Evaluation of efficacy and safety of budesonide delivered via two dry powder inhalers

A "real-life" study on height in prepubertal asthmatic children receiving inhaled steroids

INTRODUCTION

Asthma is the most common chronic respiratory disease in children and inhaled corticosteroids (ICS) constitute the first line of treatment for these patients. However, the potential growth-inhibiting effect of ICS has often been a cause of concern for both caregivers as well as physicians, and there still remains conflict regarding their safety profile.

OBJECTIVE

To assess whether the administration of ICS in low or medium doses is associated with height reduction in prepubertal children.

METHODS

We performed a retrospective study to examine the association between ICS treatment and growth deceleration in children with mild persistent asthma. The comparison of height measurements every 6 months from 3 to 8 years of age was conducted among three groups of patients: patients not receiving ICS, patients being treated with low dose of ICS and patients being treated with medium dose of ICS (GINA Guidelines 2015).

RESULTS

This study included 284 patients (198 male, 86 female) aged 3-8 years; 75 patients were not receiving ICS, 63 patients were on low-dose ICS and 146 patients were on medium-dose ICS. The measured height every 6 months did not differ significantly (p > 0.05) among the three groups while the difference remained stable (p > 0.05), even when we evaluated males and females separately.

CONCLUSIONS

In this "real-life" study we found that long-term treatment with ICS in low or medium doses is not associated with height reduction in prepubertal children with asthma.

Inhaled Corticosteroids and Respiratory Infections in Children With Asthma: A Meta-analysis

CONTEXT

Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in adult patients with chronic obstructive pulmonary disease.

OBJECTIVE

To assess the association between ICS use and risk of pneumonia and other respiratory infections in children with asthma.

DATA SOURCES

We searched PubMed from inception until May 2015. We also searched clinicaltrials.gov and databases of pharmaceutical manufacturers.

STUDY SELECTION

We selected randomized trials that compared ICS with placebo for at least 4 weeks in children with asthma.

DATA EXTRACTION

We included 39 trials, of which 31 trials with 11 615 patients contributed data to meta-analyses.

RESULTS

The incidence of pneumonia was 0.58% (44/7465) in the ICS group and 1.51% (63/4150) in the placebo group. The meta-analysis of 9 trials that revealed at least 1 event of pneumonia revealed a reduced risk of pneumonia in patients taking ICS (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.44 to 0.94). Using risk difference as effect measure, the meta-analysis including all 31 trials revealed no significant difference in the risk of pneumonia between the ICS and placebo groups (risk difference: -0.1%; 95% CI: -0.3% to 0.2%). No significant association was found between ICS and risk of pharyngitis (RR: 1.01; 95% CI: 0.87 to 1.18), otitis media (RR: 1.07; 95% CI: 0.83 to 1.37), and sinusitis (RR: 0.89; 95% CI: 0.76 to 1.05).

LIMITATIONS

Lack of clearly defined criteria for respiratory infections and possible publication bias.

CONCLUSIONS

Regular use of ICS may not increase the risk of pneumonia or other respiratory infections in children with asthma.

Inhaled corticosteroids in children with persistent asthma: dose-response effects on growth

BACKGROUND

Inhaled corticosteroids (ICS) are the first-line treatment for children with persistent asthma. Their potential for growth suppression remains a matter of concern for parents and physicians.

OBJECTIVES

To assess whether increasing the dose of ICS is associated with slower linear growth, weight gain and skeletal maturation in children with asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov website up to March 2014.

SELECTION CRITERIA

Studies were eligible if they were parallel-group randomised trials evaluating the impact of different doses of the same ICS using the same device in both groups for a minimum of three months in children one to 17 years of age with persistent asthma.

DATA COLLECTION AND ANALYSIS

Two review authors ascertained methodological quality independently using the Cochrane Risk of bias tool. The primary outcome was linear growth velocity. Secondary outcomes included change over time in growth velocity, height, weight, body mass index and skeletal maturation.

MAIN RESULTS

Among 22 eligible trials, 17 group comparisons were derived from 10 trials (3394 children with mild to moderate asthma), measured growth and contributed data to the meta-analysis. Trials used ICS (beclomethasone, budesonide, ciclesonide, fluticasone or mometasone) as monotherapy or as combination therapy with a long-acting beta2 -agonist and generally compared low (50 to 100 μg) versus low to medium (200 μg) doses of hydrofluoroalkane (HFA)-beclomethasone equivalent over 12 to 52 weeks. In the four comparisons reporting linear growth over 12 months, a significant group difference was observed, clearly indicating lower growth velocity in the higher ICS dose group of 5.74 cm/y compared with 5.94 cm/y on lower-dose ICS (N = 728 school-aged children; mean difference (MD)0.20 cm/y, 95% confidence interval (CI) 0.02 to 0.39; high-quality evidence): No statistically significant heterogeneity was noted between trials contributing data. The ICS molecules (ciclesonide, fluticasone, mometasone) used in these four comparisons did not significantly influence the magnitude of effect (X(2) = 2.19 (2 df), P value 0.33). Subgroup analyses on age, baseline severity of airway obstruction, ICS dose and concomitant use of non-steroidal antiasthmatic drugs were not performed because of similarity across trials or inadequate reporting. A statistically significant group difference was noted in unadjusted change in height from zero to three months (nine comparisons; N = 944 children; MD 0.15, 95% CI -0.28 to -0.02; moderate-quality evidence) in favour of a higher ICS dose. No statistically significant group differences in change in height were observed at other time points, nor were such differences in weight, bone mass index and skeletal maturation reported with low quality of evidence due to imprecision.

AUTHORS' CONCLUSIONS

In prepubescent school-aged children with mild to moderate persistent asthma, a small but statistically significant group difference in growth velocity was observed between low doses of ICS and low to medium doses of HFA-beclomethasone equivalent, favouring the use of low-dose ICS. No apparent difference in the magnitude of effect was associated with three molecules reporting one-year growth velocity, namely, mometasone, ciclesonide and fluticasone. In view of prevailing parents' and physicians' concerns about the growth suppressive effect of ICS, lack of or incomplete reporting of growth velocity in more than 86% (19/22) of eligible paediatric trials, including those using beclomethasone and budesonide, is a matter of concern. All future paediatric trials comparing different doses of ICS with or without placebo should systematically document growth. Findings support use of the minimal effective ICS dose in children with asthma.

PLAIN LANGUAGE SUMMARY

Does altering the dose of inhaled corticosteroids make a difference in growth among children with asthma?

BACKGROUND

Asthma guidelines recommend inhaled corticosteroids (ICS) as the first choice of treatment for children with persistent asthma that is not well controlled when only a reliever inhaler is used to treat symptoms. Steroids work by reducing inflammation in the lungs and are known to control underlying symptoms of asthma. However, parents and physicians remain concerned about the potential negative effect of ICS on growth.

REVIEW QUESTION

Does altering the dose of inhaled corticosteroids make a difference in the growth of children with asthma? WHAT EVIDENCE DID WE FIND?: We studied whether a difference could be seen in the growth of children with persistent asthma who were using different doses of the same ICS molecule and the same delivery device. We found 22 eligible trials, but only 10 of them measured growth or other measures of interest. Overall, 3394 children included in the review combined 17 group comparisons (i.e. 17 groups of children with mild to moderate asthma using a particular dose and type of steroid in 10 trials). Trials used different ICS molecules (beclomethasone, budesonide, ciclesonide, fluticasone or mometasone) either on their own or in combination with a long-acting beta2 -agonist (a drug used to open up the airways) and generally compared low doses of corticosteroids (50 to 100 μg) with low to medium (200 μg) doses of corticosteroids (converted in μg HFA-beclomethasone equivalent) over 12 to 52 weeks.

RESULTS

We found a small but statistically significant group difference in growth over 12 months between these different doses clearly favouring the lower dose of ICS. The type of corticosteroid among newer molecules (ciclesonide, fluticasone, mometasone) did not seem to influence the impact on growth over one year. Differences in corticosteroid doses did not seem to affect the change in height, the gain in weight, the gain in bone mass index and the maturation of bones. QUALITY OF THE EVIDENCE: This review is based on a small number of trials that reported data and were conducted on children with mild to moderate asthma. Only 10 of 22 studies measured the few outcomes of interest for this review, and only four comparisons reported growth over 12 months. Our confidence in the quality of evidence is high for this outcome, however it is low to moderate for several other outcomes, depending on the number of trials reporting these outcomes. Moreover, a few outcomes were reported only by a single trial; as these findings have not been confirmed by other trials, we downgraded the evidence for these outcomes to low quality. An insufficient number of trials have compared the effect of a larger difference in dose, for example, between a high dose and a low dose of ICS and of other popular molecules such as budesonide and beclomethasone over a year or longer of treatment.

CONCLUSIONS

We report an evidence-based ICS dose-dependent reduction in growth velocity in prepubescent school-aged children with mild to moderate persistent asthma. The choice of ICS molecule (mometasone, ciclesonide or fluticasone) was not found to affect the level of growth velocity response over a year. The effect of corticosteroids on growth was not consistently reported: among 22 eligible trials, only four comparisons reported the effects of corticosteroids on growth over one year. In view of parents' and clinicians' concerns, lack of or incomplete reporting of growth is a matter of concern given the importance of the topic. We recommend that growth be systematically reported in all trials involving children taking ICS for three months or longer. Until further data comparing low versus high ICS dose and trials of longer duration are available, we recommend that the minimal effective ICS dose be used in all children with asthma.

Inhaled corticosteroids in children with persistent asthma: dose-response effects on growth

BACKGROUND

Inhaled corticosteroids (ICS) are the first-line treatment for children with persistent asthma. Their potential for growth suppression remains a matter of concern for parents and physicians.

OBJECTIVES

To assess whether increasing the dose of ICS is associated with slower linear growth, weight gain and skeletal maturation in children with asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov website up to March 2014.

SELECTION CRITERIA

Studies were eligible if they were parallel-group randomised trials evaluating the impact of different doses of the same ICS using the same device in both groups for a minimum of three months in children one to 17 years of age with persistent asthma.

DATA COLLECTION AND ANALYSIS

Two review authors ascertained methodological quality independently using the Cochrane Risk of bias tool. The primary outcome was linear growth velocity. Secondary outcomes included change over time in growth velocity, height, weight, body mass index and skeletal maturation.

MAIN RESULTS

Among 22 eligible trials, 17 group comparisons were derived from 10 trials (3394 children with mild to moderate asthma), measured growth and contributed data to the meta-analysis. Trials used ICS (beclomethasone, budesonide, ciclesonide, fluticasone or mometasone) as monotherapy or as combination therapy with a long-acting beta2-agonist and generally compared low (50 to 100 μg) versus low to medium (200 μg) doses of hydrofluoroalkane (HFA)-beclomethasone equivalent over 12 to 52 weeks. In the four comparisons reporting linear growth over 12 months, a significant group difference was observed, clearly indicating lower growth velocity in the higher ICS dose group of 5.74 cm/y compared with 5.94 cm/y on lower-dose ICS (N = 728 school-aged children; mean difference (MD)0.20 cm/y, 95% confidence interval (CI) 0.02 to 0.39; high-quality evidence): No statistically significant heterogeneity was noted between trials contributing data. The ICS molecules (ciclesonide, fluticasone, mometasone) used in these four comparisons did not significantly influence the magnitude of effect (X(2) = 2.19 (2 df), P value 0.33). Subgroup analyses on age, baseline severity of airway obstruction, ICS dose and concomitant use of non-steroidal antiasthmatic drugs were not performed because of similarity across trials or inadequate reporting. A statistically significant group difference was noted in unadjusted change in height from zero to three months (nine comparisons; N = 944 children; MD 0.15, 95% CI -0.28 to -0.02; moderate-quality evidence) in favour of a higher ICS dose. No statistically significant group differences in change in height were observed at other time points, nor were such differences in weight, bone mass index and skeletal maturation reported with low quality of evidence due to imprecision.

AUTHORS' CONCLUSIONS

In prepubescent school-aged children with mild to moderate persistent asthma, a small but statistically significant group difference in growth velocity was observed between low doses of ICS and low to medium doses of HFA-beclomethasone equivalent, favouring the use of low-dose ICS. No apparent difference in the magnitude of effect was associated with three molecules reporting one-year growth velocity, namely, mometasone, ciclesonide and fluticasone. In view of prevailing parents' and physicians' concerns about the growth suppressive effect of ICS, lack of or incomplete reporting of growth velocity in more than 86% (19/22) of eligible paediatric trials, including those using beclomethasone and budesonide, is a matter of concern. All future paediatric trials comparing different doses of ICS with or without placebo should systematically document growth. Findings support use of the minimal effective ICS dose in children with asthma.

Placebo effect model in asthma clinical studies: longitudinal meta-analysis of forced expiratory volume in 1 second

OBJECTIVE

Our objective was to describe the time course of the placebo effect in asthma and quantitatively investigate the affective factors of the placebo effect for the placebo response simulation during the asthma clinical study design.

METHODS

We conducted a systemic search of public data sources for the study-level forced expiratory volume in 1 second (FEV(1)) to build the placebo effect model for studies by oral or inhaled administrations simultaneously. The administration routes, types of inhalation device, mean patient age, mean male proportion, baseline FEV(1), disease severity, year of publication, inhaled corticosteroid status during the treatment, and dropout rate were tested as covariates.

RESULTS

There are 34 literature sources containing 178 mean values for FEV(1) presenting the individual observations from about 3,703 patients. The exponential models adequately described the time course of placebo effect with the typical value of the maximum placebo effect (P(max)) of 0.060 L. Dropout rate incorporated in the residual error model and the disease severity (mild to moderate and moderate to severe) at baseline were covariates that remained in the final model.

CONCLUSIONS

The placebo effect is adequately described by an exponential model over time. By incorporating the dropout rate in the residual error model, the estimation precision was improved. The model could predict the placebo response profile in mild to severe asthmatic patients for the asthma clinical study design and could also be a structure model of the placebo effect for the pure drug effect evaluation in the asthma clinical trials.

Adherence to inhaled corticosteroids: comparison of available therapies

Adherence to daily anti-inflammatory therapy, the cornerstone being inhaled corticosteroids (ICSs), is critical for the control of persistent asthma. Many factors, both behavioral and treatment-related, can affect treatment adherence. In the pediatric population, adherence is often the responsibility of parents/caregivers. Thus, parents may need improved awareness of the major asthma controller medications, especially regarding the efficacy and safety of ICSs; their beliefs or concerns regarding asthma therapy have a bearing on their diligence in encouraging adherence with the prescribed treatment regimen. Dosing complexity and factors relating to inhaler use are also important components of adherence. There are currently 6 ICSs (excluding nebulized ICSs) approved for children in the United States. The purpose of this review is to examine and compare the features of the available ICSs that may influence adherence in the treatment of pediatric asthma.

Relative systemic availability of budesonide in patients with asthma after inhalation from two dry powder inhalers

BACKGROUND

To improve dosing consistency and product features, budesonide inhalation powder delivered via a dry powder inhaler (DPI) (DPI-A 200 microg) was redesigned to include lactose, a newly shaped mouthpiece, and a new dose indicator (DPI-B). Budesonide DPI-B is available in two strengths (90 microg, 180 microg).

OBJECTIVE

To compare the relative rate and extent of the systemic availability of budesonide inhaled via DPI-A and DPI-B and test for systemic absorption bioequivalence.

METHODS

Adults (n = 37) with asthma as defined by the American Thoracic Society were randomized in an open-label, crossover, single-center, single-dose study to budesonide DPI-A 200 microg x 4 inhalations, budesonide DPI-B 180 microg x 4 inhalations, or budesonide DPI-B 90 microg x 8 inhalations, on 3 days, each separated by a washout period of >or= 5 days. Plasma samples were collected immediately before and up to 12 h after dosing. Primary pharmacokinetic variables were area under the drug plasma concentration-time curve from 0 to infinity (AUC(0-infinity)) and maximum plasma concentration (C(max)); plasma concentration at 12 h (C(12h)) and time to maximum plasma concentration (T(max)) were secondary variables. Treatments were considered bioequivalent if the 90% confidence intervals (CIs) for their AUC(0-infinity) and C(max) ratios fell between 80 and 125%. Adverse events were collected.

RESULTS

The 90% CIs for the ratios of AUC(0-infinity) and C(max) for budesonide DPI-A 200 microg and DPI-B 180 microg and for both budesonide DPI-B strengths fell between 80% and 125% (AUC(0-infinity): budesonide DPI-B 180 microg x 4/DPI-A 200 microg x 4: 96.3% [90% CI: 90.9, 102.1]; budesonide DPI-B 180 microg x 4/DPI-B 90 microg x 8: 92.2% [90% CI: 87.0, 97.7]; C(max): (budesonide DPI-B 180 microg x 4/DPI-A 200 microg x 4: 100.4% [95% CI: 92.1, 109.4]; budesonide DPI-B 180 microg x 4/DPI-B 90 microg x 8: 94.4% [90% CI: 86.6, 102.9]). No differences in C(12h) and T(max) were found between treatments. All treatments were well tolerated.

CONCLUSIONS

Budesonide DPI-A 200 mug and DPI-B 180 mug have systemic absorption bioequivalence, and DPI-B 90 microg and 180 microg are dose-strength equivalent when administered at the same dose. These results may not be generalized to all patients with asthma, as this analysis included only patients with mild-to-moderate asthma aged >or= 19 years.