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Krings JG, Beasley R. The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:870-879. [PMID: 38237858 PMCID: PMC10999356 DOI: 10.1016/j.jaip.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/14/2023] [Accepted: 01/01/2024] [Indexed: 02/05/2024]
Abstract
The Global Initiative for Asthma (GINA) recommends that short-acting β2-agonist (SABA) monotherapy should no longer be prescribed, and that as-needed combination inhaled corticosteroids (ICS)-formoterol is the preferred reliever therapy in adults and adolescents with mild asthma. These recommendations are based on the risks of SABA monotherapy, the evidence that ICS-formoterol reliever therapy markedly decreases the occurrence of severe asthma exacerbations compared with SABA reliever therapy alone, and because ICS-formoterol reliever therapy has a favorable risk/benefit profile compared with maintenance ICS plus SABA reliever therapy. Data supporting the use of combination ICS-albuterol reliever therapy in mild asthma are more limited, but there are studies that inform its use in this population. In this review, we compare, using a pros and cons format, the (1) long-term safety and efficacy of ICS-formoterol reliever therapy versus SABA reliever therapy alone, (2) long-term safety and efficacy of ICS-albuterol reliever therapy versus SABA reliever therapy alone, (3) immediate bronchodilator effects of ICS-formoterol versus SABA alone, and (4) clinical and regulatory factors that may inform reliever therapy prescription decisions. By presenting the evidence of these reliever inhaler options, we hope to inform the reader while also calling for necessary future effectiveness and implementation research.
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Affiliation(s)
- James G Krings
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, Mo.
| | - Richard Beasley
- Medical Research Institute of New Zealand Victoria University of Wellington, Wellington, New Zealand
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2
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Papi A, Ferreira DS, Agache I, Baraldi E, Beasley R, Brusselle G, Coleman C, Gaga M, Gotera Rivera CM, Melén E, Pavord ID, Peñate Gómez D, Schuermans D, Spanevello A, Tonia T, Schleich F. European Respiratory Society short guidelines for the use of as-needed ICS/formoterol in mild asthma. Eur Respir J 2023; 62:2300047. [PMID: 37678955 DOI: 10.1183/13993003.00047-2023] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
Recent clinical trials of as-needed fixed-dose combination of inhaled corticosteroid (ICS)/formoterol have provided new evidence that may warrant a reconsideration of current practice. A Task Force was set up by the European Respiratory Society to provide evidence-based recommendations on the use of as-needed ICS/formoterol as treatment for mild asthma. The Task Force defined two questions that were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. The Task Force utilised the outcomes to develop recommendations for a pragmatic guideline for everyday clinical practice. The Task Force suggests that adults with mild asthma use as-needed ICS/formoterol instead of regular ICS maintenance treatment plus as-needed short-acting β2-antagonist (SABA) and that adolescents with mild asthma use either as-needed ICS/formoterol or ICS maintenance treatment plus as-needed SABA (conditional recommendation; low certainty of evidence). The recommendation for adults places a relatively higher value on the reduction of systemic corticosteroid use and the outcomes related to exacerbations, and a relatively lower value on the small differences in asthma control. Either treatment option is suggested for adolescent patients as the balance is very close and data more limited. The Task Force recommends that adult and adolescent patients with mild asthma use as-needed ICS/formoterol instead of as-needed SABA (strong recommendation; low certainty of evidence). This recommendation is based on the benefit of as-needed ICS/formoterol in mild asthma on several outcomes and the risks related to as-needed SABA in the absence of anti-inflammatory treatment. The implementation of this recommendation is hampered in countries (including European Union countries) where as-needed ICS/formoterol is not approved for mild asthma.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
- A. Papi and D.S. Ferreira contributed equally to this work
- A. Papi, D.S. Ferreira and F. Schleich are Task Force co-chairs
| | - Diogenes S Ferreira
- Private Practice, Allergy and Immunology, Belo Horizonte, Brazil
- A. Papi and D.S. Ferreira contributed equally to this work
- A. Papi, D.S. Ferreira and F. Schleich are Task Force co-chairs
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Eugenio Baraldi
- Department of Women's and Children's Health, University of Padova, Institute of Pediatric Research "Città della Speranza", Padova, Italy
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Mina Gaga
- Athens Chest Hospital, Athens, Greece
| | | | - Erik Melén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Sachsska Children's Hospital, Stockholm, Sweden
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Daniel Schuermans
- Respiratory Division, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Antonio Spanevello
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Department of Medicine and Cardiopulmonary Rehabilitation, Tradate Institute, Tradate, Italy
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- T. Tonia and F. Schleich contributed equally to this work
| | - Florence Schleich
- Respiratory Medicine, CHU Liege, Liege, Belgium
- GIGA-I3, University of Liege, Liege, Belgium
- T. Tonia and F. Schleich contributed equally to this work
- A. Papi, D.S. Ferreira and F. Schleich are Task Force co-chairs
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3
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Amirav I, Garcia G, Le BK, Barria P, Levy G, Aggarwal B, Fahrbach K, Martin A, Phansalkar A, Sriprasart T. SABAs as Reliever Medications in Asthma Management: Evidence-Based Science. Adv Ther 2023; 40:2927-2943. [PMID: 37280414 PMCID: PMC10244083 DOI: 10.1007/s12325-023-02543-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/04/2023] [Indexed: 06/08/2023]
Abstract
The role of as-needed inhaled short-acting β2-agonists (SABAs) in the management of asthma has become a subject of debate due to differing opinions in the professional community relating to the use of SABAs. In this article, we summarize the current position of SABAs when used as reliever medications and examine the challenges to appropriate use including a critique of the data that have led to the condemnation of SABA used as a reliever. We consider the evidence for the appropriate use of SABA as a reliever together with practical solutions to ensure such use, including identifying patients at risk of misusing their SABA relievers and managing issues of inhaler technique and treatment adherence. We conclude that inhaled corticosteroid (ICS)-based maintenance treatment with SABA used as-needed as a reliever is an effective and safe treatment for patients with asthma, with no scientific evidence of a causal link between SABA use as a reliever and mortality or serious adverse events (including exacerbations). Increased SABA use warns of a deterioration in asthma control, and patients at risk of misusing their ICS and SABA medication should be rapidly identified to ensure they are receiving adequate ICS-based controller therapy. Appropriate use of ICS-based controller therapy and as-needed SABA should be encouraged and promoted with educational activities.
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Affiliation(s)
- Israel Amirav
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | - Gabriel Garcia
- Servicio de Neumonología, Hospital Rossi La Plata, Buenos Aires, Argentina
| | - Bao Khac Le
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Paulina Barria
- Unidad de Respiratorio, Hospital Clínico de la Fuerza Aérea de Chile, Santiago, Chile
| | - Gur Levy
- Respiratory Medical Emerging Markets, GSK, Ciudad de Panamá, Panamá
| | | | | | | | | | - Thitiwat Sriprasart
- Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Domingo C, Singh D. The Changing Asthma Management Landscape and Need for Appropriate SABA Prescription. Adv Ther 2023; 40:1301-1316. [PMID: 36715896 PMCID: PMC10070225 DOI: 10.1007/s12325-022-02410-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/14/2022] [Indexed: 01/31/2023]
Abstract
Short-acting β2 agonists (SABAs) have been a mainstay of asthma treatment since the 1950s, and have been mainly recommended as-needed for symptom relief alongside daily inhaled corticosteroid (ICS)-based maintenance treatment for the past 30 years. However, patient adherence to regular ICS-based anti-inflammatory maintenance therapy is frequently poor, leading to SABA overuse for symptom relief and associated poor outcomes. At present, there is a lack of consensus between treatment guidelines on how SABA should be used, and as-needed ICS-formoterol is suggested by some as an alternative reliever therapy. Here, we examine the pharmacology and current use of inhaled SABAs, identify that regular dosing of ICS can encourage appropriate SABA use, and appraise the evidence used to support the changing reliever treatment recommendations. We conclude that SABA continues to play an important role in the asthma management landscape, and give our views on how it should be used in patients with mild-moderate asthma, to complement regular ICS-based maintenance treatment.
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Affiliation(s)
- Christian Domingo
- Autonomous University of Barcelona (UAB), Sabadell, Barcelona Spain
- S. Pneumologia, Planta Primera, Edifici Tauli Nou, Corporació Sanitària Parc Tauli, Parc Tauli 1, 08208 Sabadell, Barcelona Spain
| | - Dave Singh
- University of Manchester, Manchester University National Health Service Foundation Trust, Manchester, UK
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Beasley R, Bruce P, Houghton C, Hatter L. The ICS/Formoterol Reliever Therapy Regimen in Asthma: A Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:762-772.e1. [PMID: 36639054 DOI: 10.1016/j.jaip.2023.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
The Global Initiative for Asthma recommends that low-dose inhaled corticosteroid (ICS)/formoterol be preferred to short-acting beta2-agonists as reliever therapy in adolescents and adults with asthma, across the range of asthma severity. This recommendation represents the most fundamental change in asthma management for many decades. In this commentary, we review the rationale for combination ICS/formoterol therapy, the evidence on which this recommendation has been made, the limitations in the evidence, the practical issues relevant to the implementation of ICS/formoterol reliever-based regimens in clinical practice, and the emerging evidence for the efficacy and safety of combination ICS/salbutamol reliever therapy regimens.
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Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand; Capital and Coast District Health Board, Wellington, New Zealand; Victoria University of Wellington, Wellington, New Zealand.
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand; Victoria University of Wellington, Wellington, New Zealand
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Ma D, Shi H, Tan C, Zou W, Sun F, Wang K, Lei Q, Zheng X, Zhong Y, Tu C, Chen M, Huang Y, Wang Z, Wu J, Liang Y, Liu J. Quantitative CT Metrics for the Prediction of Therapeutic Effect in Asthma. J Clin Med 2023; 12:639. [PMID: 36675568 PMCID: PMC9861330 DOI: 10.3390/jcm12020639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/03/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Background: Few studies have explored the correlation between asthma medication and features on HRCT images. We aim to analyse the differences and temporal changes of lung function and airway resistance in asthma with diverse HRCT phenotypes in a short period after inhalation of budesonide/formoterol. Method: This observational study recruited 55 adult patients with varying severities of asthma. We performed detailed airway metrics measurements of chest CT scans, such as airway wall thickness (WT), wall area percentage (WA%), wall thickness percentage (T/OR), and airways with an inner perimeter of 10 mm (Pi10). The effect of lung structural features on asthma medication response was explored according to the WA% and T/OR twelve hours post-drug administration. Using multivariable regression models, we then assessed the influence of WA% on lung function. Results: WA% (p < 0.001) and T/OR (p < 0.001) significantly increased in asthma than in healthy control subjects. Compared to mild asthma, airway walls were further thickened (WA%, p = 0.023; T/OR: p = 0.029) and associated with lumen narrowing (Pi10, p = 0.055) in moderate to severe asthma. WA% and T/OR correlated well with lung function (FEV1, FVC, MMEF, and PEF) and airway resistance (R5, R20, Rp, and Fres). Regression analysis showed that MEF25 decreased with increasing age and WA% (R2 = 0.58, p < 0.001). Patients with thickened airway walls experienced a maximal increase in FVC, FEV1, and PEF at 2 h (p < 0.001) and a maximal decrease of R5, Z5, and Rp at 2 h (p < 0.001) in those with a thickened airway pattern. Conclusions: Asthma patients with different bronchial wall thicknesses exhibited variable lung function changes. Specifically, patients with thick airway wall patterns were more sensitive to inhaled budesonide in the short term.
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Affiliation(s)
- Donghai Ma
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital Sun Yat-sen University, Zhuhai 519000, China
| | - Honglei Shi
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital Sun Yat-sen University, Zhuhai 519000, China
| | - Cuiyan Tan
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Wei Zou
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital Sun Yat-sen University, Zhuhai 519000, China
| | - Fengfei Sun
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital Sun Yat-sen University, Zhuhai 519000, China
| | - Kongqiu Wang
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Qianqian Lei
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Xiaobin Zheng
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Yuanyuan Zhong
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Changli Tu
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Meizhu Chen
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Yiying Huang
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Zhenguo Wang
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Jian Wu
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Yingjian Liang
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Jing Liu
- Department of Respiratory and Critical Care Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital Sun Yat-sen University, Zhuhai 519000, China
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Sriprasart T, Waterer G, Garcia G, Rubin A, Andrade MAL, Roguska A, Phansalkar A, Fulmali S, Martin A, Mittal L, Aggarwal B, Levy G. Safety of SABA Monotherapy in Asthma Management: a Systematic Review and Meta-analysis. Adv Ther 2023; 40:133-158. [PMID: 36348141 PMCID: PMC9859883 DOI: 10.1007/s12325-022-02356-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/11/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Short-acting β2-agonist (SABA) reliever overuse is common in asthma, despite availability of inhaled corticosteroid (ICS)-based maintenance therapies, and may be associated with increased risk of adverse events (AEs). This systematic literature review (SLR) and meta-analysis aimed to investigate the safety and tolerability of SABA reliever monotherapy for adults and adolescents with asthma, through analysis of randomized controlled trials (RCTs) and real-world evidence. METHODS An SLR of English-language publications between January 1996 and December 2021 included RCTs and observational studies of patients aged ≥ 12 years treated with inhaled SABA reliever monotherapy (fixed dose or as needed) for ≥ 4 weeks. Studies of terbutaline and fenoterol were excluded. Meta-analysis feasibility was dependent on cross-trial data comparability. A random-effects model estimated rates of mortality, serious AEs (SAEs), and discontinuation due to AEs (DAEs) for as-needed and fixed-dose SABA treatment groups. ICS monotherapy and SABA therapy were compared using a fixed-effects model. RESULTS Forty-two studies were identified by the SLR for assessment of feasibility. Final meta-analysis included 24 RCTs. Too few observational studies (n = 2) were available for inclusion in the meta-analysis. One death unrelated to treatment was reported in each of the ICS, ICS + LABA, and fixed-dose SABA groups. No other treatment-related deaths were reported. SAE and DAE rates were < 4%. DAEs were reported more frequently in the SABA treatment groups than with ICS, potentially owing to worsening asthma symptoms being classified as an AE. SAE risk was comparable between SABA and ICS treatments. CONCLUSIONS Meta-analysis of data from RCTs showed that deaths were rare with SABA reliever monotherapy, and rates of SAEs and DAEs were comparable between SABA reliever and ICS treatment groups. When used appropriately within prescribed limits as reliever therapy, SABA does not contribute to excess rates of mortality, SAEs, or DAEs.
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Affiliation(s)
- Thitiwat Sriprasart
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, 1873 Rama IV Road, Patumwan, Bangkok, 10330, Thailand.
| | - Grant Waterer
- University of Western Australia, Royal Perth Hospital, Perth, Australia
| | | | - Adalberto Rubin
- Pulmonary Department of Santa Casa Hospital, Federal University of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | | | | | | | | | | | | | | | - Gur Levy
- Respiratory Medical Emerging Markets, GSK, Panama City, Panama
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Marques L, Vale N. Salbutamol in the Management of Asthma: A Review. Int J Mol Sci 2022; 23:14207. [PMID: 36430683 PMCID: PMC9696300 DOI: 10.3390/ijms232214207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Asthma is a common inflammatory disease of the lungs. The prevalence of asthma is increasing worldwide, and the tendency indicates that the number of asthma sufferers will soar in the coming years for several reasons, in particular, the lifestyles we have adopted that expose us to risk factors. Salbutamol is the first selective short-acting β2-agonist (SABA) used as an alternative reliever in the treatment of asthma. Its therapeutic effect is based on its potent smooth muscle relaxant properties, which allow the inhibition of bronchial smooth muscle contraction and subsequent bronchodilation. Salbutamol can be administered orally, intravenously (IV), intramuscularly (IM), subcutaneously, or by inhalation. For this reason, the pharmacokinetic (PK) parameters-absorption, distribution, metabolism, and elimination-are highly diverse and, consequently, the efficacy and adverse effects also differ between each formulation. Here, we review the pharmacological profile of different salbutamol formulations, focusing on their efficacy and adverse effects for its original application, asthma.
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Affiliation(s)
- Lara Marques
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548 Coimbra, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Health Information and Decision (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
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