Umeclidinium for the treatment of uncontrolled asthma

Real-world effects of once-daily inhaled steroid (fluticasone furoate) combined with long-acting beta-2 agonist (vilanterol) and long-acting muscarinic antagonist (umeclidinium) on lung function tests of asthma patients in Japan

Background: The Japanese drug use system allowed the once-daily use of inhaled corticosteroid fluticasone furoate (FF) combined with a long-acting beta-2 agonist vilanterol (VI) and a long-acting muscarinic antagonist umeclidinium (UMEC) against asthma on 18 February 2021. We investigated the real-world effects of these drugs (FF/UMEC/VI) mainly on lung function tests. Methods: This was an open-label, uncontrolled, within-group time-series (before-after) study. Prior asthma treatment (inhaled corticosteroid with/without a long-acting beta-2 agonist with/without a long-acting muscarinic antagonist) was switched to FF/UMEC/VI 200/62.5/25 μg. Subjects were evaluated by lung function tests prior to, and 1-2 months after, initiation of FF/UMEC/VI 200/62.5/25 μg. Patients were asked questions regarding the asthma control test and preference for drugs. Results: Overall, 114 asthma outpatients (97% Japanese) were enrolled from February 2021 to April 2022: 104 subjects completed the study. Forced expiratory volume in 1 s, peak flow, and asthma control test score of FF/UMEC/VI 200/62.5/25 μg-treated subjects were significantly increased (p < 0.001, p < 0.001, and p < 0.01, respectively). In contrast with FF/VI 200/25 μg, instantaneous flow at 25% of the forced vital capacity and expiratory reserve volume were significantly increased by FF/UMEC/VI 200/62.5/25 μg (p < 0.01, p < 0.05, respectively). Sixty-six percent of subjects declared they wanted to continue FF/UMEC/VI 200/62.5/25 μg in the future. Adverse effects, mainly local, were seen in 30% of patients, but no serious adverse effects were seen. Conclusion: Once-daily FF/UMEC/VI 200/62.5/25 μg was effective against asthma without serious adverse events. This is the first report that demonstrated FF/UMEC/VI dilated peripheral airways using lung function tests. This evidence on drug effects may improve our understanding of pulmonary physiology and the pathophysiology of asthma.

The reality of LAMAs for adult asthmatic patients

INTRODUCTION

The use of tiotropium is approved for the treatment of asthma. There are several studies completed or currently ongoing with the long-acting muscarinic antagonists (LAMAs) umeclidinium and glycopyrronium as an add-on asthma treatment. Adding a second bronchodilator with a different mechanism of action for the treatment of uncontrolled asthma may be a suitable therapeutic approach, although several issues still under discussion.

AREAS COVERED

The reality of LAMA plus long-acting beta-agonists (LABA) treatment for adult asthma. A systematic search was conducted on March 2020, and included 6 electronic databases: EMBASE, MEDLINE, Scopus, The Cochrane Library, Web of Science and Google Scholar.

EXPERT OPINION

A growing body of evidence generated from several randomized clinical trials is supporting the use of LAMA in adulthood asthma always in association with inhaled corticosteroid (ICS). Currently, only tiotropium has been approved and included in the guidelines. Other LAMAs are under evaluation in clinical trials. Several clinical trials are supporting the use of a triple therapy (ICS/LABA/LAMA) in uncontrolled asthmatic patients under ICS/LABA.

G Protein-Coupled Receptors in Asthma Therapy: Pharmacology and Drug Action

Asthma is a heterogeneous inflammatory disease of the airways that is associated with airway hyperresponsiveness and airflow limitation. Although asthma was once simply categorized as atopic or nonatopic, emerging analyses over the last few decades have revealed a variety of asthma endotypes that are attributed to numerous pathophysiological mechanisms. The classification of asthma by endotype is primarily routed in different profiles of airway inflammation that contribute to bronchoconstriction. Many asthma therapeutics target G protein-coupled receptors (GPCRs), which either enhance bronchodilation or prevent bronchoconstriction. Short-acting and long-acting β 2-agonists are widely used bronchodilators that signal through the activation of the β 2-adrenergic receptor. Short-acting and long-acting antagonists of muscarinic acetylcholine receptors are used to reduce bronchoconstriction by blocking the action of acetylcholine. Leukotriene antagonists that block the signaling of cysteinyl leukotriene receptor 1 are used as an add-on therapy to reduce bronchoconstriction and inflammation induced by cysteinyl leukotrienes. A number of GPCR-targeting asthma drug candidates are also in different stages of development. Among them, antagonists of prostaglandin D2 receptor 2 have advanced into phase III clinical trials. Others, including antagonists of the adenosine A2B receptor and the histamine H4 receptor, are in early stages of clinical investigation. In the past decade, significant research advancements in pharmacology, cell biology, structural biology, and molecular physiology have greatly deepened our understanding of the therapeutic roles of GPCRs in asthma and drug action on these GPCRs. This review summarizes our current understanding of GPCR signaling and pharmacology in the context of asthma treatment. SIGNIFICANCE STATEMENT: Although current treatment methods for asthma are effective for a majority of asthma patients, there are still a large number of patients with poorly controlled asthma who may experience asthma exacerbations. This review summarizes current asthma treatment methods and our understanding of signaling and pharmacology of G protein-coupled receptors (GPCRs) in asthma therapy, and discusses controversies regarding the use of GPCR drugs and new opportunities in developing GPCR-targeting therapeutics for the treatment of asthma.

Barriers to achieving asthma control in adults: evidence for the role of tiotropium in current management strategies

Despite the availability of a range of treatment options and management guidelines, a high proportion of adults with asthma remain uncontrolled. The challenge of managing uncontrolled asthma includes providing efficacious treatment while limiting side effects, recognizing situations when a change in asthma therapy is required, and considering patient preferences and satisfaction. In line with the Global Initiative for Asthma report, asthma management is based on a backbone of inhaled corticosteroid (ICS) therapy and use of add-on therapies to achieve disease control. This review considers whether add-on options could be better utilized in clinical practice. A number of long-acting muscarinic antagonists are in development, but tiotropium is the most widely studied for use in asthma. Evidence demonstrating the efficacy of tiotropium as an add-on therapy to at least ICS in adults with symptomatic mild, moderate, and severe asthma is presented from randomized controlled trials and real-world evidence. In addition, the benefit of tiotropium therapy in a wide range of patient phenotypes and disease severities without the need for biomarker assessment is discussed. Additional strategies that complement this approach, such as recognizing and overcoming barriers to adherence, ensuring optimal device use, and education and support to enhance patient–physician communication, are discussed. Physician education can also help raise awareness that additional management options are available for patients with moderate-to-severe asthma who remain uncontrolled on ICS/long-acting β₂-agonist treatment.

The mode of action of anticholinergics in asthma

Acetylcholine binds to muscarinic receptors to play a key role in the pathophysiology of asthma, leading to bronchoconstriction, increased mucus secretion, inflammation and airway remodelling. Anticholinergics are muscarinic receptor antagonists that are used in the treatment of chronic obstructive pulmonary disease and asthma. Recent in vivo and in vitro data have increased our understanding of how acetylcholine contributes to the disease manifestations of asthma, as well as elucidating the mechanism of action of anticholinergics. This review assesses the latest literature on acetylcholine in asthma pathophysiology, with a closer look at its role in airway inflammation and remodelling. New insights into the mechanism of action of anticholinergics, their effects on airway remodelling, and a review of the efficacy and safety of long-acting anticholinergics in asthma treatment will also be covered, including a summary of the latest clinical trial data.

Pre-clinical data suggest that anticholinergics can reduce acetylcholine-induced airway inflammation and remodellinghttp://ow.ly/xqAQ30loP8F