Weekly self-measurement of FEV1 and PEF and its impact on ACQ (asthma control questionnaire)-scores: 12-week observational study with 76 patients

Latent myofascial trigger points injection therapy for adult cough variant asthma: A randomized controlled trial

Background

Cough variant asthma (CVA) is a chronic inflammatory airway disease characterized by airway hyper-responsiveness (AHR), of which cough is the only symptom. The cough is a result of the contraction of the vocal cords, diaphragm, sternocleidomastoid muscle, and other respiratory related muscles caused by the AHR. Long-term chronic coughing can lead to repetitive contraction and chronic strain of the muscles involved in the head and neck, ultimately contributing to the formation of latent myofascial trigger points (MTrPs). In turn, latent MTrPs can also irritate or compress the nerves around them, triggering cough. The date indicated that latent MTrPs can induce autonomic phenomena and are effective in allergic rhinitis. But their roles in asthma are unclear. In this article, the efficacy and safety of latent MTrPs injection therapy in CVA were investigated.

Methods

This randomized controlled trial was conducted with 110 patients. Patients were assigned to the intervention or control group in a 1:1.5 ratio. Intervention group (n = 44): single injection therapy with latent MTrPs. Control group (n = 66): budesonide-formoterol plus montelukast for 8 weeks. During the 36-week follow up period, the recurrence rate at week 36, cough visual analog scale (VAS), ACT (asthma control test)-scores, ACQ5 (asthma control questionnaire)-scores, AQLQ (asthma quality of life questionnaire)-scores, proportion of using rescue medication, and adverse events were evaluated.

Results

The recurrence rate at week 36 was lower in the intervention group than in the control group (36 weeks, 5.0 vs. 34.55%, p = 0.001). There were significant differences between groups in change from baseline to 36 weeks in VAS [36 weeks, 1.70 (1.49) vs. 3.18 (2.04), p < 0.001]; ACT-score [36 weeks, 21.38 (2.65) vs. 18.53 (3.00), p < 0.001]; ACQ5-score [36 weeks, 0.85 (0.55) vs. 1.52 (0.62), p < 0.001]; AQLQ-score [36w, 174.40 (18.22) vs. 151.69 (24.04), p < 0.001]; proportion of using rescue medication (36 weeks, 5.0 vs. 29.1%, p = 0.003). Fewer adverse events occurred in the two groups.

Conclusion

Latent myofascial trigger points injection therapy provided long-acting, practical, short treatment duration and safety methods for CVA.

Clinical Trials Registration

http://www.chictr.org.cn/index.aspx, Chinese Clinical Trial Registry Center, ChiCTR2100044079.

Tiotropium Add-On and Treatable Traits in Asthma-COPD Overlap: A Real-World Pilot Study

Purpose

The 'treatable traits' strategy for patients with chronic inflammatory airway diseases, especially asthma and chronic obstructive pulmonary disease (COPD), is a focus of interest, because it implements precision and personalized medicine. Asthma-COPD overlap (ACO), a phenotype involving both asthma and COPD, is an important disease entity because patients with ACO have significantly worse outcomes, conferring greater economical and social burdens. Some guidelines for ACO recommend add-on therapy of long-acting muscarinic antagonists to inhaled corticosteroids and long-acting β2 agonists. However, this approach is based on extrapolation from patients with asthma or COPD alone. Consequently, a 'treatable traits' approach suitable for ACO remains obscure.

Methods

A 12-week open-label cross-over pilot study was conducted in patients with ACO to investigate the effect of tiotropium bromide (TIO) 5 µg/day add-on therapy to fluticasone propionate/formoterol fumarate (FP/FM) 500/20 µg/day compared with FP/FM 500/20 µg/day alone. A 4-week run-in period and two 4-week treatment periods were included.

Results

A total of 18 male patients with stable ACO participated in this pilot study. All patients were ex-smokers. Mean values ± standard deviation (SD) for forced expiratory volume in 1 second (FEV1) were 1.21 ± 0.49 L after the run-in period, 1.20 ± 0.51 L after the FP/FM combination therapy period, and 1.30 ± 0.48 L after the TIO add-on therapy to FP/FM period. FEV1 values after the TIO add-on therapy FP/FM period were significantly higher than those after the run-in period (p < 0.01).

Conclusion

TIO add-on therapy to FP/FM in patients with ACO, considered difficult to treat because of the presence of both asthma and COPD, resulted in improvements in lung function parameters in this real-world pilot study, indicating the potential value of TIO add-on therapy as a "treatable traits" option for standard treatment for ACO.

Post hoc analysis of initial treatments and control status in the INITIAL study: an observational study of newly diagnosed patients with asthma

BACKGROUND

The 12-week, multicentre, observational INITIAL study (NCT02143739) assessed asthma severity in newly diagnosed Chinese patients.

METHODS

Post hoc analysis of medication combinations prescribed per routine clinical practice at baseline, and the impact on control levels evaluated using 2012 vs 2018 Global Initiative for Asthma (GINA) criteria.

RESULTS

In total, 4491 patients were included in the analysis. At baseline, intermittent, mild, moderate and severe asthma was reported in 3.9, 12.0, 22.6 and 61.6% of patients, respectively. Most patients (90.2%) were prescribed inhaled corticosteroid/long-acting β₂ agonist (ICS/LABA). ICS/LABA plus ≥1 additional medication(s) was prescribed to 66.7% of patients, with leukotriene receptor antagonist (LTRA, 54.7%) being the most common additional medication. Distribution of ICS/LABA vs ICS/LABA+LTRA was comparable in patients with intermittent (3.2% vs 3.0%), mild (11.5% vs 9.7%), moderate (21.2% vs 19.9%) and severe asthma (64.1% vs 67.4%). Control levels among patients using ICS/LABA+LTRA vs ICS/LABA were comparable using GINA 2012 and lower using GINA 2018 criteria. The proportion of patients using ICS/LABA+LTRA vs ICS/LABA with intermittent, mild, moderate and severe asthma controlled at Week 12 (using GINA 2012) were 78.1% vs 80.0, 86.5% vs 85.8, 78.5% vs 71.3, and 59.6% vs 61.8%, respectively. Using GINA 2018 criteria proportions were 86.8% vs 95.9, 86.1% vs 93.2, 82.1% vs 85.3, and 71.9% vs 77.6%, respectively.

CONCLUSIONS

Asthma control was not improved by adding LTRA to ICS/LABA and may have been unnecessary for some newly diagnosed patients. These findings were irrespective of the GINA criteria (2012 vs 2018) used and baseline severity.

Onset of Effect, Changes in Airflow Obstruction and Lung Volume, and Health-Related Quality of Life Improvements with Benralizumab for Patients with Severe Eosinophilic Asthma: Phase IIIb Randomized, Controlled Trial (SOLANA)

Objective

In the SOLANA trial, we sought to physiologically characterize benralizumab’s onset of effect and maintenance of that effect for patients with severe eosinophilic asthma.

Methods

SOLANA (NCT02869438) was a multicenter, randomized, double-blind, parallel-group, placebo-controlled, Phase IIIb study conducted at 49 centers in six countries (Chile, Germany, Hungary, the Philippines, South Korea, and the United States). Eligible patients with baseline blood eosinophil counts ≥300 cells/µL were randomized to subcutaneous benralizumab (30 mg) or placebo administered at Days 0, 28, and 56. The primary endpoint was the average change from baseline in prebronchodilator forced expiratory volume in 1 s (pre-BD FEV₁) during the Day 28‒Day 84 period for benralizumab vs placebo. Secondary endpoints included patient-reported outcomes (PROs). A subset of patients participated in a whole-body plethysmography substudy. Safety was also assessed.

Results

In total, 233 patients were randomized to benralizumab (n=118) or placebo (n=115). Improvement from baseline in pre-BD FEV₁ with benralizumab 30 mg was not statistically significant compared with placebo (least-squares mean change difference [95% confidence interval] 57 mL [−22 to 135]; p=0.16). Compared with placebo, benralizumab demonstrated early (Day 7) nonstatistically significant improvements in whole-body plethysmography assessments of hyperinflation and clinically meaningful improvements in PRO measures (Asthma Control Questionnaire 6 at Day 14 and St. George’s Respiratory Questionnaire at Day 28), which were maintained over the treatment period. Benralizumab’s safety profile was commensurate with previously reported studies.

Conclusion

The observed early changes in lung volume despite relatively small improvements in airflow obstruction suggest that the anti-inflammatory effect of benralizumab may be manifested as deflation over time for patients with hyperinflation, who potentially have a greater degree of airway remodeling. This early effect could partially explain the rapid PRO improvements observed for certain patients.

Triple Therapy with Budesonide/Glycopyrrolate/Formoterol Fumarate Improves Inspiratory Capacity in Patients with Asthma-Chronic Obstructive Pulmonary Disease Overlap

Purpose

Asthma-chronic obstructive pulmonary disease overlap (ACO), characterized by airway limitation, is an important condition with high incidence and mortality. Although some guidelines recommend triple therapy with inhaled corticosteroids/long-acting muscarinic antagonists/long-acting β2 agonists, this treatment approach is based on the extrapolation of data from studies of asthma or chronic obstructive pulmonary disease (COPD) alone.

Methods

A 12-week, randomized, open-label cross-over pilot study was conducted in 19 patients with ACO to investigate the effect of triple therapy with glycopyrrolate (GLY) 50 µg/day on budesonide/formoterol fumarate (BUD/FORM) 640/18 µg/day. The study period included a 4-week wash-out, 4-week run-in, and 4-week treatment period. Respiratory function tests, fractional exhaled nitric oxide (FeNO), a COPD assessment test (CAT) and an asthma control questionnaire (ACQ) were carried out 0, 4, and 8 weeks after randomization.

Results

A total of 19 patients with stable ACO (19 males and no females) with a mean age of 70.7 ± 7.6 years (± standard deviation, SD; range 55-83 years) participated in this study. All patients were ex-smokers with a smoking history of 63.1 ± 41.1 pack-years (± SD). Mean values for inspiratory capacity (IC), an index of hyperinflation of the lung that causes exertional dyspnea and reduced exercise, were 1.93 L (± 0.47 L) after the run-in, 1.85 L (± 0.51 L) after the BUD/FORM dual therapy period and 2.11 L (± 0.58 L) after the BUD/GLY/FORM triple therapy period. IC values after the BUD/GLY/FORM triple therapy were significantly higher than those after the run-in (p < 0.02). FeNO values, ACQ, and CAT scores were not significantly different among the run-in, wash-out, and triple-therapy periods.

Conclusion

The present pilot study showed that triple therapy with BUD/GLY/FORM results in an improvement in lung function parameters including IC, indicating the potential value of triple therapy as standard treatment for ACO.

Special Considerations and Perspectives for Exercise-Induced Bronchoconstriction (EIB) in Olympic and Other Elite Athletes

Diagnosing and treating elite and Olympic athletes with exercise-induced bronchoconstriction has been well established. However, a subset of elite and Olympic athletes with exercise-induced bronchoconstriction experience symptoms of breathlessness due to lack of adherence, improper medications, and/or generalized breathing dysfunction. A short review of traditional treatment plans for elite and Olympic athletes is presented along with the challenges of adherence, managing dysfunctional breathing, and measuring and treating mental skills deficits that may impact breathing. Elite and Olympic athletes may not respond to traditional treatment for exercise-induced bronchospasm, and we present some of the reasons why the athletes fail to respond. Furthermore, we present information on how to detect and treat elite and Olympic athletes with difficult-to-treat asthma. As part of this review we developed a flow diagram for medical providers to identify the reasons for lack of response to traditional treatment plans for exercise-induced bronchoconstriction with options for other treatment modalities.