currently under investigation in two double-blind randomized studies, SYGMA1/2 (NCT02149199/NCT02224157), comparing budesonide/formoterol as needed with budesonide plus SABA and SABA alone.

Description of the protocol for the PRACTICAL study: a randomised controlled trial of the efficacy and safety of ICS/LABA reliever therapy in asthma

Introduction

In adult asthma, combination inhaled corticosteroid (ICS)/fast-onset long-acting beta agonist (LABA) used solely as reliever therapy may represent an effective and safe alternative to ICS maintenance and short-acting beta agonist (SABA) reliever therapy.

Objective

To compare the efficacy and safety of ICS/fast-onset LABA reliever therapy with ICS maintenance and SABA reliever therapy in adults with asthma.

Methods and analysis

A 52-week, open-label, parallel group, multicentre, phase III randomised controlled trial with 1:1 randomisation to either budesonide/formoterol Turbuhaler 200/6 µg, one actuation as required for symptom relief, or budesonide Turbuhaler 200 µg, one actuation twice daily and terbutaline Turbuhaler 250 µg, two actuations as required for symptom relief. 890 adults aged 18–75 years with asthma for whom maintenance ICS and SABA reliever therapy is indicated by current guidelines will be recruited in New Zealand. The primary outcome variable is the rate of severe exacerbations per patient per year. This study will investigate a novel treatment regimen that might lead to a paradigm shift in asthma management for adults for whom guidelines currently recommend maintenance ICS and SABA reliever therapy.

Ethics and dissemination

Ethical approval has been granted (15/NTB/178). Study findings will be published according to Iinternational Committee of Medical Journal Editors' recommendations.

Trial registration number

ACTRN12616000377437; Pre-results.

Beta-agonist overuse and delay in obtaining medical review in high risk asthma: a secondary analysis of data from a randomised controlled trial

Asthma mortality surveys report delays in seeking medical review and overuse of beta-agonist therapy as factors contributing to a fatal outcome. However, the strength of these associations is limited because many asthma deaths are unwitnessed. We undertook a secondary analysis of data from a 24-week randomised controlled trial of 303 patients with high-risk asthma, randomised to combination budesonide/formoterol inhaler according to a single maintenance and reliever therapy regimen or fixed dose budesonide/formoterol with salbutamol as reliever (Standard) regimen. Medication use was measured by electronic monitors. The thresholds for high, marked and extreme beta-agonist use days were defined in the single maintenance and reliever therapy arm as: >8, >12 and >16 actuations of budesonide/formoterol in excess of four maintenance doses, respectively; and in the Standard arm as: >16, >24 and >32 actuations of salbutamol, respectively. Whether a medical review was obtained within 48 h of an overuse episode was determined by review of data collected during the study by participant report. The mean (standard deviation) proportion of days in which high, marked and extreme beta-agonist overuse occurred without medical review within 48 h was 0·94(0·20), 0·94(0·15) and 0·94(0·17), and 0·92(0·19), 0·90(0·26) and 0·94(0·15) for single maintenance and reliever therapy and Standard regimens, respectively. In at least 90% of days, in which beta-agonist overuse occurred, patients did not obtain medical review within 48 h of beta-agonist overuse, regardless of the magnitude of overuse or the inhaled corticosteroid/long-acting beta-agonist regimen.

In asthma, overuse of beta-agonist reliever medication and delay in seeking medical review in an exacerbation are linked to asthma deaths. Janine Pilcher at the Medical Research Institute of New Zealand, and co-workers, conducted a review of data from a study of 303 adult patients with severe asthma, followed over 24 weeks. The patients were allocated to either a budesonide/formoterol, or a salbutamol inhaler to take for symptom relief, in addition to their maintenance treatment. Inhalers were fitted with electronic monitors, to accurately document every use. In both groups, on 90% of days when an exacerbation requiring excess use of an inhaler occurred, patients did not follow-up with medical professionals within 48 h as advised. Further, in both groups, ‘extreme’ reliever inhaler use was recorded at least once in around one in four patients.

Addressing unmet needs in understanding asthma mechanisms: From the European Asthma Research and Innovation Partnership (EARIP) Work Package (WP)2 collaborators

Asthma is a heterogeneous, complex disease with clinical phenotypes that incorporate persistent symptoms and acute exacerbations. It affects many millions of Europeans throughout their education and working lives and puts a heavy cost on European productivity. There is a wide spectrum of disease severity and control. Therapeutic advances have been slow despite greater understanding of basic mechanisms and the lack of satisfactory preventative and disease modifying management for asthma constitutes a significant unmet clinical need. Preventing, treating and ultimately curing asthma requires co-ordinated research and innovation across Europe. The European Asthma Research and Innovation Partnership (EARIP) is an FP7-funded programme which has taken a co-ordinated and integrated approach to analysing the future of asthma research and development. This report aims to identify the mechanistic areas in which investment is required to bring about significant improvements in asthma outcomes.

The Digital Asthma Patient: The History and Future of Inhaler Based Health Monitoring Devices

The wave of digital health is continuously growing and promises to transform healthcare and optimize the patients' experience. Asthma is in the center of these digital developments, as it is a chronic disease that requires the continuous attention of both health care professionals and patients themselves. The accurate and timely assessment of the state of asthma is the fundamental basis of digital health approaches and is also the most significant factor toward the preventive and efficient management of the disease. Furthermore, the necessity of inhaled medication offers a basic platform upon which modern technologies can be integrated, namely the inhaler device itself. Inhaler-based monitoring devices were introduced in the beginning of the 1980s and have been evolving but mainly for the assessment of medication adherence. As technology progresses and novel sensing components are becoming available, the enhancement of inhalers with a wider range of monitoring capabilities holds the promise to further support and optimize asthma self-management. The current article aims to take a step for the mapping of this territory and start the discussion among healthcare professionals and engineers for the identification and the development of technologies that can offer personalized asthma self-management with clinical significance. In this direction, a technical review of inhaler based monitoring devices is presented, together with an overview of their use in clinical research. The aggregated results are then summarized and discussed for the identification of key drivers that can lead the future of inhalers.