Budesonide/formoterol for maintenance and reliever therapy in the management of moderate to severe asthma

Budesonide/formoterol maintenance and reliever therapy versus fluticasone/salmeterol fixed-dose treatment in patients with COPD

BACKGROUND

Maintenance and reliever therapy (MART) with inhaled corticosteroid (ICS)/formoterol effectively reduces exacerbations in asthma. We aimed to investigate its efficacy compared with fixed-dose fluticasone/salmeterol in chronic obstructive pulmonary disease (COPD).

METHODS

Patients with COPD and ≥1 exacerbation in the previous 2 years were randomly assigned to open-label MART (Spiromax budesonide/formoterol 160/4.5 µg 2 inhalations twice daily+1 prn) or fixed-dose therapy (Diskus fluticasone propionate/salmeterol combination (FSC) 500/50 µg 1 inhalation twice daily+salbutamol 100 µg prn) for 1 year. The primary outcome was rate of moderate/severe exacerbations, defined by treatment with oral prednisolone and/or antibiotics.

RESULTS

In total, 195 patients were randomised (MART Bud/Form n=103; fixed-dose FSC n=92). No significant difference was seen between MART and FSC therapy in exacerbation rates (1.32 vs 1.32 /year, respectively, rate ratio 1.05 (95% CI 0.79 to 1.39); p=0.741). No differences in lung function parameters or health status were observed. Total ICS dose was significantly lower with MART than FSC therapy (budesonide-equivalent 928 µg/day vs 1747 µg/day, respectively, p<0.05). Similar proportions of patients reported adverse events (MART Bud/Form: 73% vs fixed-dose FSC: 68%, p=0.408) and pneumonias (MART: 5% vs FSC: 1%, p=0.216).

CONCLUSIONS

This first study of MART in COPD found that budesonide/formoterol MART might be similarly effective to fluticasone/salmeterol fixed-dose therapy in moderate to severe patients with COPD, at a lower daily ICS dosage. Further evidence is needed about long-term safety.

Inhaled beclometasone dipropionate/formoterol fumarate extrafine fixed combination for the treatment of asthma

Inhaled therapy is often considered the cornerstone of asthma management and international guidelines recommend combination therapy of inhaled corticosteroids (ICS) and long-acting-beta2-agonists (LABA) in a large proportion of asthmatic patients. The effectiveness of ICS/LABA is dependent on the correct choice of device and proper inhalation technique, this influences drug delivery and distribution along the bronchial tree, including the most peripheral airways. The fixed combination of beclometasone dipropionate/formoterol fumarate (BDP/FF) is the only extrafine formulation available in pressurized metered dose inhaler (pMDI) and in dry powder inhaler (DPI). Here, we focus on the recent significant advances regarding BDP/FF fixed combination for the treatment of asthma.

Fixed-Dose combination of the inhaled corticosteroid and long-acting beta2-agonist therapy in adults with persistent asthma

INTRODUCTION

Asthma is a respiratory condition characterized by airway inflammation, airflow obstruction, and bronchial hyperresponsiveness. The standard treatment of asthma comprises inhaled corticosteroid and beta2-agonist. Inhaled short-acting-beta2-agonists have been used as rescue medication for exacerbation. However, long-acting-beta2-agonists (LABA) used as monotherapy for asthma had been reported for having a safety concern. Consequently, it had been recommended as an add-on treatment to inhaled corticosteroid (ICS) in moderate to severe persistent asthma. The fixed-dose combination (FDC) of ICS and LABA has been approved since the year 2000. Evidences revealed using the combination of these medications is more effective in asthma control.

AREAS COVERED

The rational and phase III onward randomized-controlled studies were reviewed. Sources of evidences were from studies published in Medline until November 2015.

EXPERT OPINION

There are six FDC inhaler regimens approved worldwide. The significant synergistic effects of ICS and LABA in one device are well evidenced. A FDC reduces the daily dosage of ICS and asthma exacerbation. It is safe to use regularly as controller. The efficacy of each individual combination on asthma treatment is generally similar. Clinical experience, ease of use, cost and side effects of medication would guide the clinician's preferences.

Regular versus as-needed budesonide and formoterol combination treatment for moderate asthma: a non-inferiority, randomised, double-blind clinical trial

BACKGROUND

Treatment guidelines for patients with moderate persistent asthma recommend regular therapy with a combination of an inhaled corticosteroid and a longacting β2 agonist plus as-needed rapid-acting bronchodilators. We investigated whether symptom-driven budesonide and formoterol combination therapy administered as needed would be as effective as regular treatment with this combination plus as-needed symptom-driven terbutaline for patients with moderate asthma.

METHODS

In this non-inferiority randomised clinical trial, we recruited adult patients (18-65 years of age) with stable moderate persistent asthma, according to 2006 Global Initiative for Asthma guidelines. Patients were recruited from outpatient clinics of secondary and tertiary referral hospitals and university centres. After a 6-week run-in period of inhaled regular budesonide and formoterol plus as-needed terbutaline, the patients were randomly assigned in a 1:1 ratio to receive placebo twice daily plus as-needed treatment with inhaled 160 μg budesonide and 4·5 μg formoterol (as-needed budesonide and formoterol therapy) or twice-daily 160 μg budesonide and 4·5 μg formoterol combination plus symptom-driven 500 μg terbutaline (regular budesonide/formoterol therapy) for 1 year. Randomisation was done according to a list prepared with the use of a random number generator and a balanced-block design stratified by centre. Patients and investigators were masked to treatment assignment. The primary outcome was time to first treatment failure measured after 1 year of treatment using Kaplan-Meier estimates, and the power of the study was calculated based on the rate of treatment failure. Analyses were done on the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT00849095.

FINDINGS

Between April 20, 2009, and March 31, 2012, we screened 1010 patients with moderate asthma and randomly assigned 866 eligible patients to the two treatment groups (424 to as-needed budesonide and formoterol therapy and 442 to regular budenoside and formoterol therapy). Compared with regular budesonide and formoterol therapy, as-needed budesonide and formoterol treatment was associated with a lower probability of patients having no treatment failure at 1 year (Kaplan-Meier estimates 53·6% for as-needed treatment vs 64·0% for regular treatment; difference 10·3% [95% CI 3·2-17·4], at a predefined non-inferiority limit of 9%). Patients in the as-needed budesonide and formoterol group had shorter time to first treatment failure than those in the regular therapy group (11·86 weeks vs 28·00 weeks for the first quartile [ie, the time until the first 25% of patients experienced treatment failure]). The difference in treatment failures was largely attributable to nocturnal awakenings (82 patients in the as-needed treatment group vs 44 in the regular treatment group). Both treatment regimens were well tolerated.

INTERPRETATION

In patients with moderate stable asthma, as-needed budesonide and formoterol therapy is less effective than is the guideline-recommended regular budesonide and formoterol treatment, even though the differences are small.

FUNDING

Italian Medicines Agency.

Budesonide/formoterol maintenance and reliever therapy via Turbuhaler versus fixed-dose budesonide/formoterol plus terbutaline in patients with asthma: phase III study results

BACKGROUND AND OBJECTIVE

To evaluate the efficacy and tolerability of budesonide/formoterol as maintenance and reliever therapy versus budesonide/formoterol maintenance plus terbutaline in adults with persistent asthma not adequately controlled with inhaled corticosteroid (ICS) therapy alone.

METHODS

In this 12-month, randomized, double-blind, parallel-group, phase III study (NCT00839800), patients (age ≥ 16 years; receiving maintenance ICS; ≥ 1 severe exacerbation in the 12 months prior to study entry) were randomized to either budesonide/formoterol 160/4.5 μg 1 inhalation twice daily plus budesonide/formoterol 160/4.5 μg as-needed or budesonide/formoterol 160/4.5 μg 1 inhalation twice daily plus terbutaline 0.4 mg as-needed for 12 months.

PRIMARY OUTCOME

time to first severe asthma exacerbation; secondary outcomes included: lung function, asthma symptom variables and tolerability.

RESULTS

Two thousand and ninety-one patients were randomized: 170 (16%) receiving budesonide/formoterol maintenance and reliever therapy experienced 259 severe exacerbations versus 229 patients (22%) receiving budesonide/formoterol plus terbutaline who experienced 363 severe exacerbations. Budesonide/formoterol maintenance and reliever therapy prolonged the time to first severe exacerbation versus budesonide/formoterol plus terbutaline (P = 0.0007) and reduced the instantaneous risk of an exacerbation by 30% (hazard ratio 0.70, 95% confidence interval 0.57-0.85, P = 0.0003). Times to first oral steroid use, first hospitalization and first emergency room treatment were all significantly prolonged in the budesonide/formoterol maintenance and reliever group versus budesonide/formoterol plus terbutaline. Both treatment groups were well tolerated.

CONCLUSIONS

Budesonide/formoterol maintenance and reliever therapy provided more effective asthma control, including a prolonged time to first severe asthma exacerbation, than budesonide/formoterol plus terbutaline and was well tolerated. Budesonide/formoterol maintenance and reliever therapy also improved lung function and asthma symptoms.

Pharmacotherapy for exercise-induced asthma: allowing normal levels of activity and sport

Exercise-induced bronchoconstriction (EIB) is experienced by the majority of an estimated 300 million individuals who have asthma, a condition that affects all ages and is increasing globally. Respiratory water loss with dehydration of the airways causing mediator release and airway narrowing is considered the cause of EIB, the severity of which will be increased if the inhaled air is cold or polluted. Adequate control of asthma is essential to minimize or prevent EIB and permit normal levels of physical activity and sport. This is important because exercise is a necessary component of daily living, assists in obtaining and maintaining a healthy body and has been demonstrated to benefit asthmatics. Inhaled glucocorticosteroids and inhaled β(2)-adrenoceptor agonists (IβA) are the pharmacological agents of choice to manage asthma and minimize EIB, assisted when necessary, by other drugs including leukotriene receptor antagonists and chromones. Tolerance from daily use of IβA is of concern and more flexible drug therapy needs to be considered. Optimal use of inhalers to deliver drugs effectively requires closer attention. Pharmacogenetics may hold the key to future drug therapy.

Relief of methacholine-induced bronchospasm with extrafine beclomethasone dipropionate/formoterol in comparison with salbutamol in asthma

BACKGROUND

Short-acting beta2-agonists like salbutamol and terbutaline are used as rescue medications for acute bronchoconstriction and relief of symptoms due to their rapid onset of action. The aim of this study was to assess whether inhaled beclomethasone dipropionate (BDP)/formoterol fumarate (FF) combination in extrafine formulation is non-inferior to salbutamol in the speed of reverting methacholine-induced bronchoconstriction and symptoms.

METHODS

Fifty-six asthmatic patients were examined in a multicentre, randomised, double blind, double dummy, active treatment and placebo controlled three period cross-over study. On three different days, a single dose of BDP/FF 100/6 μg in pressurised metered-dose inhaler (pMDI) extrafine formulation or salbutamol 200 μg pMDI or placebo was inhaled after FEV(1) had dropped by 30-45% with methacholine challenge.

RESULTS

The median time to recovery of FEV(1) to 85% of baseline was similar for BDP/FF and salbutamol (3.66 and 2.15 min, respectively), but significantly longer for placebo (21.1 min). The planned analysis on adjusted mean time to recovery showed that the difference from methacholine-induced bronchoconstriction between BDP/FF and salbutamol was 3.82 min (95% confidence interval: -0.85 to 8.5), therefore greater than 3 min supposed in the study design. The difference between BDP/FF and salbutamol was not clinically significant. The two active treatments were also comparable in terms of the relief of symptoms (as assessed by the Borg dyspnoea scale).

CONCLUSIONS

BDP/FF combination has a fast onset of action, similar to that of salbutamol, and may represent a good alternative as rescue medication in asthmatic patients.

The management of asthma and chronic obstructive pulmonary disease: current status and future perspectives

Asthma and chronic obstructive pulmonary disease (COPD) represent the leading chronic respiratory diseases of interest in the word, owing to their high prevalence and burden on the health system. Care of these patients, undergoing frequent exacerbations, is a heavy burden on healthcare systems. In the last few years, large improvements in the management of asthma and COPD have been made, owing to new drugs and management strategies, and to the improvement of the nonpharmacologic treatment of COPD. There are still many unmet needs in the treatment of these diseases. In asthma, strategies to improve control should be implemented. There is a need to use more biomarkers to tailor treatment, in the assessment and choice of appropriate therapy, especially in severe patients. In COPD, there is growing evidence of individual differences in lung function decline rate and associated differences in appropriate management strategies. Early effective and prolonged bronchodilation can slow disease progression and reduce the frequency of exacerbations. New perspectives include the use of biologic drugs (anticytokine monoclonal antibodies) in selected categories of severe asthmatics, potential new inhibitors of chemokines and cytokines involved in the pathobiology of asthma and COPD, and a further improvement of current drugs and better implementation of management strategies, particularly in COPD patients.

[Asthma exacerbations: pharmacological prevention]

Asthma exacerbations are responsible for many emergency medical interventions and account for a significant proportion of the health costs of the disease. Increased airway inflammation is a key feature of exacerbations in asthma and therefore inhaled corticosteroids (ICS) are considered as first-line therapy for long-term asthma control. ICS have been demonstrated to reduce the risk of asthma exacerbations, as well as improving lung function. Oral leukotriene receptor antagonists also reduce the incidence of asthma exacerbations but are less effective than ICS. In patients with inadequately controlled persistent asthma despite low-dose ICS, the addition of a long-acting inhaled beta-agonist (LABA) should be considered. LABA should not be given alone and should always be associated with ICS in asthma. The anti-immunoglobulin E antibody, omalizumab, reduces severe exacerbations and emergency visits in patients with severe allergic asthma. In clinical trials measurement of the inflammatory response in induced sputum could provide information concerning appropriate drug therapy. Asthma-associated comorbidities should be investigated and treated, particularly in severe asthma. Despite a high prevalence of both gastro-oesophageal reflux and allergic rhinitis among patients with asthma, treatment with proton-pump inhibitors or nasal corticosteroids does not reduce the rate of asthma exacerbations.

Rapid nongenomic actions of inhaled corticosteroids on long-acting β(2)-agonist transport in the airway

Corticosteroids inhibit organic cation transporters (OCTs) that play an important role in drug absorption, tissue distribution and elimination. Corticosteroid sensitivity of bronchodilator trafficking in the airway tissue, however, is poorly understood. To assess the effects of inhaled corticosteroids on airway absorption and disposal mechanisms of long-acting β(2)-agonists, human airway epithelial and smooth muscle cell uptake of tritiated formoterol and salmeterol was measured in vitro. Corticosteroids caused a rapid, concentration-dependent inhibition of uptake of the cationic formoterol by airway smooth muscle cells, but not airway epithelial cells. Uptake of the non-charged lipophilic salmeterol was corticosteroid-insensitive in both cell types. In smooth muscle cells, inhaled corticosteroids inhibited formoterol uptake with a novel potency rank order: des-ciclesonide > budesonide > beclomethasone 17-monopropionate > beclomethasone dipropionate > ciclesonide > fluticasone. The inhibitory action was rapidly reversible, and was not enhanced by prolonged corticosteroid exposure or sensitive to a transcription inhibitor. Suppression of OCT3 expression using lentivirus-mediated production of shRNA reduced corticosteroid sensitivity of formoterol uptake by smooth muscle cells. Our data support a corticosteroid insensitive absorption and a corticosteroid-sensitive disposition mechanism for cationic long-acting β(2)-agonist bronchodilators in the airway. Potency rank order and other 'classical' features of anti-inflammatory effects do not apply to inhaled corticosteroids' rapid drug transport actions.

Effects of formoterol-budesonide on airway remodeling in patients with moderate asthma

AIM

To evaluate the effect of inhaled formoterol-budesonide on airway remodeling in adult patients with moderate asthma.

METHODS

Thirty asthmatic patients and thirty control subjects were enrolled. Asthmatic subjects used inhaled Symbicort 4.5/160 μg twice daily for one year. The effect of formoterol-budesonide on airway remodeling was assessed with comparing high-resolution computer tomography (HRCT) images of asthmatic patients and controls, as well as expression levels of cytokines and growth factors, inflammatory cell count in induced sputum, and airway hyper-responsiveness.

RESULTS

The differences in age and gender between the two groups were not significant. However, differences in FVC %pred, FEV(1) %pred, and PC(20) between the two groups were significant. After treatment with formoterol-budesonide, the asthma patients' symptoms were relieved, and their lung function was improved. The WT and WA% of HRCT images in patients with asthma was increased, whereas treatment with formoterol-budesonide caused these values to decrease. The expression of MMP-9, TIMP-1, and TGF-β(1) in induced sputum samples increased in patients with asthma and decreased dramatically after treatment with formoterol-budesonide. The WT and WA% are correlated with the expression levels of cytokines and growth factors, inflammatory cell count in induced sputum, and airway hyper-responsiveness, while these same values are correlated negatively with FEV(1)/FVC and FEV(1)%.

CONCLUSION

Formoterol-budesonide might interfere in chronic inflammation and airway remodeling in asthmatic patients. HRCT can be used to effectively evaluate airway remodeling in asthmatic patients.

Single maintenance and reliever therapy (SMART) of asthma: a critical appraisal

The use of a combination inhaler containing budesonide and formoterol as both maintenance and quick relief therapy (SMART) has been recommended as an improved method of using inhaled corticosteroid/long-acting β agonist (ICS/LABA) therapy. Published double-blind trials show that budesonide/formoterol therapy delivered in SMART fashion achieves better asthma outcomes than budesonide monotherapy or lower doses of budesonide/formoterol therapy delivered in constant dosage. Attempts to compare budesonide/formoterol SMART therapy with regular combination ICS/LABA dosing using other compounds have been confounded by a lack of blinding and unspecified dose adjustment strategies. The asthma control outcomes in SMART-treated patients are poor; it has been reported that only 17.1% of SMART-treated patients are controlled. In seven trials of 6–12 months duration, patients using SMART have used quick reliever daily (weighted average 0.92 inhalations/day), have awakened with asthma symptoms once every 7–10 days (weighted average 11.5% of nights), have suffered asthma symptoms more than half of days (weighted average 54.0% of days) and have had a severe exacerbation rate of one in five patients per year (weighted average 0.22 severe exacerbations/patient/year). These poor outcomes may reflect the recruitment of a skewed patient population. Although improvement from baseline has been attributed to these patients receiving additional ICS therapy at pivotal times, electronic monitoring has not been used to test this hypothesis nor the equally plausible hypothesis that patients who are non-compliant with maintenance medication have used budesonide/formoterol as needed for self-treatment of exacerbations. Although the long-term consequences of SMART therapy have not been studied, its use over 1 year has been associated with significant increases in sputum and biopsy eosinophilia. At present, there is no evidence that better asthma treatment outcomes can be obtained by moment-to-moment symptom-driven use of ICS/LABA therapy than conventional physician-monitored and adjusted ICS/LABA therapy.

Noradrenaline acting at central beta-adrenoceptors induces interleukin-10 and suppressor of cytokine signaling-3 expression in rat brain: implications for neurodegeneration

Evidence indicates that the monoamine neurotransmitter noradrenaline elicits anti-inflammatory actions in the central nervous system (CNS), and consequently may play a neuroprotective role where inflammatory events contribute to CNS pathology. Here we examined the ability of pharmacologically enhancing central noradrenergic tone to induce expression of anti-inflammatory cytokines in rat brain. Administration of the noradrenaline reuptake inhibitor reboxetine (15mg/kg; ip) combined with the alpha(2)-adrenoceptor antagonist idazoxan (1mg/kg; ip) induced interleukin-10 (IL-10) expression in rat cortex and hippocampus. In addition, these drug treatments induced IL-10 signaling as indicated by increased STAT3 phosphorylation and suppressor of cytokine signaling-3 (SOCS-3) mRNA expression. In contrast to the profound increase in IL-10 induced by the reboxetine/idazoxan combination, the other two broad spectrum anti-inflammatory cytokines IL-4 and TGF-beta were not induced by this treatment. The ability of combined treatment with reboxetine and idazoxan to induce IL-10 and SOCS3 expression was mediated by beta-adrenoceptor activation, as their induction was blocked by pre-treatment with the beta-adrenoceptor antagonist propranolol. Moreover, administration of the brain penetrant beta(2)-adrenoceptor agonist clenbuterol induced a time- and dose-dependent increase in central IL-10 and SOCS3 expression, and the ability of clenbuterol to induce IL-10 and SOCS-3 expression was blocked by the centrally acting beta-adrenoceptor antagonist, propranolol, and was mimicked by the highly selective beta(2)-adrenoceptor agonist formoterol. In all, these data indicate that increasing central noradrenergic tone induces IL-10 production and signaling in the CNS, which may protect against neurodegeneration.

Budesonide/formoterol dry powder in asthma: an option for control as maintenance and reliever therapy

IMPORTANCE OF THE FIELD

Asthma is a heterogeneous disease with various components that may contribute to symptoms. Obtaining global control of is one of the fundamental parts of the management of this disease.

AREAS COVERED IN THIS REVIEW

The Cochrane trial database, Medline and Embase, were searched systematically, and approximately 20 respiratory journals and conference abstracts were searched manually. The search was limited to publications in English language of last 20 years and which included the keywords 'budesonide', 'formoterol', 'asthma' and 'control'.

WHAT THE READER WILL GAIN

The purposes of this review are: i) to discuss the rationale about possibility of using combination therapy administered with a single inhaler for both daily maintenance and relief as needed of breakthrough symptoms in asthma management; ii) to give readers the current status of clinical pharmacological treatment of asthma; iii) to discuss the evidence on the use of budesonide/formoterol dry powder in one inhaler.

TAKE HOME MESSAGE

Among the various inhalatory drugs, budesonide and formoterol can be conveniently delivered in one dry powder inhaler and simplify treatment by providing immediate step-up when symptoms increase. Alongside the anti-inflammatory component, formoterol provides both short- and long-acting bronchodilator effects with maintenance and reliever properties. The option of using one inhaler simplifies treatment by simultaneously providing bronchodilator and anti-inflammatory activity, thus enhancing compliance. As indicated in guidelines, all these characteristics are essential for optimizing asthma treatment and control.

Advances in treating acute asthma exacerbations in children

PURPOSE OF REVIEW

Asthma continues to be a major chronic disease in children, and acute asthma exacerbations are common. Although the basic therapy of asthma exacerbations has not changed, recent studies have demonstrated improved outcomes with different modes of delivery of medications, improved patients' self-management of their asthma, and recognition of risk factors for severe exacerbations.

RECENT FINDINGS

Recent studies in children have shown that written action plans based on symptom recognition are more effective than action plans based on peak expiratory flows. Bronchodilator administration by metered-dose inhaler is becoming the preferred therapy for treating mild-to-moderate asthma exacerbations in the emergency department, but nebulizers may still have a role in home and inpatient asthma management. High-dose inhaled corticosteroids may be as effective as oral corticosteroids for acute asthma exacerbations. A novel treatment strategy has titrated combination therapy with budesonide and formoterol for both maintenance and relief of symptoms. Lastly, the contributions of obesity and genetic variation to severe asthma exacerbations are becoming known, and noninvasive positive pressure ventilation has become an option for patients in severe asthma exacerbations.

SUMMARY

Improvements in management strategies can significantly improve outcomes in children with asthma.