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Baker JA. 2022 Year in Review: Pediatric Asthma. Respir Care 2023; 68:1430-1437. [PMID: 37160339 PMCID: PMC10506641 DOI: 10.4187/respcare.10913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Asthma is the most common chronic disease in children. Asthma is a heterogeneous disease characterized by variable, reversible airway obstruction and hyper-responsive airways. There is a high economic burden due to a child having poorly controlled asthma with one or more asthma exacerbations resulting in an emergency department visit or hospitalization in a year. Publications on diagnosis, treatment, and management of pediatric asthma are ongoing with over 2,549 papers published from January-November 2022. The intent of this paper is to summarize 8 key topics that have prompted discussions with local, regional, and national asthma experts due to a shift in clinical practice or lessons learned from the recent pandemic that may have future application.
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Affiliation(s)
- Joyce A Baker
- Breathing Institute, Children's Hospital Colorado, Aurora, Colorado.
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Muiser S, Imkamp K, Seigers D, Halbersma NJ, Vonk JM, Luijk BHD, Braunstahl GJ, van den Berg JW, Kroesen BJ, Kocks JWH, Heijink IH, Reddel HK, Kerstjens HAM, van den Berge M. Budesonide/formoterol maintenance and reliever therapy versus fluticasone/salmeterol fixed-dose treatment in patients with COPD. Thorax 2023; 78:451-458. [PMID: 36725331 DOI: 10.1136/thorax-2022-219620] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/19/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Maintenance and reliever therapy (MART) with inhaled corticosteroid (ICS)/formoterol effectively reduces exacerbations in asthma. We aimed to investigate its efficacy compared with fixed-dose fluticasone/salmeterol in chronic obstructive pulmonary disease (COPD). METHODS Patients with COPD and ≥1 exacerbation in the previous 2 years were randomly assigned to open-label MART (Spiromax budesonide/formoterol 160/4.5 µg 2 inhalations twice daily+1 prn) or fixed-dose therapy (Diskus fluticasone propionate/salmeterol combination (FSC) 500/50 µg 1 inhalation twice daily+salbutamol 100 µg prn) for 1 year. The primary outcome was rate of moderate/severe exacerbations, defined by treatment with oral prednisolone and/or antibiotics. RESULTS In total, 195 patients were randomised (MART Bud/Form n=103; fixed-dose FSC n=92). No significant difference was seen between MART and FSC therapy in exacerbation rates (1.32 vs 1.32 /year, respectively, rate ratio 1.05 (95% CI 0.79 to 1.39); p=0.741). No differences in lung function parameters or health status were observed. Total ICS dose was significantly lower with MART than FSC therapy (budesonide-equivalent 928 µg/day vs 1747 µg/day, respectively, p<0.05). Similar proportions of patients reported adverse events (MART Bud/Form: 73% vs fixed-dose FSC: 68%, p=0.408) and pneumonias (MART: 5% vs FSC: 1%, p=0.216). CONCLUSIONS This first study of MART in COPD found that budesonide/formoterol MART might be similarly effective to fluticasone/salmeterol fixed-dose therapy in moderate to severe patients with COPD, at a lower daily ICS dosage. Further evidence is needed about long-term safety.
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Affiliation(s)
- Susan Muiser
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands .,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Kai Imkamp
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Dianne Seigers
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Nynke J Halbersma
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Judith M Vonk
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart H D Luijk
- Department of Pulmonology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | | | - Bart-Jan Kroesen
- Laboratory of Medical Immunology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Janwillem W H Kocks
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,General Practitioners Research Institute, Groningen, The Netherlands.,Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | - Irene H Heijink
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Pathology and Medical Biology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Helen K Reddel
- Woolcock Institute of Medical Research, Glebe, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Huib A M Kerstjens
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten van den Berge
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Baker JA, Houin PR. Comparison of National and Global Asthma Management Guiding Documents. Respir Care 2023; 68:114-128. [PMID: 36566032 PMCID: PMC9993509 DOI: 10.4187/respcare.10254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Asthma is a common chronic disease that affects both adults and children, and that continues to have a high economic burden. Asthma management guidelines were first developed nearly 30 years ago to standardize care, maintain asthma control, improve quality of life, maintain normal lung function, prevent exacerbations, and prevent asthma mortality. The two most common asthma guidelines used today were developed by the National Asthma Education and Prevention Program (NAEPP) Expert Panel Working Group and the Global Initiative for Asthma Science Committee. Both guiding documents use scientific methodology to standardize their approach for formulating recommendations based on pertinent literature. Before the 2020 National Asthma Education and Prevention Program (Expert Panel Report 4), nothing had been released since the 2007 guidelines, whereas the Global Initiative for Asthma publishes updates annually. Although each of these asthma strategies is similar, there are some noted differences. Over the years, the focus of asthma treatment has shifted from acute to chronic management. Frontline respiratory therapists and other health-care providers should have a good understanding of these 2 guiding references and how they can impact acute and chronic asthma management. The primary focus of this narrative is to look at the similarities and differences of these 2 guiding documents as they pertain to the 6 key questions identified by the Expert Panel of the National Asthma Education and Prevention Program.
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Affiliation(s)
- Joyce A Baker
- Breathing Institute, Children's Hospital Colorado, Aurora, Colorado.
| | - Paul R Houin
- Breathing Institute, Children's Hospital Colorado, Aurora, Colorado
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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SMART - is it practical in the United States? Curr Opin Pulm Med 2022; 28:245-250. [PMID: 35131990 DOI: 10.1097/mcp.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The 2020 focused updates to the asthma management guidelines by the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group advocate for inhaled corticosteroid (ICS)-formoterol combinations as single maintenance and reliever therapy (SMART) for patients with persistent asthma. We review the rationale, the evidence supporting SMART use in asthma, and barriers limiting its wide adoption in the United States. RECENT FINDINGS A growing body of evidence supports the use of SMART over the conventional use of controller medicaments with an as-needed short-acting β2 agonist for rescue therapy for the purpose of reducing the risk of asthma exacerbation and maintaining asthma control in adolescents and adults with persistent disease. Lack of US Food and Drug Administration approval, inconsistent insurance coverage, and limited options of ICS-formoterol combination available for use as SMART represent obstacles to wider integration of SMART in clinical practice. SUMMARY SMART represents a paradigm shift in asthma management. By identifying and addressing the current and anticipated barriers to implementing SMART, its adoption by providers is likely to increase in the United States.
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Abstract
Airway inflammation is a major contributing factor in both asthma and chronic obstructive pulmonary disease (COPD) and represents an important target for treatment. Inhaled corticosteroids (ICS) as monotherapy or in combination therapy with long-acting β2-agonists or long-acting muscarinic antagonists are used extensively in the treatment of asthma and COPD. The development of ICS for their anti-inflammatory properties progressed through efforts to increase topical potency and minimise systemic potency and through advances in inhaled delivery technology. Budesonide is a potent, non-halogenated ICS that was developed in the early 1970s and is now one of the most widely used lung medicines worldwide. Inhaled budesonide's physiochemical and pharmacokinetic/pharmacodynamic properties allow it to reach a rapid and high airway efficacy due to its more balanced relationship between water solubility and lipophilicity. When absorbed from the airways and lung tissue, its moderate lipophilicity shortens systemic exposure, and its unique property of intracellular esterification acts like a sustained release mechanism within airway tissues, contributing to its airway selectivity and a low risk of adverse events. There is a large volume of clinical evidence supporting the efficacy and safety of budesonide, both alone and in combination with the fast- and long-acting β2-agonist formoterol, as maintenance therapy in patients with asthma and with COPD. The combination of budesonide/formoterol can also be used as an as-needed reliever with anti-inflammatory properties, with or without regular maintenance for asthma, a novel approach that is already approved by some country-specific regulatory authorities and currently recommended in the Global Initiative for Asthma (GINA) guidelines. Budesonide remains one of the most well-established and versatile of the inhaled anti-inflammatory drugs. This narrative review provides a clinical reappraisal of the benefit:risk profile of budesonide in the management of asthma and COPD.
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Jain N, Satish K, Abhyankar N, Velayudhan N, Gurunathan J. Repeated exacerbation of asthma: An intrinsic phenotype of uncontrolled asthma. Lung India 2019; 36:131-138. [PMID: 30829247 PMCID: PMC6410599 DOI: 10.4103/lungindia.lungindia_434_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Asthma is a chronic disease of the airways affecting a large number of people across the globe. Uncontrolled asthma poses an emotional as well as the physical burden on patients and results in a great economic burden. “Exacerbation-prone phenotype” asthmatics are a cluster of patients who may suffer from more frequent and severe exacerbations than other asthmatics. Factors such as inadequate symptom control, improper adherence to medications, and incorrect use of inhalers are responsible for frequent asthma exacerbations. Caring for the patient with “exacerbation-prone asthma” needs participation from both the doctor as well as the patient. Self-management, improving knowledge about the disease, control of comorbidities, and a stepwise approach with the use of a single inhaler maintenance and reliever therapy in patients with severe asthma could help in delivering better care for the “exacerbation-prone phenotype” of asthmatics.
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Affiliation(s)
- Neeraj Jain
- Department of Pulmonary Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - K Satish
- Department of Pulmonary Medicine, Fortis Hospital, Cunningham Road, Bengaluru, Karnataka, India
| | - Nitin Abhyankar
- Department of Pulmonary Medicine, Poona Hospital and Research Centre, Pune, Maharashtra, India
| | - Nila Velayudhan
- Respiratory Medical Affairs, AstraZeneca Pharma India Limited, Bengaluru, Karnataka, India
| | - Jayakumar Gurunathan
- Respiratory Medical Affairs, AstraZeneca Pharma India Limited, Bengaluru, Karnataka, India
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Lin J, Zhou X, Wang C, Liu C, Cai S, Huang M. Symbicort® Maintenance and Reliever Therapy (SMART) and the evolution of asthma management within the GINA guidelines. Expert Rev Respir Med 2018; 12:191-202. [PMID: 29400090 DOI: 10.1080/17476348.2018.1429921] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The Global Initiative for Asthma (GINA) annual report summarizes the latest evidence for asthma management. GINA recommends stepwise pharmacological treatment, advocating inhaled corticosteroids (ICS) plus rapid, long-acting β2-agonists (LABA) delivered in a single inhaler for maintenance and relief at Steps 3 (moderate persistent asthma requiring 1-2 controllers plus as-needed reliever), 4 (severe persistent asthma requiring ≥2 controllers plus as-needed reliever), and 5 (higher level care and/or add-on treatment). Areas covered: Randomized controlled trials and real-world evidence demonstrate that flexibly dosed budesonide/formoterol for maintenance and relief (Symbicort® Maintenance And Reliever Therapy [SMART]) is associated with reductions in severe exacerbations, prolongs time to first exacerbation, and provides fast symptom relief. Expert commentary: SMART provides greater or equal levels of sustained asthma control than similar or higher fixed doses of ICS/LABA plus short-acting β2-agonist (SABA) as needed or higher ICS plus SABA as needed, with lower overall ICS doses and cost. The simplified dosing strategy may improve adherence and overall asthma control but relies on patient education. Budesonide/formoterol as needed in mild asthma (patients qualifying for regular low-dose ICS) is currently under investigation in two double-blind randomized studies, SYGMA1/2 (NCT02149199/NCT02224157), comparing budesonide/formoterol as needed with budesonide plus SABA and SABA alone.
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Affiliation(s)
- Jiangtao Lin
- a Department of Pulmonary and Critical Care Medicine , China-Japan Friendship Hospital , Beijing , China
| | - Xin Zhou
- b Department of Respiratory Medicine , Shanghai General Hospital , Shanghai , China
| | - Changzheng Wang
- c Department of Respiratory Medicine , Xinqiao Hospital, Third Military Medical University , Chongqing , China
| | - Chuntao Liu
- d Department of Respiratory Medicine , West China Hospital, West China School of Medicine , Chengdu , China
| | - Shaoxi Cai
- e Department of Respiratory Medicine , Nanfang Hospital, Southern Medical University , Guangzhou , China
| | - Mao Huang
- f Department of Respiratory Medicine , Jiangsu Province Hospital , Nanjing , China
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Haahtela T, Selroos O, O'Byrne PM. Revisiting early intervention in adult asthma. ERJ Open Res 2015; 1:00022-2015. [PMID: 27730140 PMCID: PMC5005140 DOI: 10.1183/23120541.00022-2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/31/2015] [Indexed: 11/13/2022] Open
Abstract
The term "early intervention" with inhaled corticosteroids (ICS) in asthma is used in different ways, thereby causing confusion and misinterpretation of data. We propose that the term should be reserved for start of ICS therapy in patients with a diagnosis of asthma but within a short period of time after the first symptoms, not from the date of diagnosis. Prospective clinical studies suggest a time frame of 2 years for the term "early" from the onset of symptoms to starting anti-inflammatory treatment with ICS. The current literature supports early intervention with ICS for all patients with asthma including patients with mild disease, who often have normal or near-normal lung function. This approach reduces symptoms rapidly and allows patients to achieve early asthma control. Later introduction of ICS therapy may not reduce effectiveness in terms of lung function but delays asthma control and exposes patients to unnecessary morbidity. Results of nationwide intervention programmes support the early use of ICS, as it significantly minimises the disease burden. Acute asthma exacerbations are usually preceded by progressing symptoms and lung function decline over a period of 1-2 weeks. Treatment with an increased dose of ICS together with a rapid- and long-acting inhaled β2-agonist during this phase has reduced the risk of severe exacerbations.
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Affiliation(s)
- Tari Haahtela
- Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Olof Selroos
- Semeco AB, Ängelholm, Sweden and Helsinki University, Helsinki, Finland
| | - Paul M. O'Byrne
- Firestone Institute for Respiratory Health, St Joseph's Hospital and McMaster University, Hamilton, ON, Canada
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Chapman KR, Barnes NC, Greening AP, Jones PW, Pedersen S. Single maintenance and reliever therapy (SMART) of asthma: a critical appraisal. Thorax 2010; 65:747-52. [PMID: 20581409 PMCID: PMC2975956 DOI: 10.1136/thx.2009.128504] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The use of a combination inhaler containing budesonide and formoterol as both maintenance and quick relief therapy (SMART) has been recommended as an improved method of using inhaled corticosteroid/long-acting β agonist (ICS/LABA) therapy. Published double-blind trials show that budesonide/formoterol therapy delivered in SMART fashion achieves better asthma outcomes than budesonide monotherapy or lower doses of budesonide/formoterol therapy delivered in constant dosage. Attempts to compare budesonide/formoterol SMART therapy with regular combination ICS/LABA dosing using other compounds have been confounded by a lack of blinding and unspecified dose adjustment strategies. The asthma control outcomes in SMART-treated patients are poor; it has been reported that only 17.1% of SMART-treated patients are controlled. In seven trials of 6–12 months duration, patients using SMART have used quick reliever daily (weighted average 0.92 inhalations/day), have awakened with asthma symptoms once every 7–10 days (weighted average 11.5% of nights), have suffered asthma symptoms more than half of days (weighted average 54.0% of days) and have had a severe exacerbation rate of one in five patients per year (weighted average 0.22 severe exacerbations/patient/year). These poor outcomes may reflect the recruitment of a skewed patient population. Although improvement from baseline has been attributed to these patients receiving additional ICS therapy at pivotal times, electronic monitoring has not been used to test this hypothesis nor the equally plausible hypothesis that patients who are non-compliant with maintenance medication have used budesonide/formoterol as needed for self-treatment of exacerbations. Although the long-term consequences of SMART therapy have not been studied, its use over 1 year has been associated with significant increases in sputum and biopsy eosinophilia. At present, there is no evidence that better asthma treatment outcomes can be obtained by moment-to-moment symptom-driven use of ICS/LABA therapy than conventional physician-monitored and adjusted ICS/LABA therapy.
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Affiliation(s)
- Kenneth R Chapman
- Asthma and Airway Centre, University Health Network, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada.
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