A new approach to the treatment of asthma

Physiologic evaluation of bronchial asthma

Preview No physician would treat hypertension without monitoring blood pressure, but some treat bronchial asthma without objectively measuring pulmonary function. This empirical approach is inappropriate, according to the authors, who discuss key measurements that should be taken to assess disease status, guide therapy, and monitor response. Three illustrative cases stress the importance of objective evaluation of asthma.

Maintenance therapy for obstructive lung disease

Preview In all cases of obstructive lung disease, smoking cessation, proper use of metered-dose inhalers, up-to-date immunizations, adequate nutrition, and general physical conditioning are important components of treatment. Dr Jacobs summarizes these components as well as stepwise pharmacologic approaches to controlling the inflammation of asthma, the bronchospasm of chronic bronchitis and emphysema, and the symptoms of secondary or coexisting conditions.

The Finnish experience to save asthma costs by improving care in 1987-2013

The Finnish National Asthma Program 1994-2004 markedly improved asthma care in the 1990s. We evaluated the changes in costs during 26 years from 1987 to 2013. Direct and indirect costs were calculated by using data from national registries. Costs from both the societal and patient perspectives were included. The costs were based on patients with persistent, physician-diagnosed asthma verified by lung function measurements. We constructed minimum and maximum scenarios to assess the effect of improved asthma care on total costs. The number of patients with persistent asthma in the national drug reimbursement register increased from 83,000 to 247,583. Improved asthma control reduced health care use and disability, resulting in major cost savings. Despite a 3-fold increase in patients, the total costs decreased by 14%, from €222 million to €191 million. Costs for medication and primary care visits increased, but overall annual costs per patient decreased by 72%, from €2656 to €749. The theoretical total cost savings for 2013, comparing actual with predicted costs, were between €120 and €475 million, depending on the scenario used. The Finnish Asthma Program resulted in significant cost savings at both the societal and patient levels during a 26-year period.

Asthma Patient Education

Patient education is a very important aspect of the treatment of asthma. Success of therapy is highly dependent upon patients' knowledge of asthma and the correct use of their medications. Over the last decade the morbidity and mortality rates due to asthma have increased. Education of patients is necessary to reduce these rates. Pharmacists can play a major role in the education of patients. Pharmacists are readily available and see most patients frequently for refills. Regular use of anti-inflammatory medications, use of β2-agonists for rescue therapy, and prevention of exercise induced asthma, and correct inhaler technique should be stressed. Spacer devices and peak flow meters should be routinely recommended by pharmacists. Educational aids such as handouts, pamphlets, and video tapes are available from many different organizations that can help make education more time efficient. Asthma education is a rewarding service to offer asthma patients and helps to develop loyalty as well as overall better health care for patients.

Direct Involvement of Community Pharmacists in the Care of Asthma Patients: Dream or a Reality?

Everyday community pharmacists encounter children and adults who have asthma. Pharmacists in community and ambulatory care settings are in excellent positions to provide interventions that improve the care and the quality of life of asthmatics. This can be accomplished when community pharmacists learn more about asthma therapy, identify problem asthmatics in their practices, design asthma treatment and monitoring plans, develop patient teaching programs, and overcome barriers to direct intervention in the care of these patients.

Cell surface antigen expression by peripheral blood monocytes in allergic asthma: results of 2.5 years therapy with inhaled beclomethasone dipropionate

At present, inhaled glucocorticoids are widely accepted as the therapy of choice in chronic asthma. Treatment with inhaled glucocorticoids significantly suppresses local airway inflammation in asthmatics, but may also have systemic effects, e.g. a reduction of the number of circulating hypodense eosinophils or a down-modulation of HLA-DR antigen (Ag) expression by T lymphocytes in peripheral blood. However, the effect of long-term therapy with inhaled glucocorticoids on peripheral blood monocytes (PBM), which are the precursors of the most numerous cell type in the lung, the alveolar macrophage, have not yet been evaluated. We therefore investigated the expression of various cell surface Ag on PBM from non-smoking patients with allergic asthma who were treated for 2.5 years with a β₂-receptor agonist plus either an inhaled glucocorticoid (beclomethasone dipropionate, BDP) (n = 4) or an anticholinergic or placebo (n = 8). We compared the results with healthy volunteers (n = 7). Long-term treatment of allergic asthmatics with inhaled BDP, but not anticholinergic or placebo therapy, was associated with a significantly lower CDllb Ag expression (p < 0.04) and higher expression of CD13, CD14 and CD18 Ag (p < 0.05, p < 0.02 and p < 0.04, respectively) when compared with the healthy control subjects (n = 7). Most interestingly, PBM of asthmatics treated with inhaled BDP expressed an almost two-fold higher level of CD14 Ag on their cell surface than PBM of patients treated with anticholinergic or placebo (p < 0.03). No significant differences in the expression of CD16, CD23, CD25, CD32 and CD64 Ag or HLA-DR were observed between PBM from the different patient groups or healthy controls. Taken together, this study shows that long-term local therapy with inhaled BDP coincides with an altered expression of at least one cell surface Ag on PBM from allergic asthmatics.

[Long-acting beta(2)-adrenoceptor agonists for asthma and COPD]

The introduction of long-acting beta(2)-adrenoceptor agonists such as salmeterol and formoterol has opened new perspectives for the treatment of asthma and, possibly, also COPD. These drugs are particularly useful in bronchial asthma and meet the requirements of several treatment guidelines to combine long-acting bronchodilator therapy with inhaled corticosteroids in patients with persistent asthma. The role of long-acting beta(2)-adrenoceptor agonists for management of COPD is less clear. While effects on lung function will be small, parameters of improved quality of life and exercise tolerance may verify the clinical role of long-acting beta(2)-adrenoceptor agonists for COPD treatment in the future.

The 2007 National Asthma Education and Prevention Program asthma guidelines: accelerating their implementation and facilitating their impact on children with asthma

Nearly 2 decades have elapsed since the National Center for Health Statistics raised concerns regarding the trends in increasing asthma prevalence. Additional research highlighted the large racial disparities and geographic variations in asthma morbidity and mortality rates. Although there was little national consensus on the care of children with asthma at the time, there were improvements in the understanding of the mechanisms and treatment of asthma. It was in this context that the National Heart, Lung, and Blood Institute launched the National Asthma Education and Prevention Program, which convened its first panel of experts to create the national consensus clinical practice guidelines on the treatment of asthma. More than 15 years have passed since the publication of those first guidelines and, in August 2007, the National Heart, Lung, and Blood Institute released its newest updates, which are the product of the National Asthma Education and Prevention Program third expert panel. The release of the updated guidelines serves as an occasion to examine important issues regarding the dissemination and clinical implementation of National Asthma Education and Prevention Program guidelines. The goals of this report are to examine the adoption of earlier versions of the National Asthma Education and Prevention Program guidelines and to suggest opportunities for rapid adoption of the newly released guidelines.

Use of prescription drugs in athletes

Although athletes are young and generally healthy, they use a variety of non-doping classified medicines to treat injuries, cure illnesses and obtain a competitive edge. Athletes and sports medicine physicians try to optimize the treatment of symptoms related to extreme training during an elite athlete's active career. According to several studies, the use of antiasthmatic medication is more frequent among elite athletes than in the general population. The type of training and the kind of sport influence the prevalence of asthma. Asthma is most common among those competing in endurance events, such as cycling, swimming, cross-country skiing and long-distance running. Recent studies show that athletes use also NSAIDs and oral antibacterials more commonly than age-matched controls, especially athletes competing in speed and power sports. Inappropriately high doses and concomitant use of several different NSAIDs has been observed. All medicines have adverse effects that may have deleterious effects on elite athletes' performance. Thus, any unnecessary medication use should be minimized in elite athletes. Inhaled beta(2)-agonists may cause tachycardia and muscle tremor, which are especially harmful in events requiring accuracy and a steady hand. In experimental animal models of acute injury, especially selective cyclo-oxygenase-2 inhibitors have been shown to be detrimental to tissue-level repair. They have been shown to impair mechanical strength return following acute injury to bone, ligament and tendon. This may have clinical implications for future injury susceptibility. However, it should be noted that the current animal studies have limited translation to the clinical setting. Adverse effects related to the CNS and gastrointestinal adverse reactions are commonly reported in connection with NSAID use also in elite athletes. In addition to the potential for adverse effects, recent studies have shown that NSAID use may negatively regulate muscle growth by inhibiting protein synthesis. Physicians and pharmacists taking care of athletes' medication need to be aware of the medicines that an athlete is taking and how those medicines interact with performance, exercise, environment and other medicines. Sport associations should repeatedly monitor not only the use of banned substances, but also the trends of use of legal medicines in athletes. Not only physicians and pharmacists, but also athletes and coaches should be better educated with respect to potential benefits and risks, and how each agent may affect an athlete's performance. The attitudes and beliefs leading to ample use of legal medicines in athletes is an interesting area of future research.

Airways inflammation and treatment during acute exacerbations of COPD

INTRODUCTION

Inflammation is a core feature of acute chronic obstructive pulmonary disease (COPD) exacerbations. It is important to focus on inflammation since it gives insight into the pathological changes causing an exacerbation, thereby possibly providing directions for future therapies which modify inflammation.

OBJECTIVES

To provide a cell-by-cell overview of the inflammatory processes during COPD exacerbations. To evaluate cell activation, and cytokine production, cellular interactions, damaging effects of inflammatory mediators to tissue, and the relation to symptoms at the onset of COPD exacerbations. To speculate on future therapeutic options to modify inflammation during COPD exacerbations.

RESULTS

During COPD exacerbations, there is increased airway wall inflammation, with pathophysiological influx of eosinophils, neutrophils, and lymphocytes. Although links have been suggested between the increase in eosinophils and lymphocytes and a viral etiology of the exacerbation, and between the increase in neutrophils and a bacterial aetiology, these increases in both inflammatory cell types are not limited to the respective aetiologies and the underlying mechanisms remain elusive.

CONCLUSION

Further research is required to fully understand the inflammatory mechanisms in the onset and development of COPD exacerbations. This might make inflammatory pathway-specific intervention possible, resulting in a more effective treatment of COPD exacerbations with fewer side effects.

Once-daily inhaled glucocorticosteroid administration in controlled asthma patients

BACKGROUND

Inhaled glucocorticosteroids are usually administered in two equal daily doses. To simplify the method of treatment, once-daily administration has been used. However, little information regarding whether once-daily treatment can sufficiently control airway inflammation is available. We aimed to investigate whether once-daily administration of inhaled glucocorticosteroids can control airway inflammation.

METHODS

Twenty-four well-controlled asthma patients were enrolled in a randomized crossover trial to compare the efficacies of once-daily and twice-daily administration of inhaled glucocorticosteroids. Initially, the patients were randomly assigned to receive either once-daily or twice-daily administration for 16 weeks. After an 8-week washout period, patients who originally received twice-daily administration were assigned to once-daily administration for 16 weeks and vice versa. We assessed the changes in the forced expiratory volume in 1s, morning and evening peak expiratory flows, asthma symptoms, health-related quality of life and fractional exhaled nitric oxide levels.

RESULTS

Patients with once-daily administration showed the same level of clinical control and lung functions as patients receiving twice-daily administration. There was no difference in the fractional exhaled nitric oxide levels between the beginning and end of the twice-daily treatment (35.69 and 33.23ppb, respectively). In contrast, the fractional exhaled nitric oxide level was significantly higher at the end of the once-daily treatment (33.87 and 39.38ppb, respectively, p< 0.001).

CONCLUSION

Although once-daily administration is sufficient for clinical control of asthma, it might not control airway inflammation sufficiently.

Acute effects of Asian dust events on respiratory symptoms and peak expiratory flow in children with mild asthma

The aim of this study was to investigate the possible adverse effects of Asian dust events on respiratory health in asthmatic children. Fifty-two children with mild asthma were studied for eight consecutive weeks in the spring of 2004 (March 8 to May 2). During the study period, five Asian dust days were identified; we included a lag period of two days following each of the events. Subjects recorded their respiratory symptom diaries and peak expiratory flow (PEF) twice daily during the study period; and they underwent methacholine bronchial challenge tests. The subjects reported a significantly higher frequency of respiratory symptoms during the Asian dust days than during the control days. They showed significantly more reduced morning and evening PEF values, and more increased PEF variability (10.1%+/-3.5% vs. 5.5%+/-2.2%) during the Asian dust days than during the control days. Methacholine PC(20) was not significantly different between before and after the study period (geometric mean: 2.82 mg/mL vs. 3.16 mg/mL). These results suggest that the short-term Asian dust events might be associated with increased acute respiratory symptoms and changes in PEF outcomes. However, there might be little long-term influence on airway hyperresponsiveness in children with mild asthma.

Oral corticosteroid-dependent asthma: a 30-year review

OBJECTIVE

To identify novel aspects of the pathogenesis, therapeutic options, and prophylaxis measures of corticosteroid-dependent asthma.

DATA SOURCES

PubMed searches were undertaken of studies published between 1966 and 2006 on the pathogenesis of and corticosteroid-sparing therapies for corticosteroid-dependent asthma. Identified review articles were surveyed for additional and earlier citations. Recent American Academy of Asthma, Allergy, and Immunology meeting abstracts were also searched to identify other recently published and unpublished studies.

STUDY SELECTION

Inclusion of studies in the review was decided by simple agreement of both reviewers, who independently read the "Methods" and "Discussion" sections of articles identified using the search strategy. Quality assessment was performed by the 2 reviewers.

RESULTS

High-dose inhaled corticosteroids are the first-line option for corticosteroid-dependent asthmatic patients with clear efficacy. Omalizumab is effective in reducing oral corticosteroid requirements in allergic asthma. Methotrexate, gold, and cyclosporine have corticosteroid-sparing effects clinically that must be weighed against a serious adverse effect profile. Nebulized diuretics and lidocaine, with a low adverse effect profile, offer promising results but require further study. Clarithromycin and telithromycin seem to have an independent mechanism of inflammatory modulation, but their effect on corticosteroid-dependent asthma remains to be seen. Etanercept offers only early clinical evidence of a role in corticosteroid-dependent asthma.

CONCLUSIONS

With no clear consensus on corticosteroid-sparing treatment in corticosteroid-dependent asthmatic patients, systemic glucocorticoids remain the foremost therapy, with adverse effects that require monitoring and prophylaxis.

Theophylline and its metabolites produce a stimulating cholinergic effect on the small intestine and a nonadrenergic noncholinergic relaxing effect on the colon: a comparative study in the rabbit intestine

The present study examines comparatively the effects of theophylline and its metabolites, 1-methylxanthine (1-MX), 3-methylxanthine (3-MX), 1,3-dimethyluric acid (1,3-DMU) and 1-methyluric acid (1-MU) along the rabbit intestine, and explores the underlying mechanism(s). In the small intestine, theophylline produces atropine- and hexamethonium-sensitive increases in both the amplitude of phasic contractions and the basal tone. All metabolites mimic the theophylline's stimulating effect. In particular, concerning the phasic contractions, all metabolites are more potent than theophylline in the duodenum and jejunum, while in the ileum, only 1-MU is more potent. Regarding the basal tone, the metabolites show, in most cases, higher efficacy in all small intestinal regions, the maximum effects of 3-MX and 1-MU on the duodenum and ileum being double or triple the one of theophylline. In the ascending colon, while lower concentrations of theophylline produce an atropine- and hexamethonium-sensitive increase in the basal tone, higher ones produce a postsynaptic, nonadrenergic noncholinergic (NANC) relaxing effect. 1-MU mimics, in a weaker manner, theophylline's effect, while the other metabolites produce only relaxation, the potency rank of order being 3-MX>1-MX=1,3-DMU>theophylline. It is suggested that the theophylline and its metabolites stimulatory effect involves a cholinergic pathway, while the relaxing one is due to 3('),5(')-cyclic adenosine monophosphate (cAMP) elevation mediated by the theophylline and its metabolites inhibitory action on phosphodiesterases (PDEs).

Environmental factors and gene-environment interactions in the aetiology of asthma

The importance of early life environmental influences on the aetiology of asthma is implied by the observed geographic and temporal variation in the prevalence of the disease among children. 2. There is evidence pointing to the role of exposure to allergen, various aspects of diet and hygiene-related factors in the aetiology of asthma. 3. There is also evidence that heritable factors influence the impact of hygiene-related exposures on the risk of having asthma. Polymorphism within genes coding for the toll-like receptor-lipopolysaccharide (TLR-LPS) signalling pathway may underlie variations in effects of hygiene-related exposures, including specifically endotoxin, on the risk of developing allergic sensitization and allergic disease. 4. At present there is no unifying theory to explain the childhood origins of asthma and, hence, no solid basis for developing preventative interventions. Progress towards this goal requires better understanding of the heterogeneous nature of the disease in early childhood, improved characterization of relevant environmental exposures and long-term follow up of birth cohorts with reliable and valid measures of allergy and asthma outcomes.

Fluticasone given once versus twice a day: meta-analysis

OBJECTIVE

The aim of this study was to examine the efficacy of fluticasone administered once daily compared to twice daily in asthma.

METHODOLOGY

A meta-analysis was performed of randomized double-blind trials of at least 4 weeks duration that compared fluticasone administered once versus twice a day and presented data on at least one clinical outcome measure.

RESULTS

Six studies of 1517 children and adults with asthma met the inclusion criteria. Studies were predominantly in subjects with moderate asthma, treated with doses of fluticasone ranging from 200 to 500 microg per day. Twice-daily dosing was associated with significantly greater efficacy compared with once-daily dosing, for all outcome measures except night wakenings. The mean (95% CI) differences between twice and once-daily administration for FEV(1) and peak expiratory flow were 0.11 L (0.07-0.16) and 12.9 L/min (8.6-17.1), respectively. Twice-daily fluticasone was associated with significantly fewer withdrawals due to asthma than once-daily fluticasone, with an odds ratio of 0.44 (0.30-0.67).

CONCLUSION

The findings suggest that twice-daily administration of fluticasone will provide greater therapeutic benefit than a once-daily morning regimen.

Corticosteroids: the mainstay in asthma therapy

Inflammation is now marked as a central feature of asthma pathophysiology and aims of current asthma management are not only to treat acute symptoms of wheezing, breathlessness, chest tightness, cough but also to suppress the underlying inflammatory component. Despite the availability of a number of drugs, corticosteroids remain the mainstay in the management of all types of asthma as these are the most potent and effective antiinflammatory agents available so far. Corticosteroids suppress virtually every step in inflammation. However therapeutic doses of oral glucocorticoids are associated with a range of adverse reactions. To overcome these side effects, inhalations have been developed to deliver glucocorticoids directly to the lungs and in the process a number of aerosol preparations have become available, which have advantage of significantly lower toxicity due to low systemic absorption from the respiratory tract and rapid inactivation. Despite considerable efforts by pharmaceutical industry, it has been difficult to develop novel therapeutic agents for asthma management, which could surpass inhaled corticosteroids. Currently the data favours using inhaled corticosteroids as monotherapy in the majority of patients in all kinds of asthma. If combination therapy is recommended to achieve additional control in severe asthma cases, other drugs such as beta-agonists, antileukotrienes, theophylline, etc. are considered as adjunct therapies to corticosteroids. This review discusses the importance of corticosteroids as first line therapy for asthma treatment with the availability of inhaled corticosteroids for chronic treatment and oral formulations for treating acute exacerbations of moderate to severe asthma.

Further studies on the clinical efficacy of Solanum xanthocarpum and Solanum trilobatum in bronchial asthma

The clinical efficacy of two herbs S. xanthocarpum and S. trilobatum in a dose of 300 mg tds for 3 days was investigated in mild to moderate bronchial asthma. Their effect was compared with standard bronchodilator drugs, salbutamol (4 mg) and deriphylline (200 mg). The respiratory function was assessed by measuring the peak expiratory flow rate (PEFR) using a mini peak flow meter. In addition, improvement in lung function was assessed by physical examination (rhonchi and crepitation) and other symptoms such as cough, breathlessness and sputum. S. xanthocarpum and S. trilobatum produced a progressive improvement in the ventilatory function of asthmatic individuals over 3 days. The scores for rhonchi, cough, breathlessness and sputum were decreased by these drug treatments. The improvement in PEFR and the reduction in other symptom scores clearly indicate a bronchodilator effect, a decrease of oedema and secretions in the airway lumen. The response to these herbs can be considered to be equivalent to that of deriphylline but less than salbutamol. No untoward effects were reported during the study. The present study further confirms the traditional use of these herbs in bronchial asthma.

Platelet-activating factor receptor develops airway hyperresponsiveness independently of airway inflammation in a murine asthma model

Lipid mediators play an important role in modulating inflammatory responses. Platelet-activating factor (PAF) is a potent proinflammatory phospholipid with eosinophil chemotactic activity in vitro and in vivo. We show in this study that mice deficient in PAF receptor exhibited significantly reduced airway hyperresponsiveness to muscarinic cholinergic stimulation in an asthma model. However, PAF receptor-deficient mice developed an eosinophilic inflammatory response at a comparable level to that of wild-type mice. These results indicate an important role for PAF receptor, downstream of the eosinophilic inflammatory cascade, in regulating airway responsiveness after sensitization and aeroallergen challenge.

Targeting adenosine receptors: novel therapeutic targets in asthma and chronic obstructive pulmonary disease

Adenosine, an endogenous signaling nucleoside that modulates many physiological processes has been implicated in playing an ever increasingly important role in the pathogenesis of asthma and chronic obstructive pulmonary disease (COPD). All cells contain adenosine and adenine nucleotides and the cellular production of adenosine is greatly enhanced under conditions of local hypoxia as may occur in inflammatory conditions such as asthma and COPD. In 1983, it was first reported that inhaled adenosine causes dose-related bronchoconstriction in patients with both allergic and non-allergic asthma but not in healthy volunteers. This hyperresponsiveness was also reported in patients with COPD, with those patients who smoked exhibiting a significantly greater response. This bronchoconstrictor effect of adenosine is orchestrated through the stimulation of specific cell membrane receptors and involves an important inflammatory cell, the mast cell. There is substantial evidence which suggests that mast cell activation is central to this unique response to adenosine. Mast cell mediator release makes a significant contribution towards airflow obstruction and the consequent symptoms in patients with asthma. Over the last two decades, researchers have investigated the effect of mast cell inhibitors as well as mast cell mediator receptor antagonists and their role in attenuating the bronchoconstrictor response to inhaled adenosine 5'-monophosphate (AMP). Promising results have been shown using mast cell stabilizers, histamine H1 receptor antagonists, selective cysteinyl leukotriene-1 receptor antagonists and inhibitors of 5-lipoxygenase and cyclo-oxygenase. Through these findings, the mast cell has been recognized as being a critical inflammatory cell in the adenosine-induced response in patients with asthma and COPD. To date, four subtypes (A1, A2A, A2B, A3) of adenosine receptors have been cloned each with a unique pattern of tissue distribution and signal transduction. Activation of these receptors has pro- and anti-inflammatory consequences making the development of agonists and/or antagonists at these receptor sites a novel approach in the treatment of patients with asthma and COPD. This review highlights the importance of adenosine in the pathophysiology of asthma and COPD, the critical role of the mast cell and the potential to target the adenosine receptor subtype in patients with asthma and COPD. The complete characterization of these adenosine receptor subtypes in terms of their distribution in humans and the development of selective agonists and antagonists, holds the key to our complete understanding of the role of this important mediator in asthma and COPD.

Prevalence of esophageal candidiasis among patients treated with inhaled fluticasone propionate

OBJECTIVES

Development of oropharyngeal candidiasis is a frequently reported adverse effect of inhaled corticosteroid use, but the prevalence of esophageal candidiasis is unknown. The aim of this study was to estimate the prevalence of esophageal candidiasis among patients treated with an inhaled corticosteroid, fluticasone propionate.

METHODS

Upper GI endoscopy was performed on 49 patients treated with inhaled fluticasone propionate to examine the prevalence of esophageal candidiasis. Of the patients, 36 had bronchial asthma and 13 had chronic obstructive pulmonary disease. To compare the prevalence with control patients, upper GI endoscopy was performed on 700 consecutive patients without malignancy or immunosuppression.

RESULTS

The prevalence of esophageal candidiasis was 37% among patients treated with inhaled fluticasone propionate, whereas only 0.3% of the control patients had the infection. The prevalence was especially high among patients with diabetes mellitus or those who were treated with a high dose of inhaled fluticasone propionate. Moreover, a reduction in the daily dose of inhaled fluticasone propionate eliminated the infection in four of five patients.

CONCLUSIONS

Esophageal candidiasis is a common complication of inhaled corticosteroid use.

A randomized controlled trial of inhaled flunisolide in the management of acute asthma in children

BACKGROUND

Inhaled corticosteroids (ICS) may provide benefit in the therapy of acute asthma. The purpose of this study was to test the hypothesis that ICS are as effective as oral corticosteroids (OCS) in the management of acute childhood asthma.

METHODS

A randomized, masked, placebo-controlled study was conducted in children aged 6 to 16 years seeking emergent care for an acute exacerbation of asthma. Patients were randomized into one of two groups: group 1 (OCS), oral prednisone, 2 mg/kg (maximum of 60 mg/d) for 7 days, and placebo pressurized metered-dose inhaler with valved holding chamber, four inhalations bid; and group 2 (ICS), flunisolide, four inhalations (1 mg) bid for 7 days, and daily placebo tablets. Spirometry (FEV(1)) was performed at baseline, day 3, and day 7 of the study. A symptom diary and twice-daily peak expiratory flow were recorded.

RESULTS

A total of 58 subjects receiving ICS (n = 27) or OCS (n = 28) were enrolled. Baseline asthma severity, race, gender, and age were balanced between the two groups. chi(2) showed no significant difference in symptom severity between the two groups at any time during the study. FEV(1) percentage of predicted was lower in the ICS group on day 3 (65% vs 78%, p = 0.03) and on day 7 (77% vs 95%, p = 0.002).

CONCLUSION

ICS were found to be useful in the management of acute asthma in children; however, spirometry data suggested a more rapid resolution of asthma with OCS.

Effect of inhaled steroids on bone mineral density: a meta-analysis

Inhaled corticosteroids are currently considered first-line agents for the treatment of asthma. Medium- to long-term administration of inhaled steroids may be associated with bone loss. Various studies have evaluated their effect on bone mineral density (BMD); some have shown loss of BMD with steroid treatment, but others have failed to do so. The present meta-analysis was undertaken to determine the possible effect of inhaled steroids on bone density. Literature was collected using computerized (MEDLINE) and manual searches using index medicus and checking cross-references of the published articles. The studies identified were screened for inclusion/exclusion criteria. Grouped means (XT/XC) and pooled standard deviations (SDT/SDC) for the treatment group (XT[95% CI] = 1.144 [1.019-1.269]; SDT = 0.163, g/cm2) and control group (XC [95% CI] = 1.193 [1.073-1.313]; SDC = 0.157, g/cm2) were worked out respectively for the selected studies. Finally, a comparison between grouped means of steroid-treated and control groups was done by two-sample t-test at the 5% level of significance. The results of the meta-analysis showed that although the mean BMD of the steroid-treated group was reduced by 4.1% as compared to the control group, this failed to achieve statistical significance (p = 0.8; 95% CI for the mean difference between two groups = 0.028-0.070 g/cm2). It is concluded that inhaled steroids for the treatment of asthma can be considered safe with respect to their effect on bone loss.

Effect of long-term treatment with inhaled budesonide or theophylline on lung function, airway reactivity and asthma symptoms

Asthma is characterized by inflammation of the airways and long-term treatment with inhaled glucocorticosteroids improve clinical control in patients previously treated with inhaled rescue beta-2 agonist. We investigated whether the dose of inhaled glucocorticosteroid was related to outcome compared with oral theophylline. Budesonide 800 microg bd, budesonide 200 microg bd, or theophylline (Theo-Dur 300 mg bd was given double-blind, double-dummy and randomized, in a parallel group design for 9 months; when therapy was stopped patients were followed for an additional 3 months. Forced expiratory volume in 1 sec (FEV1), bronchial reactivity and asthma symptom scores were assessed before entering the study and after 1, 2, 3, 5, 7, and 9 months of treatment and monthly after treatment was stopped. Eighty-five patients (38 females and 47 males) were enrolled in the study during 1 1/2 year. Withdrawal from the study due to exacerbations during the treatment period was significantly increased (P <0.01) in the theophylline group. After treatment was stopped more patients withdrew in the budesonide group. In the budesonide 800 microg bd group, FEV1 improved significantly after 1 months treatment (P <0.01) and persisted throughout the study period. In the budesonide 200 microg bd group, FEV1 improved slightly and reached significance (P=0.05) after 5 months of treatment. In the theophylline group, FEV1 was unchanged during the 9 months of treatment. In both budesonide groups, FEV1 deteriorated significantly (P<0.01 and P<0.02, respectively) after termination of study medication and reached pretreatment values during the first month. In the budesonide 800 microg bd group, the concentration of histamine causing a 20% fall in FEV1 (PC20) increased significantly (P<0.01) after 1 months treatment and increased further after 9 months (P<0.0001), equivalent to two doubling dilutions. In the budesonide 200 microg bd, group PC20 histamine significantly increased (P <0.005) after 2 months of treatment and remained constant; theophylline was unchanged. After treatment with budesonide 800 microg bd and 200 microg bd were stopped, PC20 decreased significantly (P<0.002 and P=0.05, respectively) within the first month. PC20 remained unchanged after theophylline was stopped. After budesonide 800 microg bd and 200 microg bd treatment, symptom severity decreased in a dose-related and highly significant manner (P < 0.00001 and P < 0.0001, respectively). With theophylline, asthma symptoms decreased slightly after 1 and 2 months treatment (P < 0.01 and P < 0.02, respectively) and when treatment was stopped no increase in asthma symptoms was evident. Oral theophylline slightly reduced airways symptoms and had no influence on FEV1 and PC20 histamine. Maintenance treatment with inhaled budesonide gave a dose-related reduction in airways obstruction, bronchial reactivity and asthma symptom severity. The efficacy of inhaled corticosteroid was superior to oral theophylline.

Is the increase in bronchial responsiveness or FEV1 shortly after cessation of beta2-agonists reflecting a real deterioration of the disease in allergic asthmatic patients? A comparison between short-acting and long-acting beta2-agonists

Regular use of beta2-agonists might result in increased bronchial hyper-responsiveness (BHR) and decreased forced expiratory volume in 1 sec (FEV1). It has been suggested that these possible detrimental effects are not a real deterioration of the disease, but that it might be only a transient (rebound) effect shortly after discontinuing this regular use. Moreover, these effects are thought to occur especially during short-acting and not during long-acting beta2-agonists use. The aim of this study was to invest gate whether a rebound effect (a pharmacological deterioration effect diminishing after several hours) in FEV1 and PC20 (concentration of histamine causing a 20% fall in FEV1 with regard to baseline) occurred after cessation of regular use of beta2-agonists, and whether this occurred both after short-acting and long-acting beta2-agonists. Allergic asthmatic patients (n = 134) were randomly allocated to the use of a short-acting (salbutamol), a long-acting beta2-agonist (formoterol) or placebo for 12 weeks (double-blind, double-dummy). No other asthma medication was allowed, including inhaled corticosteroids. At the start and every 4 weeks later FEV and PC20 were measured, each time at least 12 h after the last doses of study medication, which is in the possible rebound period. To investigate whether a (transient) rebound effect occurred, parameters were additionally measured at least 72 h later after discontinuation of the study medication. After 12 weeks of short-acting beta2-agonist use, a drop was seen in FEV1 from 85.6 (+/- 2.21)% predicted to 78.8 (+/- 2.9)% predicted, measured 15 h (median) after the last doses of medication. This was significantly different compared to placebo. When measured 168 h (median) later FEV1 recovered to 85.5 (+/- 2.4)% predicted, comparable to baseline. PC20 decreased with -1.17 (+/- 0.44) doubling dose after 12 weeks of short-acting beta2-agonist use, measured 15 h after the last doses of medication, which was significantly different compared to placebo. However, 168 h later PC20 recovered slightly with +0.55 (+/- 0.34) doubling dose, but this value was still lower compared to placebo. In contrast, during long-acting beta2-agonist and placebo use no significant changes were seen. In conclusion, the use of short-acting beta2-agonists resulted in a transient (rebound) effect in FEV while the effects on PC20 may point to a real deterioration of the disease. Long-acting beta2-agonist and placebo use showed no changes. We conclude that a mono-therapy of short-acting and not of long-acting beta2-agonists might have deleterious effects in asthma.

Influence of respiratory spacer devices on aerodynamic particle size distribution and fine particle mass of beclomethasone from metered-dose inhalers

Respiratory spacer devices are used mainly with pressurized metered dose inhalers, especially those containing corticosteroids, to assist with patient coordination and reduce oropharyngeal side effects. This investigation examines the influence of different spacer devices on the delivered fine particle mass (aerodynamic diameter of <3.3 microm and <4.7 microm) of the corticosteroid beclomethasone dipropionate, which approximates the respirable dose. The Anderson Mark II Cascade Impactor was used to characterise the deposition of single doses of beclomethasone dipropionate from several metered-dose inhalers. Following actuation of one single dose the amount of beclomethasone dipropionate deposited on each stage of the impactor was quantified using reverse phase high-performance liquid chromatography and ultraviolet detection. The fine particle mass smaller than 4.7 microm for Respocort delivered by the Sanner and Fisonair spacer devices was 77.7% and 41.3% higher (p < 0.04), respectively, than the metered-dose inhaler alone, while the Breathatech spacer delivered 21.4% lower (p < 0.01). The fine particle mass of Becotide delivered by the Sanner, Fisonair, Nebuhaler, and Volumatic spacer devices were 81%, 42.4%, 46.9%, and 32.8% higher (p < 0.008), respectively, than be metered dose inhaler alone. The fine particle mass for Becloforte delivered by the Sanner, Fisonair, and Volumatic spacer devices was 82.8%, 36.9%, and 48.0% higher (p < 0.009) than that delivered by metered dose inhaler alone. This study suggests that there are significant differences in the fine particle mass of beclomethasone dipropionate delivered by respiratory spacer devices when used in conjunction with commercially available metered dose inhalers of this drug.

[Preparation and evaluation of press-coated aminophylline tablet using crystalline cellulose and polyethylene glycol in the outer shell for timed-release dosage forms]

In an attempt to achieve chronopharmacotherapy for asthma, press-coated tablets (250 mg), which contained aminophylline in the core tablet in the form of low-substituted hydroxypropylcellulose (L-HPC) and coated with crystalline cellulose (PH-102) and polyethylene glycol (PEG) at various molecular weights and mixing ratios in the amounts of PH-102 and PEG as the outer shell (press-coating material), were prepared (chronopharmaceutics). Their applicability as timed-release (delayed-release) tablets with a lag time of disintegration and a subsequent rapid drug release phase was investigated. Various types of press-coated tablets were prepared using a tableting machine, and their aminophylline dissolution profiles were evaluated by the JP paddle method. Tablets with the timed-release characteristics could be prepared, and the lag time of disintegration was prolonged as the molecular weight and the amount of PEG, for example PEG 500,000, in the outer shell were increased. The lag time of disintegration could be controlled by the above-mentioned method, however, the pH of the medium had no effect on disintegration of the tablet and dissolution behavior of theophylline. The press-coated tablet (core tablet:aminophylline 50 mg, L-HPC and PEG 6000; outer shell:PH-102:PEG = 8:2 200 mg) with the timed-release characteristics was administered orally to rabbits for an in vivo test. Theophylline was first detected in plasma more than 2 h after administration; thus, this tablet showed a timed-release characteristics in the gastrointestinal tract. The time (tmax) required to reach the maximum plasma theophylline concentration (Cmax) observed after administration of the press-coated tablet was significantly (p < 0.05) delayed compared with that observed after administration of aminophylline solution in the control experiment. However, there was no difference in Cmax and area under the plasma theophylline concentration-time curve (AUC0-->24) between the press-coated tablet and aminophylline solution. These results suggest that the press-coated aminophylline tablet (with the timed-release characteristic) offers a promising forms of theophylline chronotherapy for asthma.

Changing approaches to asthma management in Australia: effects on asthma morbidity

Asthma is an important public health issue in Australia and is responsible for significant morbidity and mortality in the community. Recognition of the impact of asthma on the health of Australians, and the apparent failure of new medications to reduce mortality and hospital admission rates resulted in a major review by the stakeholders in asthma care. This led to new approaches to asthma management based on strategic use of asthma medications and the development of the Asthma Management Plan (AMP). The AMP drew together current understanding of asthma to develop a simple stepwise approach to management that could be readily applied in patient management. The National Asthma Campaign (NAC), a coalition of the major stakeholders in asthma care, was launched in 1990 to lead the dissemination of the AMP. In association with other organisations interested in asthma care in Australia, the NAC has developed the AMP, and co-ordinated a decade of education and advocacy about asthma that targeted doctors, health professionals and the general public. These activities have been successful in raising awareness about asthma in the community. However, recent research, while demonstrating the continued uptake of written asthma action plans for asthma and decrease in use of inhaled bronchodilator medications, reported a decrease in use of preventive therapy by people with asthma. These activities have had a sustained impact on asthma-related health outcomes with mortality at the lowest level since 1960 and a decline in hospital readmission rates. This is useful information because there is sound evidence that the prevalence and possibly severity of asthma in children has increased. However, review of management in primary care and among people who present to emergency services with acute asthma suggest that many people continue to manage their asthma poorly. Continued education is needed to build on the progress that has been made. There are opportunities to do this through efforts to integrate general practitioners into the wider health system through the formation of Divisions of General Practice. Recognition of asthma as a health priority area at a national level will help to enhance and maintain awareness of the public health importance of asthma and facilitate the further development of the initiatives begun during the last decade or more.

Electrolyte disturbances in patients with chronic, stable asthma: effect of therapy

OBJECTIVE

To determine the prevalence of electrolyte disturbances in patients with chronic, stable asthma, and to assess whether the therapeutic agents used to treat chronic asthma have an effect on abnormal electrolyte levels.

DESIGN

Prospective, hospital-based, cross-sectional study.

SETTING

University teaching hospital in Jeddah, Saudi Arabia.

PATIENTS

Patients with chronic, stable asthma.

METHOD

Ninety-three consecutive patients with chronic, stable asthma were involved in the study. On the day of the visit to the asthma clinic, particulars such as age, sex, duration of asthma, and details of drug therapy were obtained from each asthmatic patient. Serum potassium, magnesium, phosphorus, calcium, and sodium levels were measured. Normal values were as follows: potassium, 3.5 to 5 mmol/L; magnesium, 0.74 to 1.2 mmol/L; phosphorus, 0.8 to 1.4 mmol/L; and calcium, 2.1 to 2.6 mmol/L.

RESULTS

Electrolyte disturbances were found in 43% of the patients; 85% of the patients had one electrolyte disturbance, 10% had two electrolyte disturbances, and 5% had three electrolyte disturbances. The highest proportions were for magnesium (26.9%) and phosphorus (15.1%) [serum levels were 0.69 +/- 0.04 mmol/L and 0.64 +/- 0.09 mmol/L, respectively], the lowest proportions were for potassium (5.4%) and sodium (4.3%) [serum levels were 3.3 +/- 0.01 mmol/L and 133 +/- 0.01 mmol/L, respectively], and no patient had a calcium disturbance. Logistic regression analysis showed no statistically significant association between the therapy used and electrolyte disturbances.

CONCLUSION

Hypomagnesemia and hypophosphatemia were found to be the two most common electrolyte disturbances in patients with chronic, stable asthma. Therapeutic agents used to treat patients with chronic asthma have no effect on abnormal electrolyte levels. The underlying cause still remains unclear.

Comparative responses of bronchial rings to mediators of airway hyperreactivity in healthy horses and those affected with summer pasture-associated obstructive pulmonary disease

OBJECTIVE

To compare responses of bronchial rings obtained from healthy horses and horses affected with summer pasture-associated obstructive pulmonary disease (SPAOPD) to selected mediators of airway hyperreactivity in vitro.

SAMPLE POPULATION

Bronchial rings from 6 healthy horses and 6 horses affected with SPAOPD.

PROCEDURE

Bronchial rings obtained from each group of horses were mounted in organ baths and attached to force transducers interfaced with a polygraph. After applying 2g of tension, each ring was allowed to equilibrate for 45 minutes in Tyrode's solution at 37 C. Cumulative concentration-response relationships to graded concentrations of selected mediators (10(-8) to 10(-4) M) were determined and analyzed for significance at each concentration.

RESULTS

Acetylcholine, histamine, 5-hydroxytryptamine, and leukotriene D4 induced concentration-dependent contractile responses in bronchial rings. Prostaglandin F2alpha induced weak and inconsistent contractile responses. The other 2 agents, norepinephrine and substance P, did not induce concentration-dependent responses. Considering the overall group-drug effect, acetylcholine, histamine, 5-hydroxytryptamine, and leukotriene D4 were effective in inducing consistent concentration-dependent contractile responses in both groups. Only 5-hydroxytryptamine and histamine induced significant responses in contractility between groups. The response of bronchial rings from horses with SPAOPD to 5-hydroxytryptamine was significantly greater than those from control horses, whereas the response to histamine was significantly lower. Significant responses were evident at concentrations ranging from 10(-6) to 10(-4) M for both drugs.

CONCLUSIONS AND CLINICAL RELEVANCE

Because the airways of horses with SPAOPD had increased responsiveness to 5-hydroxytryptamine in vitro, treatment modalities using 5-hydroxytryptamine antagonists should be investigated to address this phenomenon.

Bone mineral density in women with asthma on long-term inhaled corticosteroid therapy

BACKGROUND

Inhaled corticosteroids (ICS) have become first line agents in the management of moderate-to-severe asthma. Long-term use of ICS is associated with decreased bone mineral density (BMD).

OBJECTIVE

To investigate the prevalence of BMD loss and its severity in women with asthma on long-term ICS.

METHODS

Fifty-six women with asthma on long-term ICS, attending an inner-city allergy clinic were selected to undergo bone densitometry in order to evaluate the association between BMD and the long-term use of ICS at different dose ranges.

RESULTS

Women (60.7%) had decreased BMD either at the lumbar spine or hip region. Among postmenopausal women, 17.1% of those <65 years and 42.9% of those > or =65 years had osteoporosis compared with 5.7% (95% CI-3.9% to 8.5%) of those <65 and 29.3% (95% CI-25.7%-33.5%) of those > or =65 years reported in the NHANES III survey. The prevalence of low BMD increased as ICS dose increased from 5% in the low dose group to 50% in the high dose group (P < .002). There were significant linear trends of decline by dose in mean BMD for the hip (P < .001) and the lumbar spine (P < .002). Women who received medium or high doses of ICS had significantly greater bone loss than those receiving low doses.

CONCLUSION

The findings of increasing BMD loss with increasing ICS dose reinforce the necessity to monitor BMD periodically in women on ICS, particularly in the high risk postmenopausal group and those on medium to high doses. There should be a concurrent continual attempt to lower the dose by supplemental nonsteroidal controller medications and providing nutritional and pharmacologic treatment of identified BMD loss in these patients.

Effects of on-demand beta2-agonist inhalation in moderate-to-severe asthma. A randomized controlled trial

BACKGROUND

The appropriate use of short-acting beta2-agonist inhalation in asthma has been the subject of controversy in recent years. Limited information is available for the group of moderate to severe asthmatics with high intake of bronchodilator inhalants and continuous anti-inflammatory protection.

OBJECTIVE

To investigate the effects of beta2-agonist reduction in marked asthma treated with multiple asthma medications.

DESIGN

Randomized, controlled single-blind, cross-over trial.

SETTING

Outpatient clinic at a university medical centre.

SUBJECTS

A total of 80 adult patients with moderate-to-severe asthma.

INTERVENTIONS

In a 1-year study patients were assigned to on-demand vs. regular beta2-agonist inhalation treatment.

MAIN OUTCOME MEASURES

Asthmatic episodes (primary outcome), symptoms, peak expiratory flow rates (PEF) and drug use were recorded daily. Bronchodilator and airway responsiveness, lung function indices and quality of life were assessed during five clinic visits. Also, practicability of beta2-agonist tapering in multimedicated asthmatics was analysed.

RESULTS

More than 80% of moderate-to-severe asthmatics were able to reduce their beta2-agonist intake by >/=50%. Puffs per day of active therapy decreased from 7.9 in regular to 3.3 in on-demand treated patients (P = 0.0001). The type of beta2-agonist used (salbutamol/fenoterol) had no significant impact on the study findings. Almost all parameters of control of asthma improved during the on-demand treatment period.

CONCLUSION

On-demand inhalation of short-acting beta2-agonists in moderate-to-severe asthma is safe, and even in severe asthma a reduction from regular to on-demand beta2-agonist inhalation is possible, with improved asthma control.

The effect of regular salbutamol on lung function and bronchial responsiveness in patients with primary ciliary dyskinesia

STUDY OBJECTIVE

There is growing evidence that regular beta(2)-agonist use in patients with asthma is associated with decreased airway caliber and increased bronchial responsiveness. The aim of this study was to determine whether regular treatment with beta(2)-agonists induces changes in lung function and bronchial responsiveness in patients with primary ciliary dyskinesia.

DESIGN

A randomized, double-blind, placebo-controlled, crossover study.

PATIENTS

Nineteen children with primary ciliary dyskinesia.

INTERVENTIONS

Subjects received inhaled salbutamol or identical placebo (2 x 100 microg qid) for periods of 6 weeks with a wash-out period of 4 weeks.

MEASUREMENTS AND RESULTS

FEV(1) was measured before and 3 weeks and 6 weeks after salbutamol or placebo treatment. High-dose methacholine inhalation tests were performed before and 6 weeks after each treatment. The provocative concentration of methacholine producing a 20% fall in FEV(1) (PC(20)) and maximal airway narrowing (MDeltaFFEV(1)) was measured. No significant change in FEV(1) was observed during the salbutamol or placebo periods. No significant differences in the parameters of bronchial responsiveness (PC(20) and MDeltaFFEV(1)) were noted as the result of either salbutamol or placebo treatment.

CONCLUSION

Our data have shown that salbutamol, inhaled regularly for 6 weeks, did not cause either a decline in lung function or an increase in bronchial responsiveness in subjects with primary ciliary dyskinesia.

The inhibitory effect of anti-allergic agent suplatast tosilate (IPD-1151T) on methacholine- and allergen-induced bronchoconstriction in sensitized mice. asakazu@med.showa-u.dc.jp

The influence of an anti-allergic agent, suplatast tosilate (IPD-1151T; (+/-)-[2-[4-(3-ethoxy-2-hydroxypropoxy)phenyl-carbamoyl]-ethyl] dimethylsulfonium p-toluenesulfonate) on allergic bronchoconstriction induced by allergen and methacholine (MCh) were examined in mice. BALB/c mice were sensitized by intraperitoneal injection of dinitrophenylated-keyhole limpet hemocyanin (DNP-KLH) mixed with A1(OH)3 (DNP-KLH). IPD-1151T was administered orally once a day for either 5 or 14 days in doses of 10, 30 or 100 mg/kg. Bronchoconstriction was measured 24h after the final drug administration. IPD-1151T inhibited both antigen- and MCh-mediated bronchoconstriction in actively sensitized mice. The inhibition induced was closely related to the dose and frequency of oral administration of the agent. We also examined the effect of IPD-1151T on IgE production in response to DNP-KLH immunization. IPD-1151T inhibited dose-dependently both total and specific IgE concentrations in serum prepared from mice 15 days after immunization. These results strongly indicate that IPD-1151T inhibits IgE production in vivo and results in attenuating effect on bronchoconstriction.

Comparison of the efficacy of inhaled fluticasone propionate, 880 microg/day, with flunisolide, 1500 microg/day, in moderate-to-severe persistent asthma

BACKGROUND

Inhaled corticosteroids have become the mainstay of asthma therapy. Few studies however, have compared inhaled steroids in children. We compared the efficacy of inhaled fluticasone propionate (FP), 880 microg/day (2 puffs of 220 microg/puff, BID) with inhaled flunisolide (FLU), 1500 microg/day (3 puffs of 250 microg/puff, BID).

METHODS

Thirty children with moderate to severe asthma, mean age 12.7 years (range 10 to 17 years), mean duration of asthma 8.4 years, initially received flunisolide 1500 microg/day for 1 year, and then were switched to fluticasone propionate 880 microg/day and followed for an additional year. Pulmonary function tests (PFTs) were monitored and analyzed before and after the switch for the duration of study. Mean percent predicted for age values for FVC, FEV1, FEF25-75%, and FEFR were compared at 1 month, 2 to 6-month intervals, and 7 to 12-month intervals and during the same season of the year. Pulmonary function tests within 3 weeks of an exacerbation were not included in the study. The number of asthma exacerbations, emergency room visits, hospital admissions, and number of school days lost were also compared.

RESULTS

There was significant improvement in mean asthma exacerbations/patient/year (1.7 +/- 1.66 SD) versus (4 +/- 2.6) (P < .0002); mean emergency room visits/patient/year (0.23 +/- 0.62) versus (1.2 +/- 1.74) (P = .004); mean hospital admissions for asthma/patient/year (0.2 +/- 0.61) versus (1.13 +/- 1.45) (P < .0002); and number of school days lost/patient/year (1.4 +/- 2.38) versus (7.93 +/- 6.7) (P < .0002) while patients were receiving fluticasone propionate as compared with flunisolide. Also, the mean percent values predicted for age in all time-periods (at 1 month, 2 to 6 months, and 7 to 12 months) revealed significant improvement in FEV1 and FEF25-75% (P < .05 for both parameters). As PFT can be affected by seasonal changes, PFT parameters were compared during the same season of the year and significant improvement in FVC and FEV1 was observed in all seasons while patients were receiving fluticasone propionate (FP) compared with flunisolide (FLU) (P < .05 for all parameters). Significant improvement in PEFR and FEF25-75% was observed only in spring and summer season.

CONCLUSION

Fluticasone propionate 880 microg/day improved lung function and quality of life in adolescents with moderate-to-severe asthma when compared with flunisolide 1500 microg/day.

The effects of salbutamol, beclomethasone, and dexamethasone on fibronectin expression by cultured airway smooth muscle cells

Possible mechanisms of adverse drug effects in asthma include worsening of cellular hyperplasia and stimulation of extracellular matrix deposition. In this study, salbutamol, dexamethasone and beclomethasone were investigated to ascertain their ability to induce mitogenesis and stimulate fibronectin expression in cultured canine airway smooth muscle cells. In cells maintained in serum-free media for 72 h, salbutamol (1 nM-10 microM) caused mitogenesis. The control cells had 2.57 +/- 0.34 x 10(5) cells per ml (mean +/- SEM, N = 13), while salbutamol (1 microM) caused a maximal increase in cell number to 3.57 +/- 0.23 x 10(5) cells/ml (P < 0.01). In cells stimulated to replicate by addition of either fetal bovine serum or canine serum, no additional mitogenic effect of salbutamol was seen. Salbutamol did not have a detectable quantitative effect on fibronectin matrix expression. The glucocorticoids, beclomethasone and dexamethasone, significantly altered fibronectin expression by cultured airway smooth muscle cells. Beclomethasone increased fibronectin expression, while dexamethasone decreased expression.

Asthma and chronic obstructive airway diseases are associated with osteoporosis and fractures: a literature review

The objective was to assess the association between asthma and/or chronic obstructive airway diseases (COAD), and osteoporosis, and appraise treatments of osteoporosis in these patients. MEDLINE and Excerpta Medica were searched for original research with control groups which tested the above association. One cohort and nine cross-section studies of bone density in patients with asthma and/or COAD were retrieved. These demonstrated clinically important bone density reductions of up to 29% in subjects, dependent upon daily oral corticosteroids, by a variety of measurement techniques, at various bone sites. Bone density reduction has also been less consistently reported in the absence of oral corticosteroids, suggesting that other factors including high-dose inhaled corticosteroids may have a role. Fracture studies. Three studies in oral corticosteroid-dependent asthmatics demonstrated a vertebral fracture prevalence up to 56%, and annual vertebral fracture incidence of up to 42%. The strength of the available evidence is limited, but suggests that patients with asthma and/or COAD are at increased risk of osteoporosis. The evidence of the association between osteoporosis and inhaled corticosteroids is much more limited than for oral corticosteroids. Bisphosphonates are promising agents to maintain and/or promote bone mass in this patient group.

Rapid onset of control with budesonide Turbuhaler in patients with mild-to-moderate asthma

BACKGROUND

Budesonide (Pulmicort) is an inhaled corticosteroid with high topical potency but low systemic activity. Turbuhaler is a novel breath-actuated, multi-dose, dry-powder inhaler.

OBJECTIVES

This study was conducted to determine the efficacy and safety of two different dose regimens of budesonide Turbuhaler, compared with placebo, in adult patients with mild-to-moderate asthma not well-controlled with bronchodilator therapy.

METHODS

This double-blind, randomized, placebo-controlled, parallel-group, multicenter study compared the efficacy and safety of 200 microg and 400 microg of budesonide, administered twice daily via Turbuhaler, with placebo, in 273 adult patients (aged 19 to 70 years) with mild-to-moderate asthma (FEV1 67% of predicted normal), not well-controlled with bronchodilator therapy. Efficacy was assessed by pulmonary function tests and patient assessments of asthma symptom control. Safety was assessed in terms of adverse events, laboratory evaluations, and physical examinations.

RESULTS

Two hundred and 400 microg of budesonide bid were significantly more effective than placebo at improving morning PEF (mean differences from placebo of 43.63 L/min and 40.10 L/min, respectively; P < .001) and FEV1 (mean differences from placebo of 0.44 L, and 0.50 L, respectively; P < .001) over the 12-week treatment period. Onset of action as assessed by morning PEF was within two days. Basal and stimulated plasma cortisol concentrations were not significantly affected by budesonide treatment compared with placebo.

CONCLUSIONS

Treatment of adults suffering from mild-to-moderate asthma with budesonide Turbuhaler is well tolerated and results in a rapid onset of asthma control which is maintained over time.

Effect of intravenous immunoglobulin on steroid consumption in patients with severe asthma: a double-blind, placebo-controlled, randomized trial

BACKGROUND

There is a significant group of patients with severe asthma who require chronic use of systemic steroids for control of their disease. These patients are at risk for severe side effects from oral steroids. Intravenous immunoglobulin (IVIG) has immunomodulatory properties, and a few open-label trials have suggested its possible benefit in individuals with severe asthma.

OBJECTIVE

This study was designed to assess the potential benefit of IVIG as a steroid-sparing agent in patients with severe asthma.

METHODS

Thirty-eight immunocompetent steroid-requiring patients with severe asthma were randomly enrolled in a double-blind, placebo-controlled trial of IVIG.

RESULTS

Of the 38 patients enrolled, 28 patients completed the study. A significant reduction in oral steroid requirement was observed in both the IVIG-treated (n = 16) and the placebo-treated (n = 12) patients. Further exploration of the results showed that IVIG, but not placebo, had a significant steroid-sparing effect in patients requiring high doses of oral steroids (ie, >2000 mg in the year before the study). Within this subgroup, IVIG treatment (n = 9) resulted in a significant decrease in oral steroid requirement, with a median of 16.4 mg/day during the pretreatment period to 3 mg/day during the treatment phase (P =. 0078). No significant decrease in oral steroid requirement was observed in placebo-treated patients (n = 8) within this subgroup. Objective and subjective parameters of the patients' asthma were unchanged in spite of the steroid tapering achieved in the group treated with IVIG.

CONCLUSION

IVIG may be a useful steroid-sparing agent in patients with severe asthma requiring high doses of oral steroids.

Different ion channel control pH6-induced bronchoconstriction and calcitonin gene-related peptide release in the guinea-pig lung

We have studied the bronchoconstriction and the release of calcitonin gene-related peptide-like immunoreactivity induced by perfusion of pH6 buffer in the isolated guinea-pig perfused lung. Both bronchoconstriction and peptide release were completely abolished after systemic capsaicin pretreatment. Ca(2+)-free pH6 buffer infusion also completely inhibited the bronchial response, whereas the calcitonin gene-related peptide-like immunoreactivity overflow was significantly reduced. omega-Conotoxine and omega-agatoxin IVA known as N-, L- and P-type Ca2+ channel blocker, respectively, and the Na+ channel blocker tetrodotoxin decreased significantly the pH6-induced bronchial response and calcitonin gene-related peptide like immunoreactivity overflow. Nifedipine was without influence suggesting the involvement of both P- and N-type Ca2+ channel as well as the activation of an axon reflex. Ruthenium red had a more pronounced reduction effect on the functional response than on the peptide release. Ryanodine and caffeine are both agents known to influence Ca2+ release from sarcoplasmic reticulum. Ryanodine significantly reduced both bronchoconstriction and calcitonin gene-related peptide-like immunoreactivity overflow. Caffeine as well as theophylline and the Na(+)-H+ blocker, dimethylamiloride, largely depressed the functional response while producing a significant increase of calcitonin gene-related peptide-like immuno-reactivity basal value. The pH6-induced peptide overflow was slightly inhibited after caffeine and dimethylamiloride pre-treatment whereas no significant change was observed after theophylline. It is concluded that multiple ion channels including different type of Ca2+ channels appear to participate in pH6-induced bronchoconstriction and calcitonin gene-related peptide-like immunoreactivity release in the guinea-pig lung.

Clinical comparability of albuterol delivered by the breath-actuated inhaler (Spiros) and albuterol by MDI in patients with asthma

STUDY OBJECTIVE

This study compares the efficacy and safety of one and two actuations of albuterol sulfate powder delivered via a breath-actuated, effort-assisted, investigational inhaler (Spiros, Dura Pharmaceuticals, Inc) and albuterol delivered via a conventional propellant-driven metered dose inhaler (Ventolin, Glaxo, Inc).

DESIGN

Randomized, double-blind, placebo-controlled, 5-way crossover study.

PARTICIPANTS

Sixty patients with mild-to-moderate asthma (FEV1 59% predicted) were enrolled and 44 completed the study.

MEASUREMENTS AND RESULTS

FEV1 values over 6 hours were analyzed by ANCOVA and the Finney relative potency model. The relative potency of the inhalers (albuterol MDI: albuterol DPI) was 1.132 (90% CI, 0.680 to 2.252) indicating 1.132 actuations of albuterol MDI provided the same bronchodilation as one actuation of albuterol DPI. ANCOVA analyses further indicated that there were no significant differences between the two delivery systems with respect to FEV1, FVC, FEF25-75%, or PEF. Both inhalers had similar effects on serum potassium levels, QTc interval, blood pressure, and heart rate.

CONCLUSIONS

In patients with mild-to-moderate asthma in this study, the albuterol DPI was determined to be therapeutically comparable to albuterol MDI in the delivery of one and two actuations of albuterol.

Comparative efficacy and safety of albuterol sulfate Spiros inhaler and albuterol metered-dose inhaler in asthma

STUDY OBJECTIVE

To compare the long-term efficacy and safety of albuterol administration using a Spiros Inhalation System (Dura Pharmaceuticals; San Diego, CA) dry powder inhaler (DPI) and albuterol (Ventolin; Glaxo Wellcome; Research Triangle Park, NC) administration using a metered-dose inhaler (MDI) in patients with asthma.

MATERIALS AND METHODS

This was a phase III, 12-week, randomized, double-blind, double-dummy, placebo-controlled, parallel-group, multicenter study of 283 adolescent and adult patients with mild to moderate asthma. The patients were randomized into one of three treatment groups: the Spiros group, who were given 108 microg/actuation of albuterol sulfate equivalent to 90 microg of albuterol base; the MDI group, who were given 90 microg/actuation of albuterol; and the placebo group.

RESULTS

Over the length of the study, the Spiros and MDI groups were comparable in all FEV1 parameters. Both active treatment groups were superior to the placebo group for each FEV1 parameter at all visits. With the exception of differences at treatment week 0 for the maximum percent change in the FEV1, the duration of effect, and the area under the curve at baseline, there were no statistically significant differences between the Spiros and MDI groups for any FEV1 parameters. Using a repeated-measures analysis, the FEV1 parameters at week 0 for the Spiros group were not statistically significantly different from the parameters at weeks 4, 8, and 12. The same analysis effect at week 0 for the MDI group was greater for maximum percent change in the FEV1 from baseline (weeks 4, 8, and 12) and duration of effect. Adverse events and changes in clinical laboratory values, vital signs, ECG results, and physical examinations were reported with similar incidence in each of the three treatment groups.

CONCLUSION

Both active treatments were superior to the placebo treatment. The Spiros DPI was well tolerated and was as effective as the albuterol MDI in treating patients with moderate asthma.