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Suh DI, Johnston SL. The Wiser Strategy of Using Beta-Agonists in Asthma: Mechanisms and Rationales. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2024; 16:217-234. [PMID: 38910281 PMCID: PMC11199159 DOI: 10.4168/aair.2024.16.3.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 05/26/2024] [Accepted: 05/29/2024] [Indexed: 06/25/2024]
Abstract
Concerns regarding the safety of beta-2 agonists have led to revisions of the major asthma guidelines to better address these issues. Although these updates allow for a combination of previous and current strategies, they may confuse clinical practitioners. Beta-2 agonists are vital for alleviating asthma symptoms by relaxing smooth muscles; however, they also pose significant risks by inducing pro-inflammatory mediators both in vitro and in vivo. In addition to the risks of overuse and symptom masking, the use of beta-agonists alone at therapeutic doses can worsen airway inflammation and enhance virus-induced inflammation during asthma exacerbation. Inhaled corticosteroids (ICS) can effectively prevent these adverse effects. With new insights into the mechanisms of these adverse events, reserving short-acting beta-agonists for acute symptom relief during exacerbations and only for those who are already on ICS or oral steroids represents a careful approach to using beta-agonists with least adverse effects in patients with asthma. However, a major drawback of this approach is the potential non-compliance with ICS, leading to beta-agonist use without the necessary counteraction by ICS. An optimal strategy, both during and outside exacerbations, would integrate beta-agonists into an anti-inflammatory regimen that includes ICS, ideally combined with the same inhaler to ensure their concurrent use where finances allow. This would maintain the beneficial effects of beta-agonists, such as bronchodilation, while preventing the adverse effects from the induction of inflammatory mediators. This method is aligned with diverse clinical settings, maximizes the safe use of beta-agonists, and supports a comprehensive guideline-compliant management strategy.
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Affiliation(s)
- Dong In Suh
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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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: 1] [Impact Index Per Article: 1.0] [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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Ho JK, Shaker M, Greenhawt M, Sadatsafavi M, Abrams EM, Oppenheimer J, Mosnaim GS, Lee TY, Johnson KM. Cost-effectiveness of budesonide-formoterol vs inhaled epinephrine in US adults with mild asthma. Ann Allergy Asthma Immunol 2024; 132:229-239.e3. [PMID: 37879568 DOI: 10.1016/j.anai.2023.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The management of mild asthma has lacked an over-the-counter (OTC) option aside from inhaled epinephrine, which is available in the United States. However, inhaled epinephrine use without an inhaled corticosteroid may increase the risk of asthma death. OBJECTIVE To compare the cost-effectiveness of OTC as-needed budesonide-formoterol as a plausible alternative to inhaled epinephrine. METHODS We developed a probabilistic Markov model to compare OTC as-needed budesonide-formoterol inhaler use vs inhaled epinephrine use in adults with mild asthma from a US societal perspective over a lifetime horizon, with a 3% annual discount rate (2022 US dollars). Inputs were derived from the SYmbicort Given as-needed in Mild Asthma (SYGMA) trials, published literature, and commercial costs. Outcomes were quality-adjusted life-years (QALY), costs, incremental net monetary benefit (INMB), severe asthma exacerbations, well-controlled asthma days, and asthma-related deaths. Microsimulation was used to evaluate underinsured Americans living with mild asthma (n = 5,250,000). RESULTS Inhaled epinephrine was dominated (with lower QALYs gains at a higher cost) by both as-needed budesonide-formoterol (INMB, $15,541 at a willingness-to-pay of $100,000 per QALY) and the no-OTC inhaler option (INMB, $1023). Adults using as-needed budesonide-formoterol had 145 more well-controlled asthma days, 2.79 fewer severe exacerbations, and an absolute risk reduction of 0.23% for asthma-related death compared with inhaled epinephrine over a patient lifetime. As-needed budesonide-formoterol remained dominant in all sensitivity and scenario analyses, with a 100% probability of being cost-effective compared with inhaled epinephrine in probabilistic sensitivity analysis. CONCLUSION If made available, OTC as-needed budesonide-formoterol for treating mild asthma in underinsured adults without HCP management improves asthma outcomes, prevents fatalities, and is cost-saving.
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Affiliation(s)
- Joseph Khoa Ho
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John Oppenheimer
- University of Medicine and Dentistry of New Jersey, Rutgers University School of Medicine, Newark, New Jersey
| | - Giselle S Mosnaim
- Division of Allergy, Asthma, and Immunology, Department of Medicine, NorthShore University Health System, Evanston, Illinois
| | - Tae Yoon Lee
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kate M Johnson
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada; Division of Respiratory Medicine, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.
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Larenas-Linnemann D, Romeo J, Ariue B, Oppenheimer J. American College of Allergy, Asthma and Immunology members' preferred steps 1 to 3 asthma maintenance and reliever therapy and incomplete insurance coverage indicated as main practice hurdle. Ann Allergy Asthma Immunol 2023; 131:451-457. [PMID: 37328056 DOI: 10.1016/j.anai.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND New asthma guidelines (GINA, 2022; NAEPP EPR-4, 2020) include considerable changes in treatment recommendations, specifically regarding anti-inflammatory rescue and Single MAintenance and Reliever Therapy (SMART). OBJECTIVE To explore American College of Allergy, Asthma and Immunology members' preferred treatment and perceived hurdles. METHODS A survey (SurveyMonkey) regarding steps 1 to 3 asthma therapy was e-mailed to American College of Allergy, Asthma and Immunology members. RESULTS The allergists completed 147 surveys (46% with >20 years of experience; 98% from United States; 29% academic, 75% [also] private practice). In addition, 69% follow the National Asthma Education and Prevention Program and 81% the Global Initiative for Asthma recommendations. Of 147 allergists, 117 (80%) indicated correctly what SMART strategy is; 21%/36%/50%/39% would use SMART in step 3 treatment of a below 5-year-old/5- to 11-year-old/12- to 65-year-old/above 65-year-old patient, respectively. In this group, 11% to 14% incorrectly chose inhaled corticosteroid (ICS) plus salmeterol and 9% ICS plus vilanterol for SMART. In a 4-year-old needing step 1 therapy (N = 129), 55% of the respondents would add anti-inflammatory therapy; for step 2 treatment, most would prescribe ICS 100 to 200 µg budesonide equivalent daily; in step 3, 49% would prescribe ICS plus long-acting beta-agonist (LABA). In a 7-year-old needing step 1 treatment (N = 134), 40% would prescribe only short-acting beta-agonist; in step 3, 45% would institute SMART strategy, but only 8 of 135 (6%) chose very-low dose ICS plus formoterol (as recommended in Global Initiative for Asthma); most (39%) use low-dose ICS plus formoterol. As for rescue therapy, 59% is now instituting some form of anti-inflammatory rescue. Finally, in a 25-year-old patient (N = 144): in step 1, 39% would prescribe exclusively short-acting beta-agonist; in step 2, 4% only anti-inflammatory rescue and the rest prescribes ICS maintenance; one-third begins SMART strategy at step 2 and 50% in step 3. Major hurdles for prescribing one's preferred strategy included incomplete insurance coverage, insurance not approving more than one canister of ICS-formoterol per month, and cost. CONCLUSION Asthma therapy varies among physicians, with respondents suggesting underutilization of the recommended anti-inflammatory rescue and SMART therapy. A major hurdle is lack of insurance coverage of medication in line with the guidelines.
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Affiliation(s)
- Désirée Larenas-Linnemann
- Médica Sur, Clinical Foundation and Hospital, Centro de Excelencia en Asma y Alergia, Mexico City, Mexico.
| | - Jonathan Romeo
- Allergy Partners of the Triangle, Raleigh, North Carolina
| | - Barbara Ariue
- Division of Allergy/Immunology, Department of Pediatrics, Loma Linda Children's Hospital, Loma Linda, California
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Affiliation(s)
- Giselle Mosnaim
- From the Division of Allergy and Immunology, Department of Medicine, NorthShore University HealthSystem, Evanston, IL
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Krings JG, Sekhar TC, Chen V, Blake KV, Sumino K, James AS, Clover AK, Lenze EJ, Brownson RC, Castro M. Beginning to Address an Implementation Gap in Asthma: Clinicians' Views of Prescribing Reliever Budesonide-Formoterol Inhalers and SMART in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2767-2777. [PMID: 37245736 DOI: 10.1016/j.jaip.2023.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND The Global Initiative for Asthma and National Asthma Education and Prevention Program recently made paradigm-shifting recommendations regarding inhaler management in asthma. The Global Initiative for Asthma now recommends that combination inhaled corticosteroid (ICS)-formoterol inhalers replace short-acting β-agonists as the preferred reliever therapy at all steps of asthma management. Although the most recent guidelines of the National Asthma Education and Prevention Program did not review reliever ICS-formoterol usage in mild asthma, they similarly recommended single maintenance and reliever therapy (SMART) at steps 3 and 4 of asthma management. Despite these recommendations, many clinicians-particularly in the United States-are not prescribing new inhaler paradigms. Clinician-level reasons for this implementation gap remain largely unexplored. OBJECTIVE To gain an in-depth understanding of the facilitators and barriers to prescribing reliever ICS-formoterol inhalers and SMART in the United States. METHODS Community and academic primary care providers, pulmonologists, and allergists who reported regularly caring for adults with asthma were interviewed. Interviews were recorded, transcribed, qualitatively coded, and analyzed using the Consolidated Framework for Implementation Research. Interviews were continued until theme saturation. RESULTS Among 20 interviewed clinicians, only 6 clinicians described regularly prescribing ICS-formoterol inhalers as a reliever inhaler (either alone or within SMART). Significant barriers to new inhaler approaches included concerns surrounding a lack of Food and Drug Administration labeling for ICS-formoterol as a reliever therapy, a lack of awareness regarding a patient's formulary-preferred ICS-long-acting β-agonist choices, the high cost of combination inhalers, and time constraints. Facilitators to using new inhaler approaches included clinicians' beliefs that the latest inhaler recommendations are simpler and more congruent with real-world patients' behavior, and that a potential change in management strategy would offer a valuable opportunity for shared decision making. CONCLUSIONS Although new guidelines exist in asthma, many clinicians described significant barriers to using them including medicolegal issues, pharmaceutical formulary confusion, and high drug costs. Nonetheless, most clinicians believed that the latest inhaler approaches would be more intuitive for their patients and would offer an opportunity for patient-centered collaboration and care. Stakeholders may find these results useful in future attempts to increase the real-world adoption of recent asthma recommendations.
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Affiliation(s)
- James G Krings
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo.
| | - Tejas C Sekhar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Vanessa Chen
- Brown School of Social Work and Public Health, Washington University in St Louis, St Louis, Mo
| | - Kathryn V Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health, Jacksonville, Fla
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Aimee S James
- Occupational Therapy and Surgery (Public Health Sciences), Washington University in St Louis School of Medicine, St Louis, Mo
| | - Amber K Clover
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Eric J Lenze
- Department of Psychiatry, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Ross C Brownson
- Prevention Research Center, Brown School, Washington University in St Louis, St Louis, Mo
| | - Mario Castro
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Kansas, Kansas City, Kan
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Zaeh SE, Krings JG. Tracking the Trends in the Adoption of Reliever-Only ICS-Formoterol Therapy and SMART. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2765-2766. [PMID: 37684074 DOI: 10.1016/j.jaip.2023.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Sandra E Zaeh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Conn
| | - James G Krings
- Division of Pulmonary Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo.
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Hatter L, Eathorne A, Hills T, Bruce P, Houghton C, Weatherall M, Beasley R. Patterns of Asthma Medication Use in New Zealand After Publication of National Asthma Guidelines. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2757-2764.e5. [PMID: 37178765 DOI: 10.1016/j.jaip.2023.04.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND In June 2020, the New Zealand (NZ) adolescent and adult asthma guidelines recommended budesonide/formoterol, taken as maintenance and/or reliever therapy, as the preferred therapeutic approach. OBJECTIVE To investigate whether these recommendations were associated with changes in clinical practice indicated by asthma medication use trends. METHODS NZ national dispensing data for inhaler medications from January 2010 to December 2021 were reviewed. Monthly "dispensings" of inhaled budesonide/formoterol, inhaled corticosteroid (ICS), other ICS/long-acting β2-agonists (LABA), and inhaled short-acting β2-agonists (SABA), for the 12+ age group, were displayed graphically with piecewise regression used to produce plots of rates by time with a July 1, 2020, break point. The number of dispensings in the last 6 months that data were available (July-December 2021) was compared with the corresponding period, July-December 2019. RESULTS Budesonide/formoterol dispensing increased markedly after July 1, 2020 (regression coefficient 41.1 inhalers dispensed/100,000 population per month [95% confidence interval (CI): 36.3-45.6, P < .0001]; 64.7% increase in the number of dispensings between July-December 2019 and July-December 2021), in contrast to "other ICS/LABA" (regression coefficient: -15.9 [95% CI: -22.2 to -9.6, P < .0001]; -1.7% decrease) and SABA (regression coefficient: -14.7 [95% CI: -29.7 to 0.3, P = .055]; -10.6% decrease), respectively. CONCLUSION In NZ, a progressive increase in budesonide/formoterol dispensing, accompanied by a reduction in SABA and "other ICS/LABA" dispensing, occurred after publication of the 2020 NZ asthma guidelines. While acknowledging the limitations in the interpretation of temporal associations, these findings suggest that the transition to ICS/formoterol reliever-based therapy can be achieved if recommended and promoted as the preferred therapeutic approach in national guidelines.
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Affiliation(s)
- Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand; School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Tom Hills
- Medical Research Institute of New Zealand, 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
| | - Mark Weatherall
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand; School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand.
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