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Garcia G, van Dijkman SC, Pavord I, Singh D, Oosterholt S, Fulmali S, Majumdar A, Della Pasqua O. A Simulation Study of the Effect of Clinical Characteristics and Treatment Choice on Reliever Medication Use, Symptom Control and Exacerbation Risk in Moderate-Severe Asthma. Adv Ther 2024; 41:3196-3216. [PMID: 38916810 PMCID: PMC11263416 DOI: 10.1007/s12325-024-02914-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/29/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION The relationship between immediate symptom control, reliever medication use and exacerbation risk on treatment response and factors that modify it have not been assessed in an integrated manner. Here we apply simulation scenarios to evaluate the effect of individual baseline characteristics on treatment response in patients with moderate-severe asthma on regular maintenance dosing monotherapy with fluticasone propionate (FP) or combination therapy with fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR). METHODS Reduction in reliever medication use (puffs/24 h), change in symptom control scores (ACQ-5), and annualised exacerbation rate over 12 months were simulated in a cohort of patients with different baseline characteristics (e.g. time since diagnosis, asthma control questionnaire (ACQ-5) symptom score, smoking status, body mass index (BMI) and sex) using drug-disease models derived from large phase III/IV clinical studies. RESULTS Simulation scenarios show that being a smoker, having higher baseline ACQ-5 and BMI, and long asthma history is associated with increased reliever medication use (p < 0.01). This increase correlates with a higher exacerbation risk and higher ACQ-5 scores over the course of treatment, irrespective of the underlying maintenance therapy. Switching non-responders to ICS monotherapy to combination therapy after 3 months resulted in immediate reduction in reliever medication use (i.e. 1.3 vs. 1.0 puffs/24 h for FP/SAL and BUD/FOR, respectively). In addition, switching patients with ACQ-5 > 1.5 at baseline to FP/SAL resulted in 34% less exacerbations than those receiving regular dosing BUD/FOR (p < 0.01). CONCLUSIONS We have identified baseline characteristics of patients with moderate to severe asthma that are associated with greater reliever medication use, poor symptom control and higher exacerbation risk. Moreover, the effects of different inhaled corticosteroid (ICS)/long-acting beta agonist (LABA) combinations vary significantly when considering long-term treatment performance. These factors should be considered in clinical practice as a basis for personalised management of patients with moderate-severe asthma symptoms.
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Affiliation(s)
| | - Sven C van Dijkman
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK
| | - Ian Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dave Singh
- University of Manchester, Manchester University NHS Foundations Trust, Manchester, UK
| | - Sean Oosterholt
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK
| | - Sourabh Fulmali
- GSK, Global Classic and Established Medicines, Singapore, Singapore
| | - Anurita Majumdar
- GSK, Global Classic and Established Medicines, Singapore, Singapore
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK.
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK.
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van Dijkman SC, Yorgancıoğlu A, Pavord I, Brusselle G, Pitrez PM, Oosterholt S, Fumali S, Majumdar A, Della Pasqua O. Effect of Individual Patient Characteristics and Treatment Choices on Reliever Medication Use in Moderate-Severe Asthma: A Poisson Analysis of Randomised Clinical Trials. Adv Ther 2024; 41:1201-1225. [PMID: 38296921 PMCID: PMC10879282 DOI: 10.1007/s12325-023-02774-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/15/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Even though increased use of reliever medication, including short-acting beta agonists (SABA), provides an indirect measure of symptom worsening, there have been limited efforts to assess how different patterns of reliever use correlate with symptom control and future risk of exacerbations. Here, we evaluate the effect of individual baseline characteristics on reliever use in patients with moderate-severe asthma on regular maintenance therapy with fluticasone propionate (FP) or combination therapy with fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR). METHODS A drug-disease model describing the number of 24-h puffs and overnight occasions was developed with data from five clinical studies (N = 6212). The model was implemented using a nonlinear mixed effects approach and a Poisson function, considering clinical and demographic baseline characteristics. Goodness of fit and model predictive performance were assessed. Heatmaps were created to summarise the effect of concurrent baseline factors on reliever utilisation. RESULTS The final model accurately described individual patterns of reliever use, which is significantly increased with time since diagnosis, smoking, higher Asthma Control Questionnaire (ACQ-5) score and higher body mass index (BMI) at baseline. Whilst the number of puffs decreases slowly after an initial drop relative to the start of treatment, exacerbating patients utilise significantly more reliever than those who do not exacerbate. The mean effect of FP/SAL (median dose: 250/50 μg BID) on reliever use was slightly higher than that of BUD/FOR (median dose: 160/4.5 μg BID), i.e. a 75.3% vs 69.3% reduction in reliever use, respectively. CONCLUSIONS The availability of individual-level patient data in conjunction with a parametric approach enabled the characterisation of interindividual differences in the patterns of reliever use in patients with moderate-severe asthma. Taken together, individual demographic and clinical characteristics, as well as exacerbation history, can be considered an indicator of the degree of asthma control. High SABA reliever use suggests suboptimal clinical management of patients on maintenance therapy.
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Affiliation(s)
| | | | - Ian Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Paulo M Pitrez
- Hospital Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | - Sean Oosterholt
- Clinical Pharmacology Modelling and Simulation, GSK, London, UK
| | - Sourabh Fumali
- GSK, Global Classic and Established Medicines, Worli, India
| | - Anurita Majumdar
- GSK, Global Classic and Established Medicines, Singapore, Singapore
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, BMA House, Tavistock Square, London, WC1H 9JP, UK.
- GSK House, 980 Great West Rd, London, TW8 9GS, UK.
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Roche N, Yorgancıoğlu A, Cruz AA, Garcia G, Lavoie KL, Abhijith PG, Verma M, Majumdar A, Chatterjee S. Systematic literature review of traits and outcomes reported in randomised controlled trials of asthma with regular dosing of inhaled corticosteroids with short-acting β 2-agonist reliever, as-needed ICS/formoterol, or ICS/formoterol maintenance and reliever therapy. Respir Med 2024; 221:107478. [PMID: 38008385 DOI: 10.1016/j.rmed.2023.107478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/17/2023] [Accepted: 11/19/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION Asthma treatments based solely on diagnostic label do not benefit patients equally. To identify patient traits that may be associated with improved treatment response to regular inhaled corticosteroid (ICSs) dosing with short-acting β2-agonist reliever or ICS/formoterol-containing therapy, a systematic literature review (SLR) was conducted. METHODS Searches of databases including MEDLINE and Embase identified randomised controlled trials (RCTs) of patients with asthma, aged ≥12 years, published 1998-2022, containing ≥1 regular ICS dosing or ICS/formoterol-containing treatment arm, and reporting patient traits and outcomes of interest. Relevant data was extracted and underwent a feasibility assessment to determine suitability for meta-analysis. RESULTS The SLR identified 39 RCTs of 72,740 patients and 90 treatment arms, reporting 11 traits and 11 outcomes. Five patient traits (age, body mass index, FEV1, smoking history, asthma control) and five outcomes (exacerbation rate, lung function, asthma control, adherence, time to first exacerbation) were deemed feasible for inclusion in meta-analyses due to sufficient comparable reporting. Subgroups of clinical outcomes stratified by levels of patient traits were reported in 16 RCTs. CONCLUSION A systematic review of studies of regular ICS dosing with SABA or ICS/formoterol-containing treatment strategies in asthma identified consistent reporting of five traits and outcomes, allowing exploration of associations with treatment response. Conversely, many other traits and outcomes, although being potentially relevant, were inconsistently reported and limited subgroup reporting meant analyses of treatment response for subgroups of traits was not possible. We recommend more consistent measurement and reporting of clinically relevant patient traits and outcomes in respiratory RCTs.
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Affiliation(s)
- Nicolas Roche
- Pneumology, AP-HP Centre Université Paris Cité, Hôpital Cochin, Paris, France
| | | | - Alvaro A Cruz
- ProAR and Universidade Federal da Bahia, Salvador, Brazil
| | | | - Kim L Lavoie
- University of Quebec at Montreal (UQAM), Montreal, Canada; Montreal Behavioural Medicine Centre, CIUSSS-NIM, Hopital du Sacre-Coeur de Montreal, Montreal, Canada
| | - P G Abhijith
- GSK, Global Medical Affairs, General Medicine, Amsterdam, the Netherlands
| | - Manish Verma
- GSK, Global Medical Affairs, General Medicine, Mumbai, India.
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Singh D, Oosterholt S, Pavord I, Garcia G, Abhijith Pg, Della Pasqua O. Understanding the Clinical Implications of Individual Patient Characteristics and Treatment Choice on the Risk of Exacerbation in Asthma Patients with Moderate-Severe Symptoms. Adv Ther 2023; 40:4606-4625. [PMID: 37589831 PMCID: PMC10499702 DOI: 10.1007/s12325-023-02590-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/21/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION The assessment of future risk has become an important feature in the management of patients with asthma. However, the contribution of patient-specific characteristics and treatment choices to the risk of exacerbation is poorly understood. Here we evaluated the effect of interindividual baseline differences on the risk of exacerbation and treatment performance in patients receiving regular maintenance doses of inhaled corticosteroids (ICS) or ICS/long-acting beta-agonists (LABA) combination therapy. METHODS Exacerbations and changes to asthma symptoms 5-item Asthma Control Questionnaire (ACQ-5) were simulated over a 12-month period using a time-to-event and a longitudinal model developed from phase III/IV studies in patients with moderate-severe asthma (N = 16,282). Simulations were implemented to explore treatment performance across different scenarios, including randomised designs and real-world settings. Treatment options included regular dosing with ICS monotherapy [fluticasone propionate (FP)] and combination therapy [fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR)]. Exacerbation rate was analysed using the log-rank test. The cumulative incidence of events was summarised stratified by treatment. RESULTS Being a woman, smoker, having higher baseline ACQ-5 and body mass index (BMI) and lower forced expiratory volume in the first second (FEV1) are associated with increased exacerbation risk (p < 0.01). This risk is bigger in winter because of the seasonal variation effect. Across the different scenarios, the use of FP/SAL resulted in a 10% lower annual incidence of exacerbations relative to FP or regular dosing BUD/FOR, independently of baseline characteristics. Similar differences in the annual incidence of exacerbations were also observed between treatments in obese patients (BMI ≥ 25-35 kg/m2) (p < 0.01) and in patients who do not achieve symptom control on FP monotherapy. CONCLUSIONS Individual baseline characteristics and treatment choices affect future risk. Achieving comparable levels of symptom control whilst on treatment does not imply comparable risk reduction, as shown by the lower exacerbation rates in FP/SAL vs. BUD/FOR-treated patients. These factors should be considered as a basis for personalised clinical management of patients with moderate-severe asthma.
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Affiliation(s)
- Dave Singh
- University of Manchester, Manchester University NHS Foundations Trust, Manchester, UK
| | - Sean Oosterholt
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK
| | - Ian Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gabriel Garcia
- Respiratory Medicine Service, Rossi Hospital, La Plata, Argentina
| | - Abhijith Pg
- GSK, Global Classic and Established Medicines, Singapore, Singapore
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK.
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK.
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