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Aljalamdeh R, Price R, Jones MD, Bolhuis A. The effect of particle size of inhaled tobramycin dry powder on the eradication of Pseudomonas aeruginosa biofilms. Eur J Pharm Sci 2021; 158:105680. [PMID: 33346008 DOI: 10.1016/j.ejps.2020.105680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/26/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022]
Abstract
Pseudomonas aeruginosa is the predominant opportunistic bacterium that causes chronic respiratory infections in cystic fibrosis (CF) patients. This bacterium can form biofilms, which are structured communities of cells encased within a self-produced matrix. Such biofilms have a high level of resistance to multiple classes of antibiotics. A widely used treatment of P. aeruginosa lung infections in CF patients is tobramycin dry powder inhalation. The behaviour of particles in the lung has been well studied, and dry powder inhalers are optimised for optimal dispersion of the drug into different zones of the lung. However, one question that has not been addressed is whether the size of an antibiotic particle influences the antibiofilm activity against P. aeruginosa. We investigated this by fractionating tobramycin particles using a Next Generation Impactor (NGI). The fractions obtained were then tested in an in vitro model on P. aeruginosa biofilms. The results indicate that the antibiofilm activity of tobramycin dry powder inhaler can indeed be influenced by the particle size. Against P. aeruginosa biofilms of two clinical isolates, smaller tobramycin particles (aerodynamic diameter <2.82 µm) showed better efficacy by approximately 20% as compared to larger tobramycin particles (aerodynamic diameter <11.7 µm) However, this effect was only observed when biofilms were treated for 3 hours, whereas there was no difference after treatment for 24 hours. This suggests that in our model the rate of dissolution of larger particles limits the effectiveness of tobramycin over a 3-hour time period, which is relevant as this is equivalent to the time in which most tobramycin is cleared from the lung.
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Affiliation(s)
- Reham Aljalamdeh
- Department of Pharmacy and Pharmacology, University of Bath, Bath BA2 7AY, United Kingdom
| | - Robert Price
- Department of Pharmacy and Pharmacology, University of Bath, Bath BA2 7AY, United Kingdom
| | - Matthew D Jones
- Department of Pharmacy and Pharmacology, University of Bath, Bath BA2 7AY, United Kingdom
| | - Albert Bolhuis
- Department of Pharmacy and Pharmacology, University of Bath, Bath BA2 7AY, United Kingdom.
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Comparative efficacy and tolerability of beclomethasone/formoterol and fluticasone/salmeterol fixed combination in Taiwanese asthmatic patients. J Formos Med Assoc 2017; 117:1078-1085. [PMID: 29292054 DOI: 10.1016/j.jfma.2017.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/23/2017] [Accepted: 12/05/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The study was designed to compare the efficacy and tolerability of a fixed combination of extra-fine beclomethasone and formoterol, with the fixed combination fluticasone and salmeterol in Taiwanese asthmatic patients. METHODS This was a phase III, multicentre, randomized, two-arm parallel groups, controlled study. Patients with moderate to severe asthma were randomized to a 12-week treatment with either beclomethasone 100 mcg plus formoterol 6 mcg (BDP/F) or fluticasone 125 mcg plus salmeterol 25 mcg (FP/S), both delivered 2 inhalations twice daily. The efficacy and tolerability of these two combinations were compared. RESULTS Among the 253 randomized subjects, 244 patients were evaluable (119 in the BDP/F group and 125 in the FP/S group). A significant improvement from baseline to the end of treatment period was observed in both BDP/F and FP/S groups in forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), morning and evening peak expiratory flow (PEF), Asthma Control Test (ACT) score and the use of rescue medication. FVC increase from pre-dose was significant after 5 min post inhalation in the BDP/F group only, while statistically significant within group improvement was not achieved until 30 min post inhalation in the FP/S group. CONCLUSION The BDP/F combination is comparable in efficacy and tolerability to FP/S combination in Taiwanese asthmatic patients, with the advantage of rapid onset of improvement of FVC, consistent with the faster improvement of pulmonary hyperinflation with BDP/F.
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Sonnappa S, McQueen B, Postma DS, Martin RJ, Roche N, Grigg J, Guilbert T, Gouder C, Pizzichini E, Niimi A, Phipatanakul W, Chisholm A, Dandurand RJ, Kaplan A, Israel E, Papi A, van Aalderen WMC, Usmani OS, Price DB. Extrafine Versus Fine Inhaled Corticosteroids in Relation to Asthma Control: A Systematic Review and Meta-Analysis of Observational Real-Life Studies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:907-915.e7. [PMID: 28941668 DOI: 10.1016/j.jaip.2017.07.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The particle size of inhaled corticosteroids (ICSs) may affect airway drug deposition and effectiveness. OBJECTIVE To compare the effectiveness of extrafine ICSs (mass median aerodynamic diameter, <2 μm) versus fine-particle ICSs administered as ICS monotherapy or ICS-long-acting β-agonist combination therapy by conducting a meta-analysis of observational real-life asthma studies to estimate the treatment effect of extrafine ICSs. METHODS MEDLINE and EMBASE databases were reviewed for asthma observational comparative effectiveness studies from January 2004 to June 2016. Studies were included if they reported odds and relative risk ratios and met all inclusion criteria (Respiratory Effectiveness Group/European Academy of Allergy and Clinical Immunology quality standards, comparison of extrafine ICSs with same or different ICS molecule, ≥12-month follow-up). End-point data (asthma control, exacerbations, prescribed ICS dose) were pooled. Random-effects meta-analysis modeling was used. The study protocol is published in the PROSPERO register CRD42016039137. RESULTS Seven studies with 33,453 subjects aged 5 to 80 years met eligibility criteria for inclusion. Six studies used extrafine beclometasone propionate and 1 study used both extrafine beclometasone propionate and extrafine ciclesonide as comparators with fine-particle ICSs. The overall odds of achieving asthma control were significantly higher for extrafine ICSs compared with fine-particle ICSs (odds ratio, 1.34; 95% CI, 1.22-1.46). Overall exacerbation rate ratios (0.84; 95% CI, 0.73-0.97) and ICS dose (weighted mean difference, -170 μg; 95% CI, -222 to -118 μg) were significantly lower for extrafine ICSs compared with fine-particle ICSs. CONCLUSIONS This meta-analysis demonstrates that extrafine ICSs have significantly higher odds of achieving asthma control with lower exacerbation rates at significantly lower prescribed doses than fine-particle ICSs.
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Affiliation(s)
- Samatha Sonnappa
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Department of Respiratory Paediatrics, Rainbow Children's Hospital, Bengaluru, India
| | - Brett McQueen
- University of Colorado Denver, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Denver, Colo
| | - Dirkje S Postma
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Richard J Martin
- National Jewish Health and the University of Colorado Denver, Denver, Colo
| | - Nicolas Roche
- Respiratory and Intensive Care Medicine, Cochin Hospital (APHP), University Paris Descartes (EA2511), Paris, France
| | - Jonathan Grigg
- Blizard Institute, Queen Mary University London, London, United Kingdom
| | - Theresa Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Cincinnati, Ohio
| | - Caroline Gouder
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Emilio Pizzichini
- Department of Medicine, Federal University of Santa Catarina, Santa Catarina, Brazil
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Alison Chisholm
- Respiratory Effectiveness Group, Oakington, Cambridge, United Kingdom
| | - Ronald J Dandurand
- Montreal Chest Institute, Meakins-Christie Laboratories and the McGill University Health Centre Research Institute, McGill University, Montreal, Canada
| | - Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada
| | - Elliot Israel
- Pulmonary and Critical Care Division, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alberto Papi
- Department of Respiratory Medicine, University Hospital S. Anna, Ferrara, Italy
| | - Willem M C van Aalderen
- Department of Pediatric Respiratory Diseases, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, London, United Kingdom
| | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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Matera MG, Rinaldi B, Calzetta L, Cazzola M. Assessing the viability of long-acting β 2-agonists in paediatric asthma patients: a pharmacokinetic/pharmacodynamic perspective. Expert Opin Drug Metab Toxicol 2016; 13:129-136. [PMID: 27615145 DOI: 10.1080/17425255.2017.1234604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Long-acting β2-agonists (LABAs) combined with inhaled corticosteroids (ICSs) are still commonly prescribed to asthmatic children. Unfortunately, pediatric LABA use is based primarily on data from adults, despite the fact that children are not simply small adults and the magnitude of changes in dose exposure and/or exposure response may not be solely reflected by differences in body weight. Areas covered: The differences in pharmacokinetics (PK) and pharmacodynamics (PD) of LABAs are described and discussed with reference children and adults. Expert opinion: Data on the PK behavior of LABAs is very limited and there is almost no data on once-daily LABAs available in the pediatric population. We do not believe that this is due to a fundamental lack of information because therapeutic response and adverse effects are more useful for the optimization of β2-agonist treatment than measurement of plasma drug concentrations per se. Nevertheless, population PK-PD studies in children are needed according to the European rules in order to define rational, patient-tailored dosing schemes. Population PK-PD modeling and simulation using non-linear mixed effect modeling should be considered as the preferred tool to develop effective and safe dosing regimens for children because they present an opportunity to analyze sparse and unbalanced datasets, thereby minimizing the burden for each child.
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Affiliation(s)
| | - Barbara Rinaldi
- a Department of Experimental Medicine , Second University of Naples , Naples , Italy
| | - Luigino Calzetta
- b Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
| | - Mario Cazzola
- b Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
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Haidl P, Heindl S, Siemon K, Bernacka M, Cloes RM. Inhalation device requirements for patients' inhalation maneuvers. Respir Med 2016; 118:65-75. [PMID: 27578473 DOI: 10.1016/j.rmed.2016.07.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/19/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inhaled drugs are the mainstay of treatment for lung diseases such as asthma and chronic obstructive pulmonary disease. However, failure to use inhalation devices correctly can lead to a poorly controlled status. A vast number of inhalation devices exist and each device has specific requirements to achieve optimum inhalation of the drug. Currently, there is no overview of inhalation requirements considering all devices. This article presents a review of the literature on different inhalation device requirements and incorporates the data into a new inhalation flow algorithm. METHODS Data from literature on commercially available inhalation devices were evaluated and parameters, such as inhalation flow rate, flow acceleration, inhalation volume, and inspiration time assessed for the required inhalation maneuver specific to the device. All agreed upon data points were used to develop an inhalation flow algorithm. RESULTS The literature analysis revealed availability of robust data for the required inhalation flow characteristics for most devices and thus for the development of an algorithm. For those devices for which these parameters are not published, the minimum required flow criteria were defined based on published data regarding individual aspects of aerosol quality. CONCLUSIONS This review provides an overview of inhalation devices available on the market regarding requirements for an acceptable inhalation maneuver and shows which goals should be achieved in terms of inhalation flows. The presented algorithm can be used to develop a new computer based measurement system which could help to test and train patients' individual inhalation maneuvers with their inhalation devices.
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Hosseinpour M, Vatanara A, Zarghami R. Formation and Characterization of Beclomethasone Dipropionate Nanoparticles Using Rapid Expansion of Supercritical Solution. Adv Pharm Bull 2015; 5:343-9. [PMID: 26504756 DOI: 10.15171/apb.2015.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/25/2014] [Accepted: 01/11/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Particle size of Beclometasone Dipropionate (BDP) was reduced by the rapid expansion of supercritical solution (RESS) process, using CO2 as supercritical solvent. Also, the effect of RESS parameters such as extraction pressure, pre-expansion temperature, and weight fraction of co-solvent on the size and distribution of BDP particles were investigated. METHODS The effects of extraction pressure (200-260 bar), pre-expansion temperature (70-110 °C) and weight fraction of menthol as a co-solvent on mean particle size (MPS) of BDP were investigated by design of experiment (DOE). Particles were characterized using Scanning Electron Microscopy (SEM) and Dynamic Light Scattering (DLS). RESULTS The average sizes of precipitated BDP were between 64.1 and 294 nm. Analysis of variance (ANOVA) showed that extraction pressure was the most significant parameter and a higher extraction pressure caused production of smaller particles. Also, it was found that higher temperature and weight fraction of co-solvent increased the MPS. The interaction effects of extraction pressure-pre-expansion temperature and pre-expansion temperature-co-solvent ratio were significant through the analysis of variance. It was observed that the MPS of precipitated particles was mostly influenced by pressure. CONCLUSION The smallest MPS of BDP obtained from the RESS process was 65 nm that revealed a significant size reduction from its original MPS of 9 μm. Moreover, a slight change was observed for precipitated particles of BDP into spherical form while the original particles were irregular in shape. RESS process showed as a promising method for production of BDP nanoparticles that may results in improvement of drug's physicochemical properties.
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Affiliation(s)
- Mohsen Hosseinpour
- Pharmaceutical Engineering Laboratory, Multiphase Processes Department, School of Chemical Engineering, University of Tehran, Tehran, Iran
| | - Alireza Vatanara
- Aerosol Research Laboratory, Pharmaceutics Department, Faculty of Pharmacy, Tehran University of Medical Science, Tehran, Iran
| | - Reza Zarghami
- Pharmaceutical Engineering Laboratory, Multiphase Processes Department, School of Chemical Engineering, University of Tehran, Tehran, Iran
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Kuna P, Govoni M, Lucci G, Scuri M, Acerbi D, Stelmach I. Pharmacokinetics and pharmacodynamics of an extrafine fixed pMDI combination of beclometasone dipropionate/formoterol fumarate in adolescent asthma. Br J Clin Pharmacol 2015; 80:569-80. [PMID: 25808292 DOI: 10.1111/bcp.12640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/01/2015] [Accepted: 03/22/2015] [Indexed: 11/30/2022] Open
Abstract
AIM The aim was to investigate the pharmacokinetics and pharmacodynamics of an extrafine pressurized metered-dose inhaler (pMDI) fixed combination of beclometasone dipropionate (BDP)/formoterol fumarate (FF) in adolescent and adult asthma. METHODS This was a three-way crossover study, on 30 asthmatic adolescents receiving BDP/FF pMDI with or without a valved holding chamber (VHC) or a free licenced combination of BDP pMDI and FF pMDI plus a parallel arm of 30 asthmatic adults receiving BDP/FF pMDI. All patients received a single dose of BDP and FF of 400 µg and 24 µg, for each treatment, respectively. Assessments were performed over 8 hours. RESULTS In adolescents, the 90% confidence intervals (CIs) for the systemic exposure (AUC(0,t)) geometric mean ratio of the fixed combination with or without VHC vs. the free combination were within the bioequivalence range 0.80-1.25, both for beclometasone-17-monopropionate (B17MP, the active metabolite of BDP) and formoterol. Pharmacodynamic variables for plasma potassium and glucose, pulse rate and pulmonary function in adolescents were equivalent between treatments, 95% CI within 0.9, 1.09. The upper level of 90% CIs for AUC(0,t) geometric mean ratio adolescents : adults of B17MP and formoterol after treatment with BDP/FF pMDI was lower than 1.25, 90% CI 0.78, 1.04 and 0.86, 1.17, respectively. CONCLUSIONS In adolescents the pharmacodynamics and the overall systemic exposure to the active ingredients of an extrafine fixed combination of BDP/FF pMDI with or without a VHC was equivalent to that of a free licenced combination of pMDIs of established safety and efficacy profiles. The systemic exposure in adolescents was not higher than in adults. These results support the indication for use of inhaled corticosteroid/long acting β2 -adrenoceptor agonist pMDIs in adolescents at the same dosage as in adults.
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Affiliation(s)
- Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Barlicki University Hospital, Medical University of Lodz, Poland
| | - Mirco Govoni
- Department of Clinical Pharmacology, Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | - Germano Lucci
- Department of Clinical Pharmacology, Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | - Mario Scuri
- Department of Clinical Pharmacology, Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | - Daniela Acerbi
- Department of Clinical Pharmacology, Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | - Iwona Stelmach
- Department of Pediatrics and Allergy, Medical University of Lodz, Poland
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van Aalderen WMC, Grigg J, Guilbert TW, Roche N, Israel E, Martin RJ, Colice G, Postma DS, Hillyer EV, Burden A, Thomas V, von Ziegenweidt J, Price D. Small-particle Inhaled Corticosteroid as First-line or Step-up Controller Therapy in Childhood Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:721-31.e16. [PMID: 26032474 DOI: 10.1016/j.jaip.2015.04.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 04/09/2015] [Accepted: 04/23/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Because randomized controlled trials of established pediatric asthma therapies are expensive and difficult to perform, observational studies may fill gaps in the evidence base. OBJECTIVES To compare the effectiveness of representative small-particle inhaled corticosteroid (ICS) with that of standard size-particle ICS for children initiating or stepping up ICS therapy for asthma (analysis 1) and to compare the effectiveness of ICS dose step-up using small-particle ICS with adding long-acting β2-agonist (LABA) to the ICS (analysis 2). METHODS These historical matched cohort analyses drew on electronic medical records of children with asthma aged 5 to 11 years. Variables measured during 2 consecutive years (1 baseline year for confounder definition and 1 outcome year) included risk-domain asthma control (no hospital attendance for asthma, acute oral corticosteroids, or lower respiratory tract infection requiring antibiotics) and rate of severe exacerbations (asthma-related emergency, hospitalization, or oral corticosteroids). RESULTS In the initiation population (n = 797 in each cohort), children prescribed small-particle ICS versus standard size-particle ICS experienced greater odds of asthma control (adjusted odds ratio, 1.49; 95% CI, 1.10-2.02) and lower severe exacerbation rate (adjusted rate ratio, 0.56; 95% CI, 0.35-0.88). Step-up outcomes (n = 206 in each cohort) were also significantly better for small-particle ICS, with asthma control adjusted odds ratio of 2.22 (95% CI, 1.23-4.03) and exacerbations adjusted rate ratio of 0.49 (95% CI, 0.27-0.89). The number needed to treat with small-particle ICS to achieve 1 additional child with asthma control was 17 (95% CI, 9-107) for the initiation population and 5 (95% CI, 3-78) for the step-up population. Outcomes were not significantly different for stepped-up small-particle ICS dose versus ICS/LABA combination (n = 185 in each cohort). CONCLUSIONS Initiating or stepping up the ICS dose with small-particle ICS rather than with standard size-particle ICS is more effective and shows similar effectiveness to add-on LABA in childhood asthma.
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Affiliation(s)
- Willem M C van Aalderen
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Jonathan Grigg
- Blizard Institute, Queen Mary University London, London, UK
| | | | - Nicolas Roche
- Cochin Hospital Group, AP-HP, University of Paris Descartes (EA2511), Paris, France
| | - Elliot Israel
- Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Richard J Martin
- Department of Medicine, National Jewish Health and University of Colorado Denver, Denver, Colo
| | - Gene Colice
- Washington Hospital Center and George Washington University School of Medicine, Washington, DC
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | - David Price
- Research in Real Life, Ltd, Cambridge, UK; Academic Primary Care, University of Aberdeen, Aberdeen, UK.
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van Aalderen WM, Garcia-Marcos L, Gappa M, Lenney W, Pedersen S, Dekhuijzen R, Price D. How to match the optimal currently available inhaler device to an individual child with asthma or recurrent wheeze. NPJ Prim Care Respir Med 2015; 25:14088. [PMID: 25568979 PMCID: PMC4532150 DOI: 10.1038/npjpcrm.2014.88] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/22/2014] [Accepted: 08/24/2014] [Indexed: 12/05/2022] Open
Abstract
Inhaled medications are the cornerstone of treatment in early childhood wheezing and paediatric asthma. A match between patient and device and a correct inhalation technique are crucial for good asthma control. The aim of this paper is to propose an inhaler strategy that will facilitate an inhaler choice most likely to benefit different groups of children. The main focus will be on pressurised metered dose inhalers and dry powder inhalers. In this paper we will discuss (1) practical difficulties with the devices and with inhaled therapy and (2) the optimal location for deposition of medicines in the lungs, and (3) we will propose a practical and easy way to make the best match between the inhaler device and the individual patient. We hope that this paper will contribute to an increased likelihood of treatment success and improved adherence to therapy.
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Affiliation(s)
- Wim M van Aalderen
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children’s Hospital AMC, Amsterdam, The Netherlands
| | | | - Monika Gappa
- Department of Pediatrics, Marine Hospital gGmbH Wesel, Wesel, Germany
| | - Warren Lenney
- University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Søren Pedersen
- University of Southern Denmark, Paediatric Research Unit, Kolding Hospital, Kolding, Denmark
| | - Richard Dekhuijzen
- Department of Pulmonary Diseases (454), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - David Price
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Bodzenta-Łukaszyk A, Kokot M. Pharmacological consequences of inhaled drug delivery to small airways in the treatment of asthma. Adv Ther 2014; 31:803-16. [PMID: 25116888 DOI: 10.1007/s12325-014-0143-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Indexed: 11/29/2022]
Abstract
Small peripheral airways are an important target for the anti-inflammatory treatment of asthma. To make anti-inflammatory drugs (inhaled corticosteroids [ICS]) effectively reach small airways, they should be delivered using inhalation techniques containing high proportions of fine or super-fine particles. Higher proportions of fine particles are associated with higher systemic absorption of ICS leading to an increased risk of endogenous cortisol suppression. Ciclesonide, despite the highest proportion of fine and super-fine particle fractions, is the only ICS not associated with an increased risk of systemic adverse effects, including cortisol suppression. In contrary to ICS, bronchodilators should not be administered to peripheral airways. This does not improve their efficacy and may increase their risk of cardiotoxicity. Thus, from a pharmacological point of view and the theory of aerosols' deposition, fixed combinations of ICS and long-acting beta agonists are always suboptimal. In many cases, the best solution may be to use fine-particle ciclesonide and a non-fine particle beta agonist administered from separate inhalers.
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Affiliation(s)
- Anna Bodzenta-Łukaszyk
- Clinical Department of Allergic and Internal Diseases, Medical University of Białystok, Bialystok, Poland,
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Govoni M, Piccinno A, Lucci G, Poli G, Acerbi D, Baronio R, Singh D, Kuna P, Chawes BLK, Bisgaard H. The systemic exposure to inhaled beclometasone/formoterol pMDI with valved holding chamber is independent of age and body size. Pulm Pharmacol Ther 2014; 30:102-9. [PMID: 24746942 DOI: 10.1016/j.pupt.2014.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/13/2014] [Accepted: 04/05/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Asthma guidelines recommend prescription of inhaled corticosteroids at a reduced dosage in children compared to older patients in order to minimize the systemic exposure and risk of unwanted side effects. In children, pressurized metered dose inhalers (pMDI) are recommended in combination with a valved holding chamber (VHC) to overcome the problem of coordinating inhalation with actuation. However, the influence of age and body size on the systemic exposure of drugs to be administered via a pMDI with VHC is still not fully elucidated. Therefore, we aimed to compare the systemic exposure to the active ingredients of a fixed combination of beclometasone-dipropionate/formoterol-fumarate administered via pMDI with VHC in children, adolescents and adults. METHODS The pharmacokinetics of formoterol and beclometasone-17-monopropionate (active metabolite of beclometasone-dipropionate) was evaluated over 8 h from three studies, each performed in a different age and body size group. Children (7-11 years, n = 20), adolescents (12-17 years, n = 29) and adults (≥18 years, n = 24) received a single dose of beclometasone/formoterol (children: 200 μg/24 μg, adolescents and adults: 400 μg/24 μg) via pMDI with AeroChamber Plus™. RESULTS The systemic exposure in children in comparison to adolescents was equivalent for formoterol while it was halved for beclometasone-17-monopropionate in accordance with the halved dose of beclometasone administered in children (90% CIs within 0.8-1.25 for formoterol and 0.4-0.625 for beclometasone-17-monopropionate). The systemic exposure to beclometasone-17-monopropionate and formoterol was equivalent between adolescents and adults. CONCLUSIONS The systemic exposure to the active ingredients of a fixed dose combination of beclometasone/formoterol administered via pMDI with AeroChamber Plus™ correlates with the nominal dose independently of patient age and body size. Thus, dose reduction in relation to age when using a pMDI with VHC may be unnecessary for reducing the systemic exposure in children.
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Affiliation(s)
- Mirco Govoni
- Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma 43122, Italy.
| | - Annalisa Piccinno
- Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma 43122, Italy
| | - Germano Lucci
- Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma 43122, Italy
| | - Gianluigi Poli
- Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma 43122, Italy
| | - Daniela Acerbi
- Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma 43122, Italy
| | - Roberta Baronio
- Department of Statistics and Data Management, Chiesi Farmaceutici, Parma 43122, Italy
| | - Dave Singh
- University of Manchester, The Medicines Evaluation Unit, Manchester M23 9QZ, United Kingdom
| | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Barlicki University Hospital, Medical University of Lodz, 90-153, Poland
| | - Bo L K Chawes
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
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Chawes BLK, Piccinno A, Kreiner-Møller E, Vissing NH, Poorisrisak P, Mortensen L, Nilson E, Bisgaard A, Dossing A, Deleuran M, Skytt NL, Samandari N, Sergio F, Ciurlia G, Poli G, Acerbi D, Bisgaard H. Pharmacokinetic comparison of inhaled fixed combination vs. the free combination of beclomethasone and formoterol pMDIs in asthmatic children. Br J Clin Pharmacol 2013; 75:1081-8. [PMID: 22978252 DOI: 10.1111/j.1365-2125.2012.04459.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 09/10/2012] [Indexed: 11/28/2022] Open
Abstract
AIM The fixed combination of beclomethasone (BDP) and formoterol pressurized metered dose inhaler (pMDI) (Foster®, Chiesi Farmaceutici) is being developed in the lower strength (BDP/formoterol: 50/6 μg) to provide an appropriate dosage for children with asthma. The aim of this work was to investigate the systemic bioavailability of beclomethasone-17-monoproprionate (B17MP, the active metabolite of BDP) and formoterol after single inhalation of Foster® pMDI 50/6 μg vs. the free combination of BDP and formoterol pMDIs in asthmatic children. METHODS Children aged 5-11 years old inhaled BDP 200 μg and formoterol 24 μg as fixed vs. free combination in an open label, randomized, two way crossover single dose study. Blood was collected pre-dose up to 8 h post-dose for pharmacokinetic evaluation (AUC(0,t), AUC(0,∞), AUC(0,0.5 h, Cmax , tmax , t1/2 ). Pharmacodynamics included heart rate, plasma potassium, urinary glucose and cortisol excretion. Peak expiratory flow and adverse events were monitored. RESULTS Twenty subjects were evaluable. The systemic exposure of B17MP and formoterol administered as fixed combination did not exceed the free combination: B17MP AUC(0,t) (pg ml(-1) h) ratio test : reference (90% CI), 0.81 (0.697, 0.948) and formoterol AUC(0,t) (pg ml(-1) h) ratio test : reference 0.97 (0.85, 1.10). All pharmacokinetic and pharmacodynamic end points showed non-superiority in favour of the test drug. One adverse event (vertigo) occurred but was not considered treatment-related. CONCLUSION BDP and formoterol pharmacokinetic and pharmacodynamic effects are non-superior after administration of the two actives as fixed vs. the free combination in 5-11-year-old asthmatic children.
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Affiliation(s)
- Bo L K Chawes
- Copenhagen University Hospital, Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Gentofte, Denmark
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Morton RL, O'Hagan A, Eid NS. The Role of Small Airways in Childhood Asthma. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2012. [DOI: 10.1089/ped.2012.0176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Ronald L. Morton
- Division of Pulmonary Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Adrian O'Hagan
- Division of Pulmonary Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Nemr S. Eid
- Division of Pulmonary Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
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van Aalderen WMC, Sprikkelman AB. Inhaled corticosteroids in childhood asthma: the story continues. Eur J Pediatr 2011; 170:709-18. [PMID: 20931226 PMCID: PMC3098975 DOI: 10.1007/s00431-010-1319-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 09/20/2010] [Indexed: 11/14/2022]
Abstract
Inhaled corticosteroids (ICS) are the most effective anti-inflammatory drugs for the treatment of persistent asthma in children. Treatment with ICS decreases asthma mortality and morbidity, reduces symptoms, improves lung function, reduces bronchial hyperresponsiveness and reduces the number of exacerbations. The efficacy of ICS in preschool wheezing is controversial. A recent task force from the European Respiratory Society on preschool wheeze defined two different phenotypes: episodic viral wheeze, wheeze that occurs only during respiratory viral infections, and multiple-trigger wheeze, where wheeze also occurs in between viral episodes. Treatment with ICS appears to be more efficacious in the latter phenotype. Small particle ICS may offer a potential benefit in preschool children because of the favourable spray characteristics. However, the efficacy of small particle ICS in preschool children has not yet been evaluated in prospective clinical trials. The use of ICS in school children with asthma is safe with regard to systemic side effects on the hypothalamic-pituitary-adrenal axis, growth and bone metabolism, when used in low to medium doses. Although safety data in wheezing preschoolers is limited, the data are reassuring. Also for this age group, adverse events tend to be minimal when the ICS is used in appropriate doses.
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Affiliation(s)
- Wim M. C. van Aalderen
- Department of Paediatric Respiratory Medicine and Allergy, Emma Children’s Hospital AMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Aline B. Sprikkelman
- Department of Paediatric Respiratory Medicine and Allergy, Emma Children’s Hospital AMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
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15
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Particle size of inhaled corticosteroids: does it matter? J Allergy Clin Immunol 2010; 124:S88-93. [PMID: 19962042 DOI: 10.1016/j.jaci.2009.09.050] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 09/18/2009] [Accepted: 09/21/2009] [Indexed: 11/21/2022]
Abstract
A question with respect to asthma therapy revolves around the issue of whether better efficacy occurs with an ultrafine-particle inhaled corticosteroid because of better lung deposition into the distal airways. This article reviews particle size and delivery devices of different steroids, clinical outcomes of small- versus large-particle steroids, and the issue of pharmacoeconomics.
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16
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Learoyd TP, Burrows JL, French E, Seville PC. Modified release of beclometasone dipropionate from chitosan-based spray-dried respirable powders. POWDER TECHNOL 2008. [DOI: 10.1016/j.powtec.2008.02.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Robroeks CMHHT, van de Kant KDG, van Vliet D, Kester AD, Hendriks HJE, Damoiseaux JGMC, Wodzig WKWH, Rijkers GT, Dompeling E, Jöbsis Q. Comparison of the anti-inflammatory effects of extra-fine hydrofluoroalkane-beclomethasone vs fluticasone dry powder inhaler on exhaled inflammatory markers in childhood asthma. Ann Allergy Asthma Immunol 2008; 100:601-7. [PMID: 18592826 DOI: 10.1016/s1081-1206(10)60052-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Extra-fine hydrofluoroalkane-beclomethasone differs from other inhaled corticosteroids by its fine aerosol characteristics. Therefore, extra-fine hydrofluoroalkane-beclomethasone may be particularly useful for treating peripheral airway inflammation in asthma. OBJECTIVE To analyze the anti-inflammatory effects of extra-fine hydrofluoroalkane-beclomethasone vs fluticasone dry powder inhaler (DPI) in asthmatic children by measuring bronchial and alveolar nitric oxide (NO) and inflammatory markers in exhaled breath condensate (EBC). METHODS In a 6-month crossover study, 33 children aged 6 to 12 years with moderate persistent asthma were randomly treated with extra-fine hydrofluoroalkane-beclomethasone (200 microg daily via an Autohaler) and fluticasone DPI (200 microg daily via a Diskus). The primary outcome variables were alveolar NO concentration and bronchial NO flux. The secondary outcome variables were levels of inflammatory markers in EBC, lung function indices, symptoms, exacerbations, and adverse effects. All the variables were recorded at baseline and after each treatment period. RESULTS Mean +/- SE alveolar NO concentration and bronchial NO flux were comparable after treatment with hydrofluoroalkane-beclomethasone vs fluticasone DPI (4.7 +/- 0.5 vs 4.3 +/- 0.5 ppb, P = .55, and 1,124.3 +/- 253.6 vs 1,029.1 +/- 195.5 pL/s, P = .70, respectively). In addition, levels of inflammatory markers in EBC, lung function indices, and symptoms did not differ between treatments. Patients used fewer beta2-agonists during the last 2 weeks of hydrofluoroalkane-beclomethasone treatment. CONCLUSION The anti-inflammatory effects of hydrofluoroalkane-beclomethasone are similar to those of fluticasone DPI in children with moderate persistent asthma.
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van Aalderen WMC, Price D, De Baets FM, Price J. Beclometasone dipropionate extrafine aerosol versus fluticasone propionate in children with asthma. Respir Med 2007; 101:1585-93. [PMID: 17254760 DOI: 10.1016/j.rmed.2006.11.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Revised: 11/24/2006] [Accepted: 11/24/2006] [Indexed: 11/24/2022]
Abstract
Beclometasone dipropionate (BDP) extrafine is a hydrofluoroalkane-based, chlorofluorocarbon (CFC)-free inhalation aerosol. This study was conducted to determine whether BDP extrafine and CFC-fluticasone proprionate (FP) aerosols were equivalent in terms of efficacy and tolerability in children with symptomatic mild-to-moderate asthma. Male and female patients (aged 5-12 yr) with an asthma diagnosis for > or =3 months, peak expiratory flow (PEF) > or =60% of predicted normal and suboptimal asthma control were randomised to double-blind treatment with BDP extrafine 200 microg day(-1) (n=139) or CFC-FP 200 microg day(-1) (n=141) for up to 18 weeks. After 6 and 12 weeks, study medication was 'stepped down' to 100 and 50 microg day(-1), respectively, if patients had achieved good asthma control. Patients with poor asthma control discontinued from the study and those with intermediate control continued in the study but did not undergo a dose reduction. The estimated treatment difference in morning PEF% predicted at 6 weeks was -1.9% (90% CI -4.9, 1.0). There was a trend towards a greater increase in forced vital capacity (% predicted) in the BDP extrafine group (5.3 versus 0.4%; p=0.084). A 'step-down' in therapy to 100 microg day(-1) was possible in 36% and 42% of patients in the BDP extrafine and CFC-FP groups, respectively, at 6 weeks. Both drugs were well tolerated. BDP extrafine and CFC-FP aerosols were equally effective at improving asthma control in children with mild-to-moderate asthma at the same daily dose.
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Lasserson TJ, Cates CK, Jones AB, Steele EH, White J. Fluticasone versus HFA-beclomethasone dipropionate for chronic asthma in adults and children. Cochrane Database Syst Rev 2006; 2006:CD005309. [PMID: 16625634 PMCID: PMC10726986 DOI: 10.1002/14651858.cd005309.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The relative efficacy of fluticasone (FP) and beclomethasone (BDP) propelled with CFCs has been well established. The potency of HFA-BDP is thought to have been improved with new propellant and some studies suggest that it may equipotent at half the dose of CFC propelled-BDP. There is a need to revisit this question in the light of a potentially more potent new non-CFC propellant. OBJECTIVES To determine the relative efficacy of FP and HFA-propelled BDP in chronic asthma. SEARCH STRATEGY The Cochrane Airways Group Specialised Register was searched using pre-specified terms. Searches were current as of January 2006. SELECTION CRITERIA Randomised controlled trials were eligible for inclusion in the review. We compared either CFC or HFA-propelled FP with HFA-propelled BDP. We made a distinction between HFA-BDP and HFA-BDP extra fine, which dispenses smaller particles of drug, leading to different, usually more peripheral distribution in the airways. Any inhaler device was considered, and there was no restriction on studies with or without spacers. We included studies which assessed HFA-BDP given via either pMDI, breath-actuated MDI, or DPI. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed studies for inclusion in the review. Data were extracted and entered in to RevMan 4.2 using standard meta-analytical techniques with predefined criteria for exploring statistical heterogeneity. MAIN RESULTS Eight studies (1260 participants) met the inclusion criteria of the review. One study was conducted in children. Study reporting quality was fair, but all studies were of short duration (three to twelve weeks). Only studies assessing HFA-BDP extra fine in comparison with FP were identified. Lung function was not significantly different between extra fine BDP and FP when compared at the same dose in parallel studies, change in FEV1: 0.04 litres (95% CI -0.03 to 0.11 litres; three studies, 659 adults); change in am PEF: -0.69 litres (95% CI -11.21 to 9.83 litres; two studies, 364 adults). Individual studies reported non-significant findings in symptom scores and quality of life questionnaires. There was no significant difference between FP and HFA-BDP in the risk of study withdrawal, dysphonia or when data were reported as any adverse event. AUTHORS' CONCLUSIONS There was no significant difference between FP and extra fine HFA-BDP on FEV(1) or peak flow at a dose ratio of 1:1. However, the number of studies and width of the confidence intervals in the analyses do not exclude a clinically meaningful difference between these two drugs. Difficulty in the successful manipulation of the devices studied may be a barrier to the widespread use of MDIs. One paediatric study was included in the review, so extrapolation of the findings of this review to children is limited. Further longer term studies in adults and children with moderate and severe asthma are required.
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Affiliation(s)
- T J Lasserson
- St George's University of London, Community Health Sciences, Cranmer Terrace, Tooting, London, UK, SW17 ORE.
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Lasserson TJ, Cates CJ, Jones AB, Steele EH, White J. Fluticasone versus HFA-beclomethasone dipropionate for chronic asthma in adults and children. Cochrane Database Syst Rev 2005:CD005309. [PMID: 16235400 DOI: 10.1002/14651858.cd005309.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The relative efficacy of fluticasone (FP) and beclomethasone (BDP) propelled with CFCs has been well established. The potency of HFA-BDP is thought to have been improved with new propellant and some studies suggest that it may equipotent at half the dose of CFC propelled-BDP. There is a need to revisit this question in the light of a potentially more potent new non-CFC propellant. OBJECTIVES To determine the relative efficacy of FP and HFA-propelled BDP in chronic asthma. SEARCH STRATEGY The Cochrane Airways Group Specialised Register was searched using pre-specified terms. Searches were current as of March 2005. SELECTION CRITERIA Randomised controlled trials were eligible for inclusion in the review. We compared either CFC or HFA-propelled FP with HFA-propelled BDP. We made a distinction between HFA-BDP and HFA-BDP extra fine, which dispenses smaller particles of drug, leading to different, usually more peripheral distribution in the airways. Any inhaler device was considered, and there was no restriction on studies with or without spacers. We included studies which assessed HFA-BDP given via either pMDI, breath-actuated MDI, or DPI. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed studies for inclusion in the review. Data were extracted and entered in to RevMan 4.2 using standard meta-analytical techniques with predefined criteria for exploring statistical heterogeneity. MAIN RESULTS Seven studies (1230 participants) met the inclusion criteria of the review. One study was conducted in children. Study reporting quality was fair, but all studies were of short duration (three to twelve weeks). Only studies assessing HFA-BDP extra fine in comparison with FP were identified. Lung function was not significantly different between extra fine BDP and FP when compared at the same dose in parallel studies, change in FEV1: 0.04 litres (95% CI -0.03 to 0.11 litres; three studies, 659 adults); change in am PEF: -0.69 litres (95% CI -11.21 to 9.83 litres; two studies, 364 adults). Individual studies reported non-significant findings in symptom scores and quality of life questionnaires. There was no significant difference between FP and HFA-BDP in the risk of study withdrawal, dysphonia or when data were reported as any adverse event. AUTHORS' CONCLUSIONS There was no significant difference between FP and extra fine HFA-BDP on FEV(1) or peak flow at a dose ratio of 1:1. However, the number of studies and width of the confidence intervals in the analyses do not exclude a clinically meaningful difference between these two drugs. Difficulty in the successful manipulation of the devices studied may be a barrier to the widespread use of MDIs. One paediatric study was included in the review, so extrapolation of the findings of this review to children is limited. Further longer term studies in adults and children with moderate and severe asthma are required.
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Affiliation(s)
- T J Lasserson
- St George's - University of London, Division of Community Health Sciences, Cranmer Terrace, London, UK SW17 0RE.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2005. [DOI: 10.1002/pds.1025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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