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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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Bruce P, Hatter L, Houghton C, Kearns C, Holliday M, Anderson AJ, Eathorne A, Martindale J, Semprini A, Weatherall M, Pavord I, Harrison T, Papi A, Horne R, Beasley R. The Anti-Inflammatory Reliever (AIR) Algorithm Study: a protocol for a single-group study of an AIR stepwise approach to the treatment of adult asthma. ERJ Open Res 2023; 9:00239-2023. [PMID: 37753283 PMCID: PMC10518889 DOI: 10.1183/23120541.00239-2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/03/2023] [Indexed: 09/28/2023] Open
Abstract
Background The stepwise approach to long-term asthma management, which traditionally incorporates short-acting β2-agonist reliever therapy, has been a core feature of asthma guidelines for over 30 years. There have been no studies, however, directly investigating the use of an entire guideline-recommended track. Recently, inhaled corticosteroid-formoterol has been recommended as the preferred reliever therapy in adult asthma, in accordance with a stepwise "Anti-Inflammatory Reliever" (AIR) treatment track. Objective The aim of this study was to evaluate the AIR stepwise approach recommended by the New Zealand adolescent and adult asthma guidelines, in combination with a novel algorithm for transitioning between treatment steps. Methods This 52-week, open-label, single-group study will recruit 100 adults aged 18 to 75 years with mild, moderate and moderate-severe asthma (ACTRN12620001010987). Participants will be allocated to budesonide-formoterol 200/6 µg, one actuation as needed (Step 1), one actuation twice daily and as needed (Step 2), or two actuations twice daily and one as needed (Step 3). Treatment steps will be adjusted throughout the study, in response to reliever use and asthma attacks, according to a stepwise AIR algorithm. Following a 26-week period of investigator-led transitions, participants will adjust their own treatment step. The primary outcome is participant satisfaction as measured by the Global Satisfaction score of the Treatment Satisfaction Questionnaire for Medication. Secondary outcomes will assess efficacy and safety, and describe patterns of medication use and participant flow through the treatment steps. Conclusion This is the first trial to assess the AIR treatment track and algorithm. The results will provide knowledge to guide the clinical use of this approach.
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Affiliation(s)
- Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ciléin Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Holliday
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - John Martindale
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Alex Semprini
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Weatherall
- Department of Medicine, University of Otago, Wellington, New Zealand
| | | | - Tim Harrison
- University of Nottingham, Nottingham, UK
- Global Medical Affairs, AstraZeneca, UK
| | | | - Rob Horne
- University College London, London, UK
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
- School of Biological Sciences, Victoria University Wellington, Wellington, New Zealand
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3
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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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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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Vukoja M, Kopitovic I, Lazic Z, Milenkovic B, Stankovic I, Tomic-Spiric V, Zvezdin B, Hromis S, Cekerevac I, Ilic A, Vukcevic M, Dimic-Janjic S, Stjepanovic M. Diagnosis and treatment of adult asthma patients in Serbia: a 2022 experts group position statement. Expert Rev Respir Med 2022; 16:1133-1144. [PMID: 36448775 DOI: 10.1080/17476348.2022.2153674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Asthma is the most common non-communicable chronic lung condition across all ages. Epidemiological data indicate that many asthma patients in Serbia remain undiagnosed and untreated. The implementation of recent global advances in asthma management is limited due to the lack of a systematic approach, drug availability and regulatory affairs. In addition, the global coronavirus disease pandemic has posed a significant challenge, particularly in resource-limited settings. AREAS COVERED In this paper, we propose an algorithm for treating adult asthma patients in Serbia. We performed PubMed database search on published asthma clinical trials and guidelines from 1 January 2015 to 10 March 2020. The consensus process incorporated a modified Delphi method that included two rounds of e-mail questionnaires and three rounds of national asthma expert meetings. We focus on 1) objective diagnosis of asthma, 2) the implementation of up-to-date therapeutic options, and 3) the identification and referral of severe asthma patients to newly established severe asthma centers. EXPERT OPINION Regional specificities and variations in healthcare systems require the adaptation of evidence-based knowledge. Practical, clinically oriented algorithms designed to overcome local barriers in healthcare delivery may facilitate timely and adequate asthma diagnosis and the local implementation of current advances in asthma management.
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Affiliation(s)
- Marija Vukoja
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Department of Internal Medicine, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Ivan Kopitovic
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Department of Internal Medicine, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Zorica Lazic
- Pulmonary Department, University Clinical Centre Kragujevac, Kragujevac, Serbia.,Department of Internal Medicine, Faculty of Medicine, University of Kragujevac, Kragujevac, Serbia
| | - Branislava Milenkovic
- Department of Pneumonology Clinic for Pulmonology Diseases, University Clinical Centre of Serbia, Belgrade, Serbia.,Department of Internal Medicine, School of Medicine, University of Belgrade, Serbia
| | - Ivana Stankovic
- Department for Asthma and Chronic Obstructive Pulmonary Diseases, Clinic for Lung Diseases, University Clinical Centre of Nis, Nis, Serbia.,Department of Internal Medicine, Faculty of Medicine, University of Nis, Nis, Serbia
| | - Vesna Tomic-Spiric
- Department of Internal Medicine, School of Medicine, University of Belgrade, Serbia.,Diagnostic-polyclinic Department, Clinic of Allergology and Immunology, University Clinical Center of Serbia
| | - Biljana Zvezdin
- Department of Internal Medicine, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Department for Allergy and Obstructive Pulmonary Diseases, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia
| | - Sanja Hromis
- Department for Allergy and Obstructive Pulmonary Diseases, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Department of Nursing, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Ivan Cekerevac
- Pulmonary Department, University Clinical Centre Kragujevac, Kragujevac, Serbia.,Department of Internal Medicine, Faculty of Medicine, University of Kragujevac, Kragujevac, Serbia
| | - Aleksandra Ilic
- Department of Pneumonology Clinic for Pulmonology Diseases, University Clinical Centre of Serbia, Belgrade, Serbia.,Department of Internal Medicine, School of Medicine, University of Belgrade, Serbia
| | - Miodrag Vukcevic
- Department of Internal Medicine, School of Medicine, University of Belgrade, Serbia.,Pulmonary Department, Clinical Hospital Centre Zemun, Belgrade, Serbia
| | - Sanja Dimic-Janjic
- Department of Pneumonology Clinic for Pulmonology Diseases, University Clinical Centre of Serbia, Belgrade, Serbia.,Department of Internal Medicine, School of Medicine, University of Belgrade, Serbia
| | - Mihailo Stjepanovic
- Department of Pneumonology Clinic for Pulmonology Diseases, University Clinical Centre of Serbia, Belgrade, Serbia.,Department of Internal Medicine, School of Medicine, University of Belgrade, Serbia
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Biyolojik Ajan Tedavisi Alan Ağır Astımlı Hastalarda COVID-19 Pandemisi Sırasında Tedaviye Uyumdaki Değişiklikler. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1168725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Aim: This study aimed to evaluate the effects of the COVID-19 pandemic on treatment adherence in patients with severe asthma who were receiving omalizumab and mepolizumab treatment in our clinic.
Material and Method: A total of 53 patients with severe asthma, 45 of whom were using omalizumab and 8 of whom were using mepolizumab, were included in the study. The medical records of the patients were recorded anonymously and retrospectively.
Results: It was seen that the rate of patients using omalizumab in the study population decreased during the pandemic period compared to the 1-year period before the pandemic. It was observed that approximately 51% of the patients using omalizumab missed routine treatment doses. The major factor in skipping treatment doses was the fear of contracting COVID-19 upon admission to the hospital. In the mepolizumab group, the rate of using biologic agents during the pandemic period increased compared to 1 year before the pandemic. Dose skipping was observed among 37.5% of the patients in this group and it was found that the major risk factor for skipping a dose was the fear of contracting COVID-19 upon admission to the hospital.
Conclusion: In this study, it was found that there was a decrease in the duration and rate of use of biologic agent therapies administered in a health institution under the supervision of a healthcare professional among patients with severe asthma during the pandemic.
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Kearns N, Williams M, Bruce P, Black M, Kearns C, Sparks J, Braithwaite I, Weatherall M, Beasley R. Single dose of budesonide/formoterol turbuhaler compared to salbutamol pMDI for speed of bronchodilator onset in asthma: a randomised cross-over trial. Thorax 2022; 78:thoraxjnl-2022-219052. [PMID: 35851045 DOI: 10.1136/thorax-2022-219052] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/01/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare bronchodilator response after to salbutamol and budesonide/formoterol in adults with stable asthma. METHODS A double-blind, cross-over, single-centre, placebo-controlled, non-inferiority trial. Adults with stable asthma were randomised to different orders of two treatment regimens: two actuations of placebo via MDI and one actuation of budesonide/formoterol 200/6 µg via turbuhaler; and one actuation of placebo turbuhaler and two actuations of salbutamol 100 µg via MDI. The primary outcome measure was FEV1 after 2 min. Secondary outcome measures included FEV1, mBorg Dyspnoea Scale score and visual analogue score for breathlessness over 30 min. RESULTS Forty-nine of 50 potential participants were randomised. One participant withdrew following the first intervention visit and another could not be randomised due to COVID-19 restrictions. The mean (SD) change from baseline FEV1 2 min after treatment administration for budesonide/formoterol and salbutamol was 0.08 (0.14) L, n=49, and 0.17 (0.18) L, n=48, respectively, mean (95% CI) paired difference of -0.097 L (-0.147 to -0.047), p=0.07, against a non-inferiority bound of -0.06 L. In the secondary analysis, FEV1 over 30 min was lower for budesonide/formoterol compared with salbutamol, difference (95% CI): -0.10 (-0.12 to -0.08) L, p<0.001. There were no differences in Visual Analogue Scale score or mBorg Dyspnoea Scale score between treatments. CONCLUSION The results do not support the primary hypothesis of non-inferiority at the boundary of -0.06 L for the difference between budesonide/formoterol 200/6 µg compared with salbutamol 200 µg for FEV1 at 2 min, and could be consistent with inferiority with a p value of 0.07. For the secondary analysis of FEV1 measurements over time, the FEV1 was higher with salbutamol. TRIAL REGISTRATION NUMBER Australian and New Zealand Clinical Trials Registry (ACTRN 12619001387112).
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Affiliation(s)
- Nethmi Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mathew Williams
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Melissa Black
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ciléin Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Jenny Sparks
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Irene Braithwaite
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Mark Weatherall
- Medical Research Institute of New Zealand, Wellington, New Zealand
- 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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8
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Tay TR, van Boven JFM, Chan A, Hew M. Electronic Inhaler Monitoring for Chronic Airway Disease: Development and Application of a Multidimensional Efficacy Framework. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1189-1201.e1. [PMID: 34915225 DOI: 10.1016/j.jaip.2021.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 06/14/2023]
Abstract
Inhaled therapy is the cornerstone of chronic airway disease therapy, but poor adherence to controller inhalers worsens clinical outcomes and increases cost. Monitoring of controller use is needed to improve adherence, and monitoring of reliever use can predict impending exacerbations. Both can be accurately achieved by electronic inhaler monitoring (EIM). However, evidence for EIM use in clinical practice is limited and varied, and knowledge gaps remain across different outcomes and health settings. We aimed to develop a framework to assess EIM systematically across all aspects of efficacy, apply this framework to the current literature, and identify gaps in efficacy to inform future development in the field. We adapted an existing framework for diagnostic tests, consisting of six levels of efficacy with ascending clinical relevance: technical, diagnostic accuracy, diagnostic thinking, therapeutic, patient outcome, and societal efficacy. Tailoring this framework to EIM, we incorporated expert feedback and applied it to the EIM efficacy literature. We found that EIM has good diagnostic accuracy, diagnostic thinking, and therapeutic efficacies, but evidence is lacking for specific aspects of technical, patient outcome, and societal efficacies. Further development of EIM requires improved reliability, usability, and data security for patients, and optimal integration with electronic medical records and overall patient care. Defining appropriate target patient groups and pairing EIM data with effective interventions, in conjunction with reducing costs through technological innovation and economies of scale, will enhance patient and societal outcome efficacies.
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Affiliation(s)
- Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, the Netherlands; Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia; Medication Adherence Expertise Center of the Northern Netherlands, Groningen, the Netherlands
| | - Amy Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mark Hew
- Allergy, Asthma, and Clinical Immunology, Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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9
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Beasley R, Harrison T, Peterson S, Gustafson P, Hamblin A, Bengtsson T, Fagerås M. Evaluation of Budesonide-Formoterol for Maintenance and Reliever Therapy Among Patients With Poorly Controlled Asthma: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e220615. [PMID: 35230437 PMCID: PMC8889464 DOI: 10.1001/jamanetworkopen.2022.0615] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE The Global Initiative for Asthma (GINA) recommends 2 alternative treatments for patients receiving treatment at steps 3 to 5: single inhaler combination inhaled corticosteroid-formoterol as both maintenance and reliever (SMART) or inhaled corticosteroid-long-acting β2-agonist as maintenance plus short-acting β2-agonist as reliever. OBJECTIVE To assess whether switching to SMART is associated with longer time to first severe asthma exacerbation compared with a step up or continuation of GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever among patients with poorly controlled asthma. DATA SOURCES For this systematic review and meta-analysis, the literature, internal study databases at AstraZeneca and the Medical Research Institute of New Zealand, and references from a previous systematic review and meta-analysis on SMART were searched to identify randomized clinical trials published from January 1990 to February 2018, that compared budesonide-formoterol by SMART with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever. STUDY SELECTION Trials of at least 24 weeks' duration were included if they reported baseline data on GINA treatment step, asthma control status, and efficacy measures of severe exacerbations. Included patients were adults and adolescents with asthma and baseline Asthma Control Questionnaire 5-item version scores of 1.5 or higher. DATA EXTRACTION AND SYNTHESIS Patient-level data were identified by independent extraction, and analyses were performed using a fixed-effect model. Data analysis was performed from August 2018 to November 2021. MAIN OUTCOMES AND MEASURES The primary outcome was time to first severe asthma exacerbation associated with each treatment, analyzed by Cox proportional hazards regression. RESULTS Overall, 4863 patients were included (3034 [62.4%] female; mean [SD] age, 39.8 [16.3] years). Switching patients with uncontrolled asthma at GINA step 3 (n = 1950) to SMART at either step 3 or 4 was associated with a prolonged time to first severe asthma exacerbation, with a 29% reduced risk compared with stepping up to step 4 inhaled corticosteroid-long-acting β2-agonist maintenance plus short-acting β2-agonist reliever (hazard ratio, 0.71; 95% CI, 0.52-0.97). For patients with uncontrolled asthma at step 3 and step 4 (n = 2913), switching to SMART was associated with a prolonged time to first severe asthma exacerbation and a 30% reduced risk compared with remaining at the same treatment step (hazard ratio, 0.70; 95% CI, 0.58-0.85). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, for patients with poorly controlled asthma, SMART was associated with longer time to first severe asthma exacerbation compared with a step up or continuation of GINA step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever. These findings suggest that if an adult or adolescent receiving treatment at GINA step 3 or 4 has poorly controlled asthma, it is preferable to switch to the SMART regimen rather than to step up or continue the GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever therapy.
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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 Wellington, Wellington, New Zealand
| | - Tim Harrison
- Nottingham National Institute for Health Research Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom
- Digital Health Research & Development, AstraZeneca, Cambridge, United Kingdom
| | | | - Per Gustafson
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Angus Hamblin
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom
| | | | - Malin Fagerås
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
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10
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Kearns N, Bruce P, Williams M, Doppen M, Black M, Weatherall M, Beasley R. Repeated dose budesonide/formoterol compared to salbutamol in adult asthma: A randomised cross-over trial. Eur Respir J 2022; 60:2102309. [PMID: 35115339 DOI: 10.1183/13993003.02309-2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/13/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine the comparative bronchodilator, systemic beta2-agonist, cardiovascular and adverse effects of salbutamol 200 µg and budesonide/formoterol 200/6 µg when taken repeatedly in stable asthma. METHODS This open-label, cross-over, single-centre, controlled trial, randomised adults with asthma to different orders of two treatment regimens: salbutamol 200 µg via MDI at t=0, 30, 60, 90 min, then salbutamol 2.5 mg via nebuliser at t=120, 140, 160 and 420 min; or budesonide/formoterol 200/6 µg one actuation via Turbuhaler at t=0, 30, 60, 90 min, two actuations at t=120, 140, 160 and 420 min. The primary outcome measure was FEV1 after 180 min. Secondary outcomes included repeat measures of FEV1, serum potassium, heart rate, and adverse events RESULTS: Of 39 patients randomised, two withdrew due to adverse events (QTCF prolongation and T wave abnormalities) after the first intervention with salbutamol. The mean (sd) change from baseline FEV1 180 min after randomisation for salbutamol and budesonide/formoterol regimens was 0.71 (0.46) L, N=38, and 0.58 (0.45) L, N=37, respectively; with a mean (sd) paired difference of -0.10 (0.40) L, N=37, and a model-based estimated difference (95% CI) -0.12 (-0.25 to 0.02) L, p=0.088. In the main secondary analysis, salbutamol resulted in significantly greater FEV1 from 30 to 240 min, but lesser FEV1 at 360 and 420 min. Salbutamol resulted in a significantly lower serum potassium, and a higher heart rate and number of adverse events. CONCLUSION The comparative bronchodilator responses of repeated administration of salbutamol 200 µg dose-1 and budesonide/formoterol 200/6 µg differed depending on the time of measurement. Salbutamol caused greater systemic beta2-agonist and cardiovascular effects and more adverse events.
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Affiliation(s)
- Nethmi Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mathew Williams
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Marjan Doppen
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Melissa Black
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Weatherall
- Department of Medicine, University of Otago, 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
- Department of Respiratory Medicine, Capital and Coast District Health Board, Wellington, New Zealand
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11
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Hatter L, Bruce P, Holliday M, Anderson AJ, Braithwaite I, Corin A, Eathorne A, Grimes A, Harwood M, Hills T, Kearns C, Kerse K, Martindale J, Montgomery B, Riggs L, Sheahan D, Shortt N, Zazulia K, Weatherall M, McNamara D, Byrnes CA, Bush A, Dalziel SR, Beasley R. The Children's Anti-inflammatory Reliever (CARE) study: a protocol for a randomised controlled trial of budesonide-formoterol as sole reliever therapy in children with mild asthma. ERJ Open Res 2021; 7:00271-2021. [PMID: 34853785 PMCID: PMC8628747 DOI: 10.1183/23120541.00271-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background Asthma is the most common chronic disease in children, many of whom are managed solely with a short-acting β2-agonist (SABA). In adults, the evidence that budesonide-formoterol as sole reliever therapy markedly reduces the risk of severe exacerbations compared with SABA alone has contributed to the Global Initiative for Asthma recommending against SABA monotherapy in this population. The current lack of evidence in children means it is unknown whether these findings are also relevant to this demographic. High-quality randomised controlled trials (RCTs) are needed. Objective The aim of this study is to determine the efficacy and safety of as-needed budesonide-formoterol therapy compared with as-needed salbutamol in children aged 5 to 15 years with mild asthma, who only use a SABA. Methods A 52-week, open-label, parallel group, phase III RCT will recruit 380 children aged 5 to 15 years with mild asthma. Participants will be randomised 1:1 to either budesonide-formoterol (Symbicort Rapihaler®) 50/3 µg, two actuations as needed, or salbutamol (Ventolin®) 100 µg, two actuations as needed. The primary outcome is asthma attacks as rate per participant per year. Secondary outcomes assess asthma control, lung function, exhaled nitric oxide and treatment step change. A cost-effectiveness analysis is also planned. Conclusion This is the first RCT to assess the safety and efficacy of as-needed budesonide-formoterol in children with mild asthma. The results will provide a much-needed evidence base for the treatment of mild asthma in children. This protocol describes the first randomised controlled trial to investigate the efficacy and safety of budesonide/formoterol as sole reliever therapy for children with mild asthma, providing urgently needed evidence in this populationhttps://bit.ly/35v0R3Z
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Affiliation(s)
- Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Holliday
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | | | | | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Arthur Grimes
- Motu Economic and Public Policy Research, Wellington, New Zealand
| | - Matire Harwood
- Dept of General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - Thomas Hills
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ciléin Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kyley Kerse
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - John Martindale
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Lynn Riggs
- Motu Economic and Public Policy Research, Wellington, New Zealand
| | | | - Nick Shortt
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Katja Zazulia
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Weatherall
- Dept of Medicine, University of Otago, Wellington, New Zealand
| | - David McNamara
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Catherine A Byrnes
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Dept of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Andrew Bush
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Stuart R Dalziel
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Dept of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand.,School of Biological Sciences, Victoria University Wellington, Wellington, New Zealand
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12
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Canonica GW, Paggiaro P, Blasi F, Musarra A, Richeldi L, Rossi A, Papi A. Manifesto on the overuse of SABA in the management of asthma: new approaches and new strategies. Ther Adv Respir Dis 2021; 15:17534666211042534. [PMID: 34587829 PMCID: PMC8488406 DOI: 10.1177/17534666211042534] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The risks of overusing short-acting β2-agonists (SABA), including an
increase in asthma-related deaths, are many and well known. The Global
Initiative on Asthma (GINA) 2019 and 2020 updates recommend as-needed inhaled
corticosteroid (ICS)/formoterol as the preferred rescue medication in mild
asthma as monotherapy and also in moderate to severe asthma when the maintenance
and reliever therapy (MART) strategy is used. Using SABA for symptom relief,
however, was the standard of treatment for many years, and consequently this
practice persists, particularly in patients not taking ICS regularly. Here, we
examine the rationale for this shift from a long-standing recommendation for
as-needed SABA treatment to the use of as-needed ICS/formoterol and consider
clinical evidence on strategies for asthma treatment and patient management.
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Affiliation(s)
- Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Personalized Medicine, Asthma and Allergy, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Italy
| | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Rossi
- Pulmonary Unit, Azienda Ospedaliera Universitaria Integrata and University of Verona, Verona, Italy
| | - Alberto Papi
- Research Center on Asthma and COPD, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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13
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Cazzola M, Matera MG, Rogliani P, Calzetta L, Ora J. Step-up and step-down approaches in the treatment of asthma. Expert Rev Respir Med 2021; 15:1159-1168. [PMID: 34032534 DOI: 10.1080/17476348.2021.1935245] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Significant intraindividual and temporal variability in symptom control is a feature of asthma that requires careful monitoring and the need to periodically review and adjust therapy. Both NHLBI/NAEPP and GINA offer helpful algorithms for a stepping approach to asthma.Areas covered: The problems arisen in applying the stepwise approach to the treatment of asthma proposed by NHLBI/NAEPP and GINA algorithms and their possible alternatives.Expert opinion: The current therapeutic stepping approach to asthma, which takes into account lung function, symptoms and quality of life, is certainly useful, but it does not consider the underlying mechanisms. Furthermore, patient's overestimation or underestimation of the severity of the disease and differences in the opinions on the level of asthma control required between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks. A reassessment of the conventional stepping approach to management of asthma is now needed. A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma which, when therapeutically targeted, will in many cases help to achieve the goals, seems more reasonable than the present stepping approach.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Division of Respiratory Medicine, University Hospital "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital "Tor Vergata", Rome, Italy
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14
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Beasley R, Bruce P, Hatter L, Braithwaite I, Semprini A, Kearns C, Weatherall M, Pavord ID. A Proposed Revision of the Stepwise Treatment Algorithm in Asthma. Am J Respir Crit Care Med 2021; 204:100-103. [PMID: 33789069 PMCID: PMC8437115 DOI: 10.1164/rccm.202101-0224le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand Wellington New Zealand.,Victoria University of Wellington Wellington, New Zealand.,Capital & Coast District Health Board Wellington, New Zealand
| | - Pepa Bruce
- Medical Research Institute of New Zealand Wellington New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand Wellington New Zealand.,Imperial College London London, United Kingdom
| | | | - Alex Semprini
- Medical Research Institute of New Zealand Wellington New Zealand
| | - Ciléin Kearns
- Medical Research Institute of New Zealand Wellington New Zealand
| | - Mark Weatherall
- Capital & Coast District Health Board Wellington, New Zealand.,University of Otago Wellington, Wellington New Zealand
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15
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New insights from GINA 2019/2020-Focus on early anti-inflammatory therapy. Wien Klin Wochenschr 2021; 133:1215-1220. [PMID: 33770268 DOI: 10.1007/s00508-021-01830-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 02/05/2021] [Indexed: 10/21/2022]
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16
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Kaplan A. The Myth of Mild: Severe Exacerbations in Mild Asthma: An Underappreciated, but Preventable Problem. Adv Ther 2021; 38:1369-1381. [PMID: 33474708 PMCID: PMC7816833 DOI: 10.1007/s12325-020-01598-2] [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: 10/29/2020] [Accepted: 12/04/2020] [Indexed: 11/26/2022]
Abstract
Asthma is a common, chronic inflammatory airway disease, characterised by unpredictable episodes of worsening symptoms, or exacerbations. Causes of asthma exacerbations include viral infections, exposure to allergen and air pollution, all of which increase the underlying inflammation that typifies asthma. Most (50-75%) patients are classed as having mild asthma, with symptoms that can be readily controlled with available inhaled medications. Paradoxically, for the past 30 years, the first treatment recommended in asthma management guidelines was short-acting β2-agonists (SABA), which not only have no anti-inflammatory properties but may, in fact, worsen inflammation. The Global Initiative for Asthma (GINA) 2019/2020 broke with this paradox by stating clearly that SABA should no longer be used alone as a reliever, for safety reasons. Instead, GINA now recommends an anti-inflammatory rescue/reliever approach for adult and adolescent patients, based on the combination of an inhaled corticosteroid with a rapid onset β2-agonist such as formoterol. This commentary highlights the fact that even patients with well-controlled mild asthma are at risk of severe, potentially life-threatening exacerbations, similar to those in patients with moderate or severe asthma, and therefore 'mild asthma', is a misnomer. The commentary describes the case history of a patient with mild asthma to illustrate how increasing use of SABA alone can worsen and prolong exacerbations when they occur. The author goes on to describe how the management of this patient's exacerbation could have been improved, and provides up-to-date advice on broader aspects of the management of mild asthma and exacerbations, supported by the recent changes to the GINA recommendations.
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Affiliation(s)
- Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
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17
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Shaw DE, Heaney LG, Thomas M, Beasley R, Gibson PG, Pavord ID. Balancing the needs of the many and the few: where next for adult asthma guidelines? THE LANCET RESPIRATORY MEDICINE 2021; 9:786-794. [PMID: 33639099 DOI: 10.1016/s2213-2600(21)00021-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/23/2020] [Accepted: 01/06/2021] [Indexed: 12/16/2022]
Abstract
Asthma differs from many other chronic conditions in that most key management decisions are made in non-specialist settings, such as general practitioner surgeries and accident and emergency departments. Diagnosis in primary care relies on recognition of a characteristic pattern of symptoms and the occurrence of asthma attacks, sometimes supplemented by basic lung function tests. Ongoing management is guided by the assessment of symptoms and simple lung function measures of airflow obstruction, with little attempt made to personalise management. This approach is flawed because the inadequate specificity of symptoms, as well as the low sensitivity of variable airflow obstruction, means that a diagnosis of asthma is often difficult to exclude with confidence. Moreover, even if diagnosed correctly, dissociation between inflammation, airflow obstruction, and symptoms means that a generalised stepwise approach to managing asthma on the basis of symptoms is unlikely to be successful in a substantial proportion of patients. As a result, effective treatments are used inefficiently, and outcomes are often worse than they could be. Rather than use of either a population-based or personalised approach for the diagnosis and management of asthma, we recommend a new combined approach, in which treatment decisions are driven by objective assessment of key treatable mechanistic traits.
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Affiliation(s)
- Dominick E Shaw
- NIHR Nottingham Biomedical Research Centre, Division of Respiratory Medicine, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Liam G Heaney
- Centre for Experimental Medicine, Queen's University, Belfast, Northern Ireland
| | - Mike Thomas
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Peter G Gibson
- Department of Respiratory and Sleep Medicine, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Ian D Pavord
- Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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18
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Papi A, Braithwaite I, Ebmeier S, Hancox RJ, Harrison T, Holliday M, Houghton C, Morandi L, Oldfield K, Pavord ID, Reddel HK, Williams M, Weatherall M, Beasley R. Budesonide-formoterol reliever therapy in intermittent versus mild persistent asthma. Eur Respir J 2021; 57:13993003.03064-2020. [PMID: 33060151 DOI: 10.1183/13993003.03064-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/23/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Alberto Papi
- Respiratory Medicine Unit, Dept of Morphology, Surgery and Experimental Medicine, Università di Ferrara, Ferrara, Italy
| | | | - Stefan Ebmeier
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Robert J Hancox
- Dept of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand.,Dept of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Tim Harrison
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Mark Holliday
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Luca Morandi
- Respiratory Medicine Unit, Dept of Morphology, Surgery and Experimental Medicine, Università di Ferrara, Ferrara, Italy
| | - Karen Oldfield
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ian D Pavord
- Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Mathew Williams
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
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19
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Cheng SL, Ho ML, Lai YF, Wang HC, Hsu JY, Liu SF, Huang MS, Lee CH, Lin CH, Hang LW, Liu YC, Yang KY, Wang JH. Budesonide/Formoterol Anti-Inflammatory Reliever and Maintenance or Fluticasone Propionate/Salmeterol Plus As-Needed, Short-Acting β 2 Agonist: Real-World Effectiveness in pAtients without Optimally Controlled asThma (REACT) Study. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:5441-5450. [PMID: 33324041 PMCID: PMC7733383 DOI: 10.2147/dddt.s266177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/10/2020] [Indexed: 11/23/2022]
Abstract
Introduction In the prospective, observational, 16-week REACT study conducted between October 21, 2008 and May 12, 2011, we compared the real-world effectiveness of anti-inflammatory reliever and maintenance therapy with budesonide/formoterol (Symbicort® Turbuhaler) and maintenance therapy with fixed-dose fluticasone/salmeterol (Seretide®) plus as-needed, short-acting β2 agonists (SABAs) in Taiwanese patients with inadequate asthma control. Methods Asthma control was assessed using the five-item Asthma Control Questionnaire (ACQ-5) and standardized pulmonary function testing. Assessments were performed at baseline and at weeks 4–5 and 12–16. Overall, we enrolled 842 patients at 11 clinics, 723 of whom were included in analyses (budesonide/formoterol, 563.3±1.3 μg/d, n=551; fluticasone/salmeterol, 1013.8±1.4 μg/d, n=172). Results At baseline, 72.5% and 27.5% of all patients had “partly” and “uncontrolled” asthma, respectively. Mean±SD ACQ-5 scores were 1.54±1.06 and 1.46±1.28 in the budesonide/formoterol and fluticasone/salmeterol groups, respectively. ACQ-5 scores significantly improved from baseline (ie, decreased) in both groups at weeks 4 and 16. ACQ-5 difference scores were significantly lower in the budesonide/formoterol group (−0.91±1.11) than the fluticasone/salmeterol group (−0.69±1.27) at the end of the study (p=0.027). Peak expiratory flow rate significantly improved from baseline in the budesonide/formoterol but not the fluticasone/salmeterol group at the end of the study. Severe exacerbation rates and medical resource utilization were comparable between the budesonide/formoterol and fluticasone/salmeterol groups. Conclusion Collectively, results indicate the real-world effectiveness of budesonide/formoterol anti-inflammatory reliever and maintenance therapy is better than fixed-dose fluticasone/salmeterol plus as-needed SABA. Trial Registration ClinicalTrials.gov registration number: NCT00784953.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Department of Chemical Engineering and Materials Science, Yuan-Ze University, Taoyuan, Taiwan
| | - Ming-Lin Ho
- Division of Chest Medicine, Kuang Tien General Hospital, Taichung, Taiwan
| | - Yun-Fa Lai
- Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jeng-Yuan Hsu
- Division of Clinical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Feng Liu
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ming-Shyang Huang
- Department of Internal Medicine, E-DA Cancer Hospital and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Cheng-Hung Lee
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Hsiung Lin
- Division of Chest Medicine, Kuang Tien General Hospital, Taichung, Taiwan.,Division of Chest Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Liang-Wen Hang
- School of Nursing & Graduate Institute of Nursing, China Medical University, Taichung, Taiwan.,Sleep Medicine Center, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Chih Liu
- Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jia-Horng Wang
- Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.,Hyperbaric Oxygen Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
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20
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Baggott C, Beasley R. Asthma in the anti-inflammatory reliever therapy era. THE LANCET. RESPIRATORY MEDICINE 2020; 9:S2213-2600(20)30465-3. [PMID: 34756192 DOI: 10.1016/s2213-2600(20)30465-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Christina Baggott
- Medical Research Institute of New Zealand, Wellington Regional Hospital, Wellington, 6021, New Zealand; Respiratory Department, University Hospitals Bristol and Weston, Bristol, UK.
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington Regional Hospital, Wellington, 6021, New Zealand
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21
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Reducing the burden of asthma: time to set research and clinical priorities. THE LANCET RESPIRATORY MEDICINE 2020; 8:943-944. [PMID: 32910896 DOI: 10.1016/s2213-2600(20)30400-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 11/24/2022]
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22
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Bruce P, Hatter L, Beasley R. Anti-inflammatory reliever therapy in asthma: The evidence mounts but more is needed. Respirology 2020; 25:776-778. [PMID: 32578277 DOI: 10.1111/resp.13889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Respiratory Medicine Department, Capital and Coast District Health Board, Wellington, New Zealand.,School of Biological Sciences, Victoria University Wellington, Wellington, New Zealand
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23
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Lipworth B, Kuo CR, Chan R. Making simple things complicated using anti-inflammatory reliever therapy. Eur Respir J 2020; 55:55/4/2000267. [PMID: 32354861 DOI: 10.1183/13993003.00267-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/15/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Rory Chan
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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24
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Beasley R, Braithwaite I, Semprini A, Kearns C, Weatherall M, Harrison T, Papi A, Pavord ID. Achieving the balance between evidence and simplicity. Eur Respir J 2020; 55:55/4/2000651. [PMID: 32354863 DOI: 10.1183/13993003.00651-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand .,Capital and Coast District Health Board, Wellington, New Zealand
| | - Irene Braithwaite
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
| | - Alex Semprini
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
| | - Ciléin Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
| | - Mark Weatherall
- Capital and Coast District Health Board, Wellington, New Zealand.,University of Otago Wellington, Wellington, New Zealand
| | - Tim Harrison
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Alberto Papi
- Respiratory Medicine Unit, Dept of Medical Sciences, Università di Ferrara, Ferrara, Italy
| | - Ian D Pavord
- Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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