Inhaled salmeterol/fluticasone propionate combination. A pharmacoeconomic review of its use in the management of asthma

Importance of allergen–environment interactions in epidemic thunderstorm asthma

Australia is home to one of the highest rates of allergic rhinitis worldwide. Commonly known as ‘hay fever’, this chronic condition affects up to 30% of the population and is characterised by sensitisation to pollen and fungal spores. Exposure to these aeroallergens has been strongly associated with causing allergic reactions and worsening asthma symptoms. Over the last few decades, incidences of respiratory admissions have risen due to the increased atmospheric concentration of airborne allergens. The fragmentation and dispersion of these allergens is aided by environmental factors like rainfall, temperature and interactions with atmospheric aerosols. Extreme weather parameters, which continue to become more frequent due to the impacts of climate change, have greatly fluctuated allergen concentrations and led to epidemic thunderstorm asthma (ETSA) events that have left hundreds, if not thousands, struggling to breathe. While a link exists between airborne allergens, weather and respiratory admissions, the underlying factors that influence these epidemics remain unknown. It is important we understand the potential threat these events pose on our susceptible populations and ensure our health infrastructure is prepared for the next epidemic.

Omalizumab for Severe Asthma: Beyond Allergic Asthma

Different subsets of asthma patients may be recognized according to the exposure trigger and the frequency and severity of clinical signs and symptoms. Regarding the exposure trigger, generally asthma can be classified as allergic (or atopic) and nonallergic (or nonatopic). Allergic and nonallergic asthma are distinguished by the presence or absence of clinical allergic reaction and in vitro IgE response to specific aeroallergens. The mechanisms of allergic asthma have been extensively studied with major advances in the last two decades. Nonallergic asthma is characterized by its apparent independence from allergen exposure and sensitization and a higher degree of severity, but little is known regarding the underlying mechanisms. Clinically, allergic and nonallergic asthma are virtually indistinguishable in exacerbations, although exacerbation following allergen exposure is typical of allergic asthma. Although they both show several distinct clinical phenotypes and different biomarkers, there are no ideal biomarkers to stratify asthma phenotypes and guide therapy in clinical practice. Nevertheless, some biomarkers may be helpful to select subsets of atopic patients which might benefit from biologic agents, such as omalizumab. Patients with severe asthma, uncontrolled besides optimal treatment, notwithstanding nonatopic, may also benefit from omalizumab therapy, although currently there are no randomized double-blind placebo controlled clinical trials to support this suggestion. However, omalizumab discontinuation according to each patient's response to therapy and pharmacoeconomical analysis are questions that remain to be answered.

Burden of illness of patients with allergic asthma versus non-allergic asthma

OBJECTIVE

Allergic and non-allergic asthma share similar symptoms, but differ in that allergic asthma is triggered by inhaled allergens. This study compared healthcare resource utilization (HCRU) and costs between these groups using US employer-based claims data.

METHODS

Health insurance claims from Truven Marketscan database (2002Q1-2010Q2) were analyzed. Included patients had ≥2 asthma diagnoses and ≥1 year of eligibility prior to and following the date of first asthma diagnosis. Patients with ≥1 diagnosis for allergic asthma and ≥1 diagnosis for other allergic conditions formed the allergic asthma cohort whereas patients without any of these diagnoses formed the non-allergic asthma cohort. Allergic and non-allergic asthma patients were matched 1:1. HCRU and costs during the study period were compared between cohorts using incidence rate ratios (IRR) and bootstrap methods.

RESULTS

Sixty four thousand four hundred and seventy three allergic and non-allergic asthma patients were matched (mean age = 30; 57.1% female; mean CCI = 0.2), with 7.1% and 0.36% having received an allergy test during the baseline period, respectively. During the study period, allergic asthma patients had significantly more asthma-related pharmacy dispensings (IRR[95% CI] = 2.25[2.22-2.28], p < 0.001) and asthma-related outpatient visits (IRR[95% CI] = 2.29[2.27-2.32], p < 0.001). Allergic asthma patients incurred 39% greater per-patient-per-year all-cause costs (allergic: $4008; non-allergic: $2889, p < 0.001) and 79% greater asthma-related costs (allergic: $1063; non-allergic: $592, p < 0.001) than non-allergic asthma patients.

CONCLUSIONS

These results indicate, even in a relatively healthy population, allergic asthma is associated with greater HCRU and costs. Guideline-recommended IgE allergy tests should be employed in distinguishing the two forms of asthma, to optimize patient management and reduce costs.

Cost-effectiveness of Advair: fluticasone propionate and salmeterol combination

The National Heart, Lung and Blood Institute guidelines for the treatment of asthma suggest that inhaled corticosteroids, with the addition of a long-acting bronchodilator, may be the most effective long-term control medication for asthma. Five inhaled corticosteroids are approved for use in the USA, including beclomethasone dipropionate, budesonide, flunisolide, triamcinolone acetonide and fluticasone propionate. Fluticasone propionate (Flixotide) and the long-acting beta2 agonist salmeterol (Serevent), are now available in the USA together in an easy to use dry powder inhaler Advair. The cost-effectiveness of this combination in the treatment of persistent asthma is reviewed. This review evaluates all the cost-effectiveness studies comparing fluticasone propionate and salmeterol from two separate inhalers or one single inhaler available in the literature. Cost-effectiveness was compared with inhaled corticosteroids alone, leukotriene receptor antagonists and other combination therapies in patients with persistent asthma.

Fluticasone versus placebo for chronic asthma in adults and children

BACKGROUND

Inhaled fluticasone propionate (FP) is a relatively new inhaled corticosteroid for the treatment of asthma.

OBJECTIVES

To assess efficacy and safety outcomes in studies that compared FP to placebo for treatment of chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register (January 2008), reference lists of articles, contacted trialists and searched abstracts of major respiratory society meetings (1997-2006).

SELECTION CRITERIA

Randomised trials in children and adults comparing FP to placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and risk of bias.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data. Quantitative analyses were undertaken using Review Manager software.

MAIN RESULTS

Eighty-six studies met the inclusion criteria, recruiting 16,160 participants. In non-oral steroid treated asthmatics with mild and moderate disease FP resulted in improvements from baseline compared with placebo across all dose ranges (100 to 1000 mcg/d) in FEV1 (between 0.1 to 0.43 litres); morning PEF (between 23 and 46 L/min); symptom scores (based on a standardised scale, between 0.44 and 0.7); reduction in rescue beta-2 agonist use (between 1 and 1.4 puffs/day). High dose FP increased the number of patients who could withdraw from prednisolone: FP 1000-1500 mcg/day Peto Odds Ratio 14.07 (95% CI 7.17 to 27.57). FP at all doses led to a greater likelihood of sore throat, hoarseness and oral Candidiasis.

AUTHORS' CONCLUSIONS

Doses of FP in the range 100-1000 mcg/day are effective. In most patients with mild-moderate asthma improvements with low dose FP are only a little less than those associated with high doses when compared with placebo. High dose FP appears to have worthwhile oral-corticosteroid reducing properties. FP use is accompanied by an increased likelihood of oropharyngeal side effects.

Long-acting beta2-agonists for chronic asthma in adults and children where background therapy contains varied or no inhaled corticosteroid

BACKGROUND

Asthma is a common respiratory disease among both adults and children and short acting inhaled beta-2 agonists are used widely for 'reliever' bronchodilator therapy. Long acting beta-2 agonists (LABA) were introduced as prospective 'symptom controllers' in addition to inhaled corticosteroid 'preventer' therapy (ICS). In this updated review we have included studies in which patients were either not on ICS as a group, or in which some patients, but not all, were on ICS to complement previous systematic reviews of studies where LABA was given in patients uniformly receiving ICS. We have focussed particularly on serious adverse events, given previous concerns about potential risks, especially of death, from regular beta-2 agonist use.

OBJECTIVES

This review aimed to determine the benefit or detriment on the primary outcome of asthma control with the regular use of LABA compared with placebo, in mixed populations in which only some were taking ICS and in populations not using ICS therapy.

SEARCH STRATEGY

We carried out searches using the Cochrane Airways Group trial register, most recently in October 2005. We searched bibliographies of identified RCTs for additional relevant RCTs and contacted authors of identified RCTs for other published and unpublished studies.

SELECTION CRITERIA

All randomised studies of at least four weeks duration, comparing a LABA given twice daily with a placebo, in chronic asthma. Selection criteria to this updated review have been altered to accommodate recently published Cochrane reviews on combination and addition of LABA to ICS therapy. Studies in which all individuals were uniformly taking ICS were excluded from this review.

DATA COLLECTION AND ANALYSIS

Two reviewers performed data extraction and study quality assessment independently. We contacted authors of studies for missing data.

MAIN RESULTS

Sixty-seven studies (representing 68 experimental comparisons) randomising 42,333 participants met the inclusion criteria. Salmeterol was used as long-acting agent in 50 studies and formoterol fumarate in 17. The treatment period was four to nine weeks in 29 studies, and 12 to 52 weeks in 38 studies. Twenty-four studies did not permit the use of ICS, and forty permitted either inhaled corticosteroid or cromones (in three studies this was unclear). In these studies between 22% and 92% were taking ICS, with a median of 62%. There were significant advantages to LABA treatment compared to placebo for a variety of measurements of airway calibre including morning peak expiratory flow (PEF), evening PEF and FEV1. They were associated with significantly fewer symptoms, less use of rescue medication and higher quality of life scores. This was true whether patients were taking LABA in combination with ICS or not. Findings from SMART (a recently published surveillance study) indicated significant increases in asthma related deaths, respiratory related deaths and combined asthma related deaths and life threatening experiences. The absolute increase in asthma-related mortality was consistent with an increase of around one per 1250 patients treated with LABA for six months, but the confidence intervals are wide (from 700 to 10,000). Post-hoc exploratory subgroups suggested that African-Americans and those not on inhaled corticosteroids were at particular risk for the primary end-point of death or life-threatening asthma event. There was also a suggestion of an increase in exacerbation rate in children. Pharmacologically predicted side effects such as headache, throat irritation, tremor and nervousness were more frequent with LABA treatment.

AUTHORS' CONCLUSIONS

LABA are effective in the control of chronic asthma in the "real-life" subject groups included. However there are potential safety issues which call into question the safety of LABA, particularly in those asthmatics who are not taking ICS, and it is not clear why African-Americans were found to have significant differences in comparison to Caucasians for combined respiratory-related death and life threatening experiences, but not for asthma-related death.

Fluticasone versus placebo for chronic asthma in adults and children

BACKGROUND

Inhaled fluticasone propionate (FP) is a relatively new inhaled corticosteroid for the treatment of asthma.

OBJECTIVES

1. To assess efficacy and safety outcomes in studies that compared FP to placebo for treatment of chronic asthma.2. To explore the presence of a dose-response effect.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register (January 2005), reference lists of articles, contacted trialists and searched abstracts of major respiratory society meetings (1997-2004).

SELECTION CRITERIA

Randomised trials in children and adults comparing FP to placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data. Quantitative analyses were undertaken using RevMan 4.2

MAIN RESULTS

Seventy-five studies met the inclusion criteria (14,208 participants). Methodological quality was high. In non-oral steroid treated asthmatics with mild and moderate disease FP resulted in improvements from baseline compared with placebo across all dose ranges (100 to 1000 mcg/d) in FEV1 (between 0.13 to 0.45 litres); morning PEF (between 23 and 47 L/min); symptom scores (based on a standardised scale, between 0.5 and 0.85); reduction in rescue beta-2 agonist use (between 1.2 and 2.2 puffs/day). High dose FP increased the number of patients who could withdraw from prednisolone: FP 1000-1500 mcg/day Peto Odds Ratio 14.07 (95% CI 7.17 to 27.57). FP at all doses led to a greater likelihood of sore throat, hoarseness and oral Candidiasis. Twenty-one patients would need to be treated for one extra to develop Candidiasis (FP 500 mcg/day), whilst only three or four patients need to be treated to avoid one extra patient being withdrawn due to lack of efficacy at all doses of FP.

AUTHORS' CONCLUSIONS

Doses of FP in the range 100-1000 mcg/day are effective. In most patients with mild-moderate asthma improvements with low dose FP are only a little less than those associated with high doses when compared with placebo. High dose FP appears to have worthwhile oral-corticosteroid reducing properties. FP use is accompanied by an increased likelihood of oropharyngeal side effects.

Fast and Sustained Efficacy of Levetiracetam during Titration and the First 3 Months of Treatment in Refractory Epilepsy

PURPOSE

To investigate whether the efficacy of levetiracetam (LEV) is sustained in adult patients with refractory partial seizures over a 3-month period.

METHODS

Treatment effect was assessed in a post hoc analysis by determining the proportion of seizure-free days during each week of a 3-month period after the initiation of treatment. Pooled data from three randomized, double-blind, placebo-controlled trials (n = 883) were analyzed.

RESULTS

The mean proportion of seizure-free days was greater in the LEV group than in the placebo group. The difference, which was statistically significant, was observed as early as the first week after the initiation of treatment. It was higher in the first week of treatment and subsequently was maintained for each week over the 3-month period (p < 0.001 or p = 0.002 at each time point). Patients in the LEV group had on average 74% to 81% days each week without any seizure, compared with 69% to 72% in the placebo group.

CONCLUSIONS

LEV is efficient in controlling seizures from the first week of drug initiation, during uptitration, and throughout the first 3 months of treatment. An interesting amplification of efficacy occurs in the first week of therapy, which is intriguing and warrants further investigation.

Combination therapy of long-acting beta2-adrenoceptor agonists and corticosteroids for asthma

Twice-daily combination therapy of inhaled corticosteroids and long-acting beta2-adrenoceptor agonists (LABA) is now established as a most effective treatment for moderate to severe asthma and is available in a combined single inhaler. The benefits of combination therapy include better day-to-day control and a reduction in exacerbations compared with monotherapy with inhaled corticosteroids at a lower dose. Total control of asthma, defined as no daytime or night-time symptoms, no use of rescue beta2-adrenoceptor agonists (beta2-agonists), no exacerbations and a peak flow rate of >80% predicted, may be achieved with the use of combined salmeterol/fluticasone in up to 41% of patients with moderate to severe asthma, compared with only 28% of patients treated with fluticasone alone. Adjustable maintenance dosing with budesonide/formoterol may provide better control when compared with fixed-dosing combination regimens. Other therapies combining effectively with inhaled corticosteroids include slow-release theophylline and leukotriene inhibitors, montelukast and zafirlukast, but LABA are the most efficacious. Molecular interactions between corticosteroids and beta2-adrenoceptors may underlie the clinical added benefits of combination therapy. Corticosteroids may increase the number of beta2-adrenoceptors and their coupling with Gs proteins, while beta2-agonists may induce glucocorticoid receptor nuclear translocation, activate transcription factor/enhancer binding protein C/EBPalpha together with corticosteroids, or phosphorylate corticosteroid receptors. The combination of corticosteroids and LABA potentiates inhibition of interleukin-8 and eotaxin release from human airway smooth muscle cells and granulocyte-macrophage colony-stimulating factor release from epithelial cells, and also the inhibition of airway smooth muscle cell proliferation. It is important to determine whether there is a potentiating effect of combination therapy compared with corticosteroid treatment alone on airway inflammation and airway wall remodelling. Improvements in combination therapy include a once-daily preparation and possible combination of inhaled corticosteroids with newer drugs such as phosphodiesterase IV inhibitors.

Budesonide/formoterol: a review of its use in asthma

Budesonide and formoterol have been combined in a single dry powder device, Symbicort Turbuhaler (budesonide/formoterol 160/9-640/18 microg/day), in an effort to simplify asthma management. The efficacy of budesonide/formoterol as maintenance therapy in patients with asthma has been examined in several randomised studies.Twice-daily budesonide/formoterol was significantly more effective than an equivalent or higher daily dose of budesonide alone or high-dose fluticasone propionate alone at improving peak expiratory flow (PEF) in adults with predominantly moderate persistent asthma. Symptom control and the risk of mild exacerbations were significantly improved versus budesonide alone. Moreover, budesonide/formoterol appeared to be as effective as concurrent therapy with equivalent dosages of budesonide and formoterol administered via separate inhalers in adults with moderate persistent asthma. Budesonide/formoterol administered once daily was as effective as twice-daily administration (equivalent daily doses) and more effective than once-daily budesonide in adults with moderate persistent asthma. Twice-daily budesonide/formoterol significantly improved PEF compared with budesonide in paediatric patients with asthma. Adjustable maintenance dosing with budesonide/formoterol was associated with significantly less study drug use than fixed dosing with budesonide/formoterol in adults with predominantly mild or moderate persistent asthma. In two of three studies (all longer than 4 months' duration), the risk of exacerbations was significantly lower with adjustable than with fixed dosing, but no difference was detected in four short-term studies. Symptom severity was maintained or improved in most patients receiving either treatment regimen. In adults with moderate-to-severe persistent asthma, adjustable maintenance dosing with budesonide/formoterol reduced the rate of exacerbations and reliever medication use compared with fixed dosing with salmeterol/fluticasone propionate. Budesonide/formoterol was well tolerated in both fixed and adjustable dosing regimens. In conclusion, in patients with persistent asthma symptoms despite treatment with inhaled corticosteroids, budesonide/formoterol administered via a single dry powder Turbuhaler device is an effective, well tolerated, convenient treatment option, which may have the potential for improved compliance. It appears to be as effective as treatment with budesonide and formoterol administered via separate inhalers and is more effective than budesonide monotherapy in improving PEF, controlling symptoms and preventing mild exacerbations. Adjustable maintenance dosing with budesonide/formoterol is associated with a lower overall dosage and appears to maintain control as effectively as fixed dosing.

Seizure-free Days Observed in Randomized Placebo-controlled Add-on Trials with Levetiracetam in Partial Epilepsy

PURPOSE

We examined the effect of adjunctive levetiracetam (LEV; 1,000 to 3,000 mg/day) on the number of seizure-free days gained per quarter in adult patients with refractory partial-onset epilepsy.

METHODS

The treatment effect was studied in a meta-analysis using individual patient data of a subpopulation of patients (n = 846) emerging from the three randomized, double-blind, placebo-controlled, phase III trials (n = 904).

RESULTS

Adding LEV effectively increased the number of days without seizures by 5.19 days per quarter [95% confidence interval (CI), 3.63-6.76; p = 0.0001; titration and stable dose periods].

CONCLUSIONS

LEV adjunctive treatment shows a clear benefit in terms of seizure-free days gained for patients with refractory epilepsy. This gain is significant for the pooled and for each LEV dose compared with placebo.

Fluticasone versus salmeterol/low-dose fluticasone for long-term asthma control

OBJECTIVE

To evaluate the relative clinical superiority of increasing the dose of fluticasone propionate versus the addition of salmeterol to low-dose fluticasone propionate for long-term asthma control.

DATA SOURCES

Literature was identified by a MEDLINE search (1966-October 2002). Key search terms included asthma, inhalation, corticosteroid, beta-adrenergic agonist, and combination drug therapy.

DATA SYNTHESIS

Current guidelines for long-term control of asthma include treatment with either inhaled corticosteroids (medium dose) or inhaled corticosteroids (low to medium dose) in combination with a long-acting bronchodilator. Previous studies evaluating salmeterol or formoterol combination therapy with beclomethasone or budesonide have generally produced superior results compared with increasing the dose of the inhaled corticosteroid. Four recent controlled clinical trials have compared the clinical utility of fluticasone propionate monotherapy versus salmeterol/low-dose fluticasone propionate for long-term asthma control in patients with moderate to severe persistent asthma. Based on spirometry data, rescue albuterol use, and symptom scores, the addition of salmeterol to low-dose fluticasone propionate was superior to increasing the dose of fluticasone propionate.

CONCLUSIONS

Based on improvements in forced expiratory volume in 1 second, peak expiratory flow, and symptom control, the addition of salmeterol to low-dose fluticasone propionate provides better control of asthma than increasing the dose of fluticasone propionate.

Recent advances in diagnosis and management of chronic bronchitis and emphysema

Chronic obstructive pulmonary disease is a progressive inflammatory disease of the airways and lung parenchyma. Expiratory airflow limitation is the hallmark of chronic obstructive pulmonary disease. It is a significant cause of morbidity and mortality in the United States and worldwide and results in a large consumption of health care resources. Unfortunately, despite efforts to curb this disease, its prevalence is increasing. The diagnosis is usually made when the patient complains of dyspnea on exertion; by this time, irreversible structural damage to the lung has already occurred. Given the nonspecific symptoms of the disease and the inability to effectively treat and reverse the damage, it is essential to diagnose the disease in its early stages and take the necessary preventive measures, thus avoiding disability or death. This review summarizes the latest developments in the diagnosis and management of chronic obstructive pulmonary disease. The first half of the review discusses functional, radiographic, biochemical, and cellular/histopathologic issues in the diagnosis of chronic obstructive pulmonary disease. The second half focuses on the current pharmacologic and nonpharmacologic advances in chronic obstructive pulmonary disease, including the role of respiratory support and surgical treatment. Based on the research on the cellular mechanisms of chronic obstructive pulmonary disease, the review also makes a reference to novel and experimental therapies for chronic obstructive pulmonary disease.