Factors affecting adherence with treatment advice in a clinical trial of patients with severe asthma

Climate-conscious inhaler prescribing for family physicians

OBJECTIVE

To provide family physicians with prescribing and diagnostic strategies that can reduce carbon emissions associated with inhalers.

SOURCES OF INFORMATION

This review is based on the authors' experience developing the climate-conscious inhaler prescribing playbooks and courses for CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). The approach was refined through patient and provider feedback since the first playbook was published in 2021. PubMed was also searched for relevant publications on inhaler use, asthma management, and chronic obstructive pulmonary disease (COPD) management. Current asthma and COPD guidelines were also reviewed.

MAIN MESSAGE

There is growing acknowledgment of the substantial impact that inhalers have on climate emissions generated by the health sector. Recent surveys indicate that most Canadian patients care about climate change and would be willing to opt for less carbon-intensive treatment and care delivery options where available. Beyond inhaler choice, there are many opportunities to address the climate impacts of respiratory care and enhance quality of care. Working with patients to ensure they are using the right medications in the right ways will produce both carbon savings and better health outcomes. The climate crisis can therefore serve as a catalyst for improving treatment of patients with respiratory conditions. Family physicians may reduce carbon emissions associated with inhalers by reducing unnecessary inhaler prescribing; ensuring patients' control of asthma and COPD is optimized; considering whether a more sustainable inhaler may be appropriate; optimizing dosing technique to reduce emissions and waste; and disposing of inhalers appropriately if possible.

CONCLUSION

Family physicians may reduce carbon emissions associated with inhalers through the following strategies: confirming diagnosis, controlling disease, considering inhaler type, optimizing dosing technique, and encouraging appropriate disposal.

Impact of pre-biologic impairment on meeting domain-specific biologic responder definitions in patients with severe asthma

BACKGROUND

There is little agreement on clinically useful criteria for identifying real-world responders to biologic treatments for asthma.

OBJECTIVE

To investigate the impact of pre-biologic impairment on meeting domain-specific biologic responder definitions in adults with severe asthma.

METHODS

This was a longitudinal, cohort study across 22 countries participating in the International Severe Asthma Registry (https://isaregistries.org/) between May 2017 and January 2023. Change in 4 asthma domains (exacerbation rate, asthma control, long-term oral corticosteroid [LTOCS] dose, and lung function) was assessed from biologic initiation to 1 year post-treatment (minimum 24 weeks). Pre- to post-biologic changes for responders and nonresponders were described along a categorical gradient for each domain derived from pre-biologic distributions (exacerbation rate: 0 to 6+/y; asthma control: well controlled to uncontrolled; LTOCS: 0 to >30 mg/d; percent-predicted forced expiratory volume in 1 second [ppFEV1]: <50% to ≥80%).

RESULTS

Percentage of biologic responders (ie, those with a category improvement pre- to post-biologic) varied by domain and increased with greater pre-biologic impairment, increasing from 70.2% to 90.0% for exacerbation rate, 46.3% to 52.3% for asthma control, 31.1% to 58.5% for LTOCS daily dose, and 35.8% to 50.6% for ppFEV1. The proportion of patients having improvement post-biologic tended to be greater for anti-IL-5/5R compared with for anti-IgE for exacerbation, asthma control, and ppFEV1 domains, irrespective of pre-biologic impairment.

CONCLUSION

Our results provide realistic outcome-specific post-biologic expectations for both physicians and patients, will be foundational to inform future work on a multidimensional approach to define and assess biologic responders and response, and may enhance appropriate patient selection for biologic therapies.

TRIAL REGISTRATION

The ISAR database has ethical approval from the Anonymous Data Ethics Protocols and Transparency (ADEPT) committee (ADEPT0218) and is registered with the European Union Electronic Register of Post-Authorization studies (ENCEPP/DSPP/23720). The study was designed, implemented, and reported in compliance with the European Network Centres for Pharmacoepidemiology and Pharmacovigilance (ENCEPP) Code of Conduct (EUPAS38288) and with all applicable local and international laws and regulation, and registered with ENCEPP (https://www.encepp.eu/encepp/viewResource.htm?id=38289). Governance was provided by ADEPT (registration number: ADEPT1220).

Benefits of specialist severe asthma management: demographic and geographic disparities

BACKGROUND

The benefits of specialist assessment and management have yet to be evaluated within the biologic era of UK severe asthma treatment, and potential disparities have not been considered.

METHODS

In an uncontrolled before-and-after study, we compared asthma symptoms (Asthma Control Questionnaire-6 (ACQ-6)), exacerbations, unscheduled secondary care use, lung function (forced expiratory volume in 1 s (FEV1)) and oral corticosteroid (OCS) dose after 1 year. We compared outcomes by sex, age (18-34, 35-49, 50-64 and ≥65 years), ethnicity (Caucasian versus non-Caucasian) and hospital site after adjusting for demographics and variation in biologic therapy use.

RESULTS

1140 patients were followed-up for 1370 person-years from 12 specialist centres. At annual review, ACQ-6 score was reduced by a median (interquartile range (IQR)) of 0.7 (0.0-1.5), exacerbations by 75% (33-100%) and unscheduled secondary care by 100% (67-100%). FEV1 increased by a median (IQR) of 20 (-200-340) mL, while OCS dose decreased for 67% of patients. Clinically meaningful improvements occurred across almost all patients, including those not receiving biologic therapy. There was little evidence of differences across demographic groups, although those aged ≥65 years demonstrated larger reductions in exacerbations (69% versus 52%; p<0.001) and unscheduled care use (77% versus 50%; p<0.001) compared with patients aged 18-34 years. There were >2-fold differences between the best and worst performing centres across all study outcomes.

CONCLUSIONS

Specialist assessment and management is associated with substantially improved patient outcomes, which are broadly consistent across demographic groups and are not restricted to those receiving biologic therapy. Significant variation exists between hospitals, which requires further investigation.

Burden of allergic disease among ethnic minority groups in high-income countries

The COVID‐19 pandemic raised acute awareness regarding inequities and inequalities and poor clinical outcomes amongst ethnic minority groups. Studies carried out in North America, the UK and Australia have shown a relatively high burden of asthma and allergies amongst ethnic minority groups. The precise reasons underpinning the high disease burden are not well understood, but it is likely that this involves complex gene–environment interaction, behavioural and cultural elements. Poor clinical outcomes have been related to multiple factors including access to health care, engagement with healthcare professionals and concordance with advice which are affected by deprivation, literacy, cultural norms and health beliefs. It is unclear at present if allergic conditions are intrinsically more severe amongst patients from ethnic minority groups. Most evidence shaping our understanding of disease pathogenesis and clinical management is biased towards data generated from white population resident in high‐income countries. In conjunction with standards of care, it is prudent that a multi‐pronged approach towards provision of composite, culturally tailored, supportive interventions targeting demographic variables at the individual level is needed, but this requires further research and validation. In this narrative review, we provide an overview of epidemiology, sensitization patterns, poor clinical outcomes and possible factors underpinning these observations and highlight priority areas for research.