Current control and future risk in asthma management

Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand

OBJECTIVE

This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.

RESULTS

Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.

CONCLUSION

Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

COVID-19 Vaccination Prioritization Strategies in Malaysia: A Retrospective Analysis of Early Evidence

The coronavirus disease 2019 (COVID-19) that can cause extreme acute respiratory syndrome has posed a catastrophic threat to public health. The vaccines had indeed restored optimism and, after more than two years of battling the pandemic, there is renewed hope for the transition to endemicity. At the start of vaccination efforts, when supply shortages of vaccines were inevitable, every nation determined the high-risk population groups to be given priority for the COVID-19 vaccines. In this paper, the characteristics of the initial COVID-19 vaccine recipients in Malaysia are described. In line with the policies of many other countries, Malaysia firstly inoculated frontline healthcare workers, and subsequently the list of front liners grew to include defense and security personnel and those involved in the provision of essential services. People with disabilities or those with special needs and several underlying medical conditions that increased their risk of developing severe COVID-related illnesses were included in the priority categories. These included patients with severe lung disease, chronic heart disease, chronic kidney disease, chronic liver disease, neurological disease, diabetes mellitus and obesity in adults, splenic dysfunction, and severe mental illness. With little information and under circumstances of great uncertainty, the Health Ministry of a middle-income country had developed a vaccination priority-list based on the disease's epidemiology and clinical data, vaccine type, operational considerations, and risk evaluation. Early evidence was presented and suggested that the full vaccination with any of the three predominant vaccines (AZD1222, BNT162b2, and CoronaVac) in the country had been highly effective in preventing COVID-19 infections, COVID-19-related ICU admissions, and death. As many SARS-CoV-2 variants of concern (VoC), such as the Omicron BA.2/4/5, are emerging, future vaccination strategies may necessitate the need to change the immunogen of the vaccine, as well as considerations for when to give high-risk groups booster injections. These considerations are valuable for future planning by policymakers and healthcare providers to make vaccination policy and decisions, especially for the inclusion of the COVID-19 vaccines into national immunization programs.

Preventing unscheduled hospitalisations from asthma: a retrospective cohort study using routine primary and secondary care data in the UK (The PUSH-Asthma Study)-protocol paper

INTRODUCTION

Asthma is the most common chronic respiratory disease in children and adults. Asthma results in significant disease-related morbidity, healthcare costs and, in some cases, death. Despite efforts through implementation of national guidelines to improve asthma care, the UK has one of the highest asthma-related morbidity and mortality rates in the western world. New approaches are necessary to prevent asthma attacks in children and adults. The objectives of this study are to assess the association between demographic and clinical factors and asthma-related hospital admissions in children and adults, describe the epidemiology of asthma phenotypes among hospital attenders, and externally validate existing asthma risk prediction models.

METHODS AND ANALYSIS

This is a retrospective cohort study of children and adults with asthma. Data will be extracted from the Clinical Practice Research Datalink (CPRD) Aurum database, which holds anonymised primary care data for over 13 million actively registered patients and covers approximately 19% of the UK population. The primary outcome will be asthma-related hospital admissions. The secondary outcomes will be prescriptions of short courses of oral corticosteroids (as a surrogate measure for asthma exacerbations), a composite outcome measure including hospital admissions and prescriptions of short courses of oral corticosteroids and delivery of asthma care management following hospital discharge. The primary analysis will use a Poisson regression model to assess the association between demographic and clinical risk factors and the primary and secondary outcomes. Latent class analysis will be used to identify distinct subgroups, which will further our knowledge on potential phenotypes of asthma among patients at high risk of asthma-related hospital admissions. A Concordance statistic (C-statistic) and logistic regression model will also be used to externally validate existing risk prediction models for asthma-related hospitalisations to allow for the optimal model to be identified and evaluated provide evidence for potential use of the optimal performing risk prediction model in primary care.

ETHICS AND DISSEMINATION

This study was approved by the CPRD Independent Scientific Advisory Committee (reference number: 21_000512). Findings from this study will be published in a peer-reviewed journal and disseminated at national and international conferences.

Risk of asthma exacerbation associated with opioid and nonopioid analgesic use in children with current asthma

BACKGROUND: In the United States, asthma occurs in a vast proportion of children and adolescents. Asthma exacerbation is an acute episodic event typically characterized by difficulty in breathing, chest tightness, coughing, or wheezing. Severe asthma exacerbation can be life-threatening and lead to service utilizations such as hospitalizations and emergency department (ED) visits. Opioid analgesic use can trigger an asthma exacerbation through 2 pharmacological mechanisms. Despite the potential mechanisms, there is lack of empirical evidence to determine the risk of asthma exacerbation and its association with opioid use. OBJECTIVE: To evaluate the risk of asthma exacerbation in children with current asthma receiving an opioid vs a nonopioid analgesic. METHODS: Eligible individuals aged under 18 years with current asthma and receiving an incident analgesic prescription were identified from a large Medicaid managed care database during 2013-2018. Current asthma was defined as receipt of an asthma diagnosis and an antiasthmatic medication in the 12 months before analgesic medication initiation. Asthma exacerbation was defined as a hospitalization or ED visit with asthma as either the primary or secondary diagnosis within 3 days of receipt of an analgesic prescription. A weighted multivariable logistic regression using inverse probability treatment weighting was performed to test the association between use of analgesic medication and risk of asthma exacerbation. RESULTS: This study included 13,359 children with current asthma who filled either an incident opioid (n = 5,363, 40.1%) or nonopioid analgesic (n = 7,996, 59.9%) prescription. Asthma exacerbation was observed in 24 (0.5%) opioid analgesic recipients and 22 (0.3%) nonopioid analgesic recipients within 3 days of analgesic initiation. Weighted logistic regression results showed that children receiving opioid analgesics (adjusted odds ratio = 1.6, 95% CI = 0.9-2.9) did not have a statistically significantly higher risk of asthma exacerbation than their nonopioid analgesic recipient counterparts in the propensity score-weighted multivariable analysis. CONCLUSIONS: Asthma exacerbation associated with analgesic use in children with current asthma was an uncommon event, and the risk was comparable among children receiving opioid vs nonopioid analgesics. DISCLOSURES: This study was supported and funded by the Agency for Healthcare Research and Quality (AHRQ), Project Number: 1R03HS026790-01A1. The study content was solely the responsibility of the authors, and AHRQ had no role in the design and conduct of the study. The authors have nothing to disclose.

An Investigation on the Consciousness of Patients and Pharmacists Regarding Inhaler Education

Few studies have focused on the awareness of inhaler education in patients and pharmacists who have crucial roles in inhaler education. The aim of this study was to investigate the difference in awareness of inhaler education between patients and pharmacists. We conducted questionnaire-based surveys involving 270 patients with asthma and chronic obstructive pulmonary disease and 139 pharmacists of 13 pharmacies belonging to the same chain dispensing pharmacy in Hyogo prefecture of Japan in July 2011. We obtained valid responses from 230 patients (85.2%) and 139 pharmacists (100%). Although 75% of pharmacists provided inhaler education about the importance of continuation, only 16% of patients felt that they had learned the importance of continuation. Similarly, 95% of pharmacists provided inhaler education about the importance of gargling, however, only 57% of patients felt that they had learned the importance of gargling. This survey clarified the difference in awareness between pharmacists and patients on inhaler education. It proved to be difficult to educate patients on the importance of compliance and gargling.

Development and equivalence of new faces for inclusion in the Childhood Asthma Control Test (C-ACT) response scale

BACKGROUND

Accurate symptom monitoring is vital when managing pediatric asthma, providing an opportunity to improve control and relieve associated burden. The CHILDHOOD ASTHMA CONTROL TEST (C-ACT) has been validated for asthma control assessment in children; however, there are concerns that response option images used in the C-ACT are not culturally universal and could be misinterpreted. This cross-sectional, qualitative study developed and evaluated alternative response option images using interviews with children with asthma aged 4-11 years (and their parents/caregivers) in the United States, Spain, Poland, and Argentina. Interviews were conducted in two stages (with expert input) to evaluate the appropriateness, understanding and qualitative equivalence of the alternative images (both on paper and electronically). This included comparing the new images with the original C-ACT response scale, to provide context for equivalence results.

RESULTS

Alternative response option images included scale A (simple faces), scale B (circles of decreasing size), and scale C (squares of decreasing quantity). In Stage 1, most children logically ranked images using scales A, B and C (66.7%, 79.0% and 70.6%, respectively). However, some children ranked the images in scales B (26.7%) and C (58.3%) in reverse order. Slightly more children could interpret the images within the context of their asthma in scale B (68.4%) than A (55.6%) and C (47.5%). Based on Stage 1 results, experts recommended scales A (with slight modifications) and B be investigated further. In Stage 2, similar proportions of children logically ranked the images used in modified scales A (69.7%) and B (75.7%). However, a majority of children ranked the images in scale B in the reverse order (60.0%). Slightly more children were able to interpret the images in the context of their asthma using scale B (57.6%) than modified scale A (48.5%). Children and parents/caregivers preferred modified scale A over scale B (78.8% and 90.9%, respectively). Compared with the original C-ACT, most children selected the same response option on items using both scales, supporting equivalency. Following review of Stage 2 results, all five experts agreed modified scale A was the optimal response scale.

CONCLUSIONS

This study developed alternative response option images for use in the C-ACT and provides qualitative evidence of the equivalency of these response options to the originals.

High Use of SABAs is Associated with Higher Exacerbation Rate in Dutch Patients with Asthma

Purpose

Many patients with asthma still have insufficient disease control, despite the availability of effective treatment options. A substantial proportion of patients appear to rely more on short-acting beta₂-agonist (SABA) rather than on anti-inflammatory maintenance treatment. The aim of this study was to describe differences in indicators of asthma symptoms and exacerbations among patients using more or less SABA than the guideline-recommended threshold of <3 times/week.

Patients and Methods

Data from Dutch respondents in the European REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey were used in this post hoc analysis. The survey included asthma patients aged 18-50 years with at least two prescriptions for their asthma in the past two years. SABA use was categorized into two groups: <3 (low-SABA users) or ≥3 (high-SABA users) times in the last week.

Results

Of the 736 asthma patients, 21% did not use SABA and 19% used SABA 1 to 2 times (all low SABA users) and 60% used SABA ≥3 times (high SABA users) in the last week. The majority of high and low SABA users also reported using an ICS-containing treatment. Significant differences were found for all indicators related to exacerbations (p<0.001): high SABA users more frequently used antibiotics and oral steroids, more frequently visited the emergency departments or needed an overnight hospital stay. Indicators of asthma symptoms were not significantly different between both groups.

Conclusion

The majority of a Dutch asthmatic population reported high SABA use and had frequent moderate/severe exacerbations. More effective interventions are needed to change healthcare providers' and patients' behaviours to improve care and reduce SABA (over)use.

Small airway dysfunction and poor asthma control: a dangerous liaison

Asthma is a common chronic condition, affecting approximately 339 million people worldwide. The main goal of the current asthma treatment guidelines is to achieve clinical control, encompassing both the patient symptoms and limitations and the future risk of adverse asthma outcomes. Despite randomized controlled trials showing that asthma control is an achievable target, a substantial proportion of asthmatics remain poorly controlled in real life. The involvement of peripheral small airways has recently gained greater recognition in asthma, and many studies suggest that the persistent inflammation at these sites leads to small airway dysfunction (SAD), strongly contributing to a worse asthma control. Overall, the impulse oscillometry (IOS), introduced in the recent years, seems to be able to sensitively assess small airways, while conventional spirometry does not. Therefore, IOS may be of great help in characterizing SAD and guiding therapy choice. The aim of this article is to review the literature on SAD and its influence on asthma control, emphasizing the most recent evidence.

Impact of comorbid asthma on severity of coronavirus disease (COVID-19)

The severity of the coronavirus disease (COVID-19) is associated with various comorbidities. However, no studies have yet demonstrated the potential risk of respiratory failure and mortality in COVID-19 patients with pre-existing asthma. We selected 7272 adult COVID-19 patients from the Korean Health Insurance Review and Assessment COVID-19 database for this nationwide retrospective cohort study. Among these, 686 patients with asthma were assessed by their severities and evaluated by the clinical outcome of COVID-19 compared to patients without asthma. Of 7272 adult COVID-19 patients, 686 with asthma and 6586 without asthma were compared. Asthma was not a significant risk factor for respiratory failure or mortality among all COVID-19 patients (odds ratio [OR] = 0.99, P = 0.997 and OR = 1.06, P = 0.759) after adjusting for age, sex, and the Charlson comorbidity score. However, a history of acute exacerbation (OR = 2.63, P = 0.043) was significant risk factors for death among COVID-19 patients with asthma. Asthma is not a risk factor for poor prognosis of COVID-19. However, asthma patients who had any experience of acute exacerbation in the previous year before COVID-19 showed higher COVID-19-related mortality, especially in case of old age and male sex.

A Questionnaire Survey of the Inhalation Instruction in Pharmacies

Few studies have focused on the inhalation instruction in pharmacies which have the crucial role on the inhalation instruction. The aim of this study is to evaluate the level of knowledge and the degree of interest for asthma inhalation instruction methods among pharmacists receiving prescription from clinics. We conducted questionnaire surveys to chief pharmacists of 39 consecutive pharmacies belonging to HANSHIN Dispensing Pharmacy in Hyogo, Japan at July 2011. We obtained valid responses from 35 pharmacies. Among them, 14 pharmacies dealt with prescriptions mainly from the clinics (clinic pharmacies) and 21 pharmacies dealt with prescriptions originated from hospitals (hospital pharmacies), including 13 pharmacies that dealt with prescription filled by respiratory physicians (specialty hospital pharmacies). Although the inhalation instruction at the first visit was provided at every pharmacy, only 54.3% of all pharmacies provided inhalation instructions after the second visit. Compared to 0% of the clinic pharmacies, 40% of the specialty hospital pharmacies visually checked the patient's inhalation procedure after the second visit. Visual confirmation of the inhalation technique, especially in the clinic pharmacies, might play an important role in maintaining treatment adherence.

A multinational observational study identifying primary care patients at risk of overestimation of asthma control

Factors related to the discrepancy between patient-perceived and actual disease control remain unclear. Identifying patients at risk of overestimation of asthma control remains elusive. This study aimed to (i) investigate the relationship between patient-reported and actual level of asthma control (ii), compare the characteristics between patients who believe their asthma is well controlled that accurately report ‘well-controlled’ asthma with those that do not, and (iii) identify factors associated with inaccurately reported ‘well-controlled’ asthma. A historical, multinational, cross-sectional study using data from the iHARP (initiative Helping Asthma in Real-life Patients) review service for adults with asthma prescribed fixed-dose combination therapy. Data from 4274 patients were analysed. A major discrepancy between patient-reported and Global Initiative for Asthma defined asthma control was detected; 71.1% of patients who reported ‘well-controlled’ asthma were inaccurate in their perception despite receiving regular maintenance therapy. Significant differences were noted in age, gender, body mass index, education level, medication use, side effects, attitudes to preventer inhaler use, inhaler technique review and respiratory specialist review between patients who accurately reported ‘well-controlled’ asthma and those who did not. Independent risk factors associated with inaccurately reported ‘well-controlled’ asthma were: having taken a maximum of 5–12 puffs or more of reliever inhaler on at least one day within the previous 4 weeks; being female; having seen a respiratory specialist more than a year ago (rather than in the previous year); and having required oral corticosteroids for worsening asthma in the previous year. The study highlighted the significant hidden burden associated with under-recognition of poor asthma control, on the part of the patient and the need for targeted interventions designed to address the continuing discrepancy between perceived and actual disease control.

Risk Factors for Asthma Exacerbation and Treatment Failure in Adults and Adolescents with Well-controlled Asthma during Continuation and Step-Down Therapy

RATIONALE

Although national and international guidelines recommend reduction of asthma controller therapy or "step-down" therapy in patients with well-controlled asthma, it is expected that some individuals may experience worsening of asthma symptoms or asthma exacerbations during step-down. Characteristics associated with subsequent exacerbations during step-down therapy have not been well defined. The effect of environmental tobacco smoke exposure on risk of treatment failure during asthma step-down therapy has not been reported.

OBJECTIVES

To identify baseline characteristics associated with treatment failure and asthma exacerbation during maintenance and guideline-based step-down therapy.

METHODS

The present analysis uses data collected from a completed randomized controlled trial of optimal step-down therapy in patients with well-controlled asthma taking moderate-dose combination inhaled corticosteroids/long-acting β-agonists. Participants were 12 years or older with physician-diagnosed asthma and were enrolled between December 2011 and May 2014.

RESULTS

An emergency room visit in the previous year was associated with subsequent treatment failure (hazard ratio, 1.53; 95% confidence interval, 1.06-2.21). For every 10% increase in baseline forced expiratory volume in one second percent predicted, the hazard ratio of treatment failure was 14% lower (hazard ratio, 0.86; 95% confidence interval, 0.74-0.99). There was no difference in the risk of treatment failure between adults and children, nor was the duration of asthma associated with the risk of treatment failure. Age of asthma onset was not associated with an increased risk of treatment failure. Unexpected emergency room visit in the previous year was the only risk factor significantly associated with subsequent asthma exacerbations requiring systemic corticosteroids. Time to treatment failure or exacerbation did not differ in participants with and without self-report of environmental tobacco smoke exposure.

CONCLUSIONS

The present findings can help clinicians identify adults and adolescents with asthma who are more likely to develop treatment failure and exacerbations and who may therefore require closer monitoring during asthma step-down treatment. Those with reduced pulmonary function, a history of exacerbations, and early-onset disease, even if otherwise well controlled, may require closer observation to prevent treatment failures and asthma exacerbations. Clinical trial registered with www.clinicaltrials.gov (NCT01437995).

Understanding reliever overuse in patients purchasing over-the-counter short-acting beta2 agonists: an Australian community pharmacy-based survey

OBJECTIVES

Overuse of asthma relievers is associated with significant adverse consequences. This study aimed to better understand the population purchasing and using short-acting beta agonists (SABA) over the counter (OTC); and compare the demographic, clinical and behavioural characteristics of those who overuse SABA with those who do not.

DESIGN AND SETTING

Real-world cross-sectional observational study in community pharmacy.

PARTICIPANTS

Of 412 participants ≥16 years requesting SABA OTC, 289 were SABA overusers (used SABA more than twice per week in the past 4 weeks).

MAIN OUTCOME MEASURE

Reliever use, Global Initiative for Asthma-defined control, healthcare utilisation, patterns of preventer use.

RESULTS

70.1% of participants were classified as SABA overusers, that is, reporting SABA use more than twice a week within the last 4 weeks, 73.6% reported not using a preventer daily and only 81.6% reported a doctor diagnosis of asthma. SABA overusers were more likely to have moderate-severe nasal symptoms (80.8% vs 63.0%, p<0.001) and a diagnosis of depression (11.1% vs 5.7%, p<0.001), when compared with SABA non-overusers. A higher proportion of SABA overusers had uncontrolled asthma (59.0% vs 15.4%, p<0.001), were more likely to use oral corticosteroids to manage worsening asthma symptoms (26.2% vs 13.5%, p<0.01) and visit the doctor for their asthma in the past 12 months (74.5% vs 62.5%, p<0.01), when compared to SABA non-overusers.

CONCLUSIONS

This study uncovers a hidden population of people who can only be identified in pharmacy with suboptimal asthma, coexisting rhinitis, poor preventer adherence and, in some cases, no asthma diagnosis.

Recent Advances in Inflammation and Treatment of Small Airways in Asthma

Small airways were historically considered to be almost irrelevant in the development and control of pulmonary chronic diseases but, as a matter of fact, in the past few years we have learned that they are not so "silent". Asthma is still a worldwide health issue due to the great share of patients being far from optimal management. Several studies have shown that the deeper lung inflammation plays a critical role in asthma pathogenesis, mostly in these not well-controlled subjects. Therefore, assessing the degree of small airways inflammation and impairment appears to be a pivotal step in the asthmatic patient's management. It is now possible to evaluate them through direct and indirect measurements, even if some obstacles still affect their clinical application. The success of any treatment obviously depends on several factors but reaching the deeper lung has become a priority and, for inhaled drugs, this is strictly connected to the molecule's size. The aim of the present review is to summarize the recent evidence concerning the small airway involvement in asthma, its physiopathological characteristics and how it can be evaluated in order to undertake a personalized pharmacological treatment and achieve a better disease control.

Identifying Asthma Exacerbation-Related Emergency Department Visit Using Electronic Medical Record and Claims Data

Background  Asthma exacerbation leading to emergency department (ED) visit is prevalent, an indicator of poor control of asthma, and is a potentially preventable clinical outcome.

Objective  We propose to utilize multiple data elements available in electronic medical records (EMRs) and claims database to create separate algorithms with high validity for clinical and research purposes to identify asthma exacerbation-related ED visit among the general population.

Methods  We performed a retrospective study with inclusion criteria of patients aged 4 to 40 years, a visit to Geisinger ED from January 1, 2006, to October 28, 2013, with asthma on their problem list. Different electronic data elements including chief complaints, vitals, season, smoking, medication use, and discharge diagnoses were obtained to create the algorithm. A stratified random sample was generated to select the charts for review. Chart review was performed to classify patients with asthma-related ED visit, that is, the gold standard. Two reviewers performed the chart review and validation was done on a small subset.

Results  There were 966 eligible ED visits in the EMR sample and 731 in the claims sample. Agreement between reviewers was 95.45% and kappa statistic was 0.91. Mean age of the EMR sample was 22 years, and mostly white (93%). Multiple models conventionally used in studies were evaluated and the final model chosen included principal diagnosis, bronchodilator, and steroid use for both algorithms, chief complaints for EMR, and secondary diagnosis for claims. Area under the curve was 0.93 (95% confidence interval: 0.91–0.94) and 0.94 (0.93–0.96), respectively, for EMR and claims data, with positive predictive value of > 94%. The algorithms are visually presented using nomograms.

Conclusion  We were able to develop two separate algorithms for EMR and claims to identify asthma exacerbation-related ED visit with excellent diagnostic ability and varying discrimination threshold for clinical and research purposes.

Relationship of Inhaled Corticosteroid Adherence to Asthma Exacerbations in Patients with Moderate-to-Severe Asthma

BACKGROUND

Patients with asthma and elevated blood eosinophils are at increased risk of severe exacerbations. Management of these patients should consider nonadherence to inhaled corticosteroid (ICS) therapy as a factor for increased exacerbation risk.

OBJECTIVE

The objective of this study was to investigate whether poor adherence to ICS therapy explains the occurrence of asthma exacerbations in patients with elevated blood eosinophil levels.

METHODS

This historical cohort study identified patients within the Optimum Patient Care Research Database, aged 18 years or more, at Global Initiative for Asthma step 3 or 4, with 2 or more ICS prescriptions during the year before the clinical review. Patient characteristics and adherence (based on prescription refills and patient self-report) for ICS therapy were analyzed for those with elevated (>400 cells/μL) or normal (≤400 cells/μL) blood eosinophils.

RESULTS

We studied 7195 patients (66% female, mean age 60 years) with median eosinophil count of 200 cells/μL and found 81% to be not fully adherent to ICS therapy. A total of 1031 patients (14%) had elevated blood eosinophil counts (58% female, mean age 60 years), 83% of whom were not fully adherent to ICS. An increased proportion of adherent patients in the elevated blood eosinophil group had 2 or more exacerbations (14.0% vs 7.2%; P = .003) and uncontrolled asthma (73% vs 60.8%; P = .004) as compared with non-fully adherent patients.

CONCLUSIONS

Approximately 1 in 7 patients had elevated eosinophils. Adherence to ICS therapy was not associated with decreased exacerbations for these patients. Additional therapy should be considered for these patients, such as biologics, which have been previously shown to improve control in severe uncontrolled eosinophilic asthma.

Anticholinergic drugs in asthma therapy

PURPOSE OF REVIEW

Current guidelines recommend a stepwise approach for pharmacological therapy aimed to achieve and maintain asthma control. Despite these recommendations, at least 50% of patients continue to be uncontrolled with risk of asthma exacerbations that can often be serious and are associated with deterioration of quality of life. In recent years, the interest in anticholinergic bronchodilators, which have been primarily used in the treatment of chronic obstructive pulmonary disease, has increased patients with uncontrolled asthma. This review analyzes the mechanisms for the proposed clinical use of anticholinergic bronchodilators as an adjunctive therapy in asthma.

RECENT FINDINGS

Based on existing and recent evidence, the use of anticholinergic bronchodilators, particularly long-acting muscarinic antagonists (LAMAs), plays an important role as add-on therapy in patients uncontrolled on existing therapies. In particular, the use of anticholinergics in asthma may have a role in patients intolerant to long-acting β2 agonist, in patients with certain pharmacogenetic profiles and in those patients with asthma symptoms mostly at night.

SUMMARY

Data from clinical trials and from real-life confirm the safety and efficacy of LAMAs, especially tiotropium, in patients who remain uncontrolled despite the use of inhaled corticosteroid therapy.

Exacerbations in Adults with Asthma: A Systematic Review and External Validation of Prediction Models

BACKGROUND

Several prediction models assessing future risk of exacerbations in adult patients with asthma have been published. Applicability of these models is uncertain because their predictive performance has often not been assessed beyond the population in which they were derived.

OBJECTIVE

This study aimed to identify and critically appraise prediction models for asthma exacerbations and validate them in 2 clinically distinct populations.

METHODS

PubMed and EMBASE were searched to April 2017 for reports describing adult asthma populations in which multivariable models were constructed to predict exacerbations during any time frame. After critical appraisal, the models' predictive performances were assessed in a primary and a secondary care population for author-defined exacerbations and for American Thoracic Society/European Respiratory Society-defined severe exacerbations.

RESULTS

We found 12 reports from which 24 prediction models were evaluated. Three predictors (previous health care utilization, symptoms, and spirometry values) were retained in most models. Assessment was hampered by suboptimal methodology and reporting, and by differences in exacerbation outcomes. Discrimination (area under the receiver-operating characteristic curve [c-statistic]) of models for author-defined exacerbations was better in the primary care population (mean, 0.71) than in the secondary care population (mean, 0.60) and similar (0.65 and 0.62, respectively) for American Thoracic Society/European Respiratory Society-defined severe exacerbations. Model calibration was generally poor, but consistent between the 2 populations.

CONCLUSIONS

The preservation of 3 predictors in models derived from variable populations and the fairly consistent predictive properties of most models in 2 distinct validation populations suggest the feasibility of a generalizable model predicting severe exacerbations. Nevertheless, improvement of the models is warranted because predictive performances are below the desired level.

Criterion validity of 8-item Morisky Medication Adherence Scale in patients with asthma

The 8-item Morisky Medication Adherence Scale (MMAS-8) is reliable and valid in patients with hypertension, but to our knowledge validity has not been established for patients with asthma. The aim of the study was to determine the criterion validity of the MMAS-8 in patients with asthma. In the cross-sectional study patients older than 12 year were recruited when dispensed asthma medications in community pharmacies. Criterion validity of the scale was assessed through associations with asthma control and quality of life. Asthma control was assessed by the Asthma Control Test (ACT) and quality of life was evaluated by the Saint George Respiratory Questionnaire (SGRQ). A total of 208 patients (mean age 56 years, 59% female) were included in the study. Almost all patients were prescribed inhaled corticosteroids (96%). Asthma was not controlled in 37% of the patients and 22% experienced at least one exacerbation requiring emergency room visit, hospitalization or treatment with oral corticosteroid therapy in the previous year. The 8-item MMAS was significantly associated with asthma control and quality of life. Patients who scored 8 points, <8 to >6 points and ≤6 points on the scale were considered to have high, medium and low adherence, respectively. High, medium and low adherence was found in 53%, 23% and 24% of the patients, respectively. As adherence improved from low to medium or from medium to high, the odds of asthma control increased by 1.7 times (OR 1.65, p = 0.027). Patients with high and medium adherence had SGRQ scores that were 6.1 and 5.3 points lower, respectively, compared with patients with low adherence. The MMAS-8 was found to be valid for assessing medication adherence and predicting health outcomes in patients with asthma.

Tiotropium Respimat Add-on Is Efficacious in Symptomatic Asthma, Independent of T2 Phenotype

BACKGROUND

Adding tiotropium to existing inhaled corticosteroid (ICS) maintenance therapy with or without a long-acting β₂-agonist (LABA) has been shown to be beneficial in patients with symptomatic asthma.

OBJECTIVE

To assess whether responses to tiotropium Respimat add-on therapy were influenced by patients' T2 status.

METHODS

In this exploratory study, data from 4 phase III trials were analyzed: once-daily tiotropium 5 μg or placebo as add-on to ICS + LABA (PrimoTinA-asthma; 2 replicate trials; NCT00772538/NCT00776984; n = 912); once-daily tiotropium 5 μg or 2.5 μg, twice-daily salmeterol 50 μg, or placebo as add-on to ICS (MezzoTinA-asthma; 2 replicate trials; NCT01172808/NCT01172821; n = 2100). The prespecified efficacy outcomes of these studies have been reported previously. Here, further exploratory subgroup analyses were performed to study whether these coprimary end points were influenced by serum IgE levels, blood eosinophil counts, and clinician judgment of allergic asthma. In addition, for the continuous parameters, namely, IgE and blood eosinophils, their influence on the treatment effect was modeled over the whole range of values.

RESULTS

Tiotropium was efficacious in improving peak FEV₁ within 3 hours postdose and trough FEV₁, independent of T2 status. Tiotropium significantly reduced the risk of severe asthma exacerbations and asthma worsening, independent of T2 phenotype; Cox regression modeling supported a beneficial effect of tiotropium on exacerbations, independent of IgE levels or eosinophil counts. Numerical improvements in the 7-question Asthma Control Questionnaire (ACQ-7) responder rate with tiotropium versus placebo were observed in T2_high and T2_low patients; logistic regression modeling provided further evidence for improvement in ACQ-7 responder rates with tiotropium, independent of IgE levels or eosinophil counts.

CONCLUSIONS

The results of our exploratory analyses suggest that the improvements seen with tiotropium Respimat as add-on to ICS ± LABA in patients with symptomatic asthma on lung function, exacerbation risk, and symptom control are independent of T2 phenotype.

Living with asthma and chronic obstructive airways disease: Using technology to support self-management - An overview

Long-term respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) are common, and cause high levels of morbidity and mortality. Supporting self-management is advocated for both asthma and increasingly so for COPD, and there is growing interest in the potential role of a range of new technologies, such as smartphone apps, the web or telehealth to facilitate and promote self-management in these conditions. Treatment goals for both asthma and COPD include aiming to control symptoms, maintain activities, achieve the best possible quality of life and minimize risks of exacerbation. To do this, health professionals should be (a) helping patients to recognize deteriorating symptoms and act appropriately; (b) promoting adherence to maintenance therapy; (c) promoting a regular review where triggers can be established, and strategies for managing such triggers discussed; and (d) promoting healthy lifestyles and positive self-management of symptoms. In particular, low uptake of asthma action plans is a modifiable contributor to morbidity and possibly also to mortality in those with asthma and should be addressed as a priority. Using technology to support self-management is an evolving strategy that shows promise. This review provides an overview of self-management support and discusses how newer technologies may help patients and health professionals to meet key treatment goals.

Lack of asthma and rhinitis control in general practitioner-managed patients prescribed fixed-dose combination therapy in Australia

OBJECTIVES

The first aim of the study (i) assess the current asthma status of general-practitioner-managed patients receiving regular fixed-dose combination inhaled corticosteroid and long-acting beta₂ agonist (FDC ICS/LABA) therapy and (ii) explore patients' perceptions of asthma control and attitudes/behaviors regarding preventer inhaler use.

METHODS

A cross-sectional observational study of Australian adults with a current physician diagnosis of asthma receiving ≥2 prescriptions of FDC ICS/LABA therapy in the previous year, who were recruited through general practice to receive a structured in-depth asthma review between May 2012 and January 2014. Descriptive statistics and Chi-Square tests for independence were used for associations across asthma control levels.

RESULTS

Only 11.5% of the patients had controlled asthma based on guideline-defined criteria. Contrarily, 66.5% of the patients considered their asthma to be well controlled. Incidence of acute asthma exacerbations in the previous year was 26.5% and 45.6% of the patients were without a diagnosis of rhinitis. Asthma medication use and inhaler technique were sub-optimal; only 41.0% of the preventer users reported everyday use. The side effects of medication were common and more frequently reported among uncontrolled and partially controlled patients.

CONCLUSIONS

The study revealed the extent to which asthma management needs to be improved in this patient cohort and the numerous unmet needs regarding the current state of asthma care. Not only there is a need for continuous education of patients, but also education of health care practitioners to better understand the way in which patient's perceptions impact on asthma management practices, incorporating these findings into clinical decision making.

Asthma management: A new phenotype-based approach using presence of eosinophilia and allergy

Asthma is a heterogeneous disease. The Czech Pneumology and Allergology Societies commissioned 10 experts to review the literature and create joint national guidelines for managing asthma, reflecting this heterogeneity. The aim was to develop an easy-to-use diagnostic strategy as a rational approach to the widening opportunities for the use of phenotype-targeted therapy. The guidelines were presented on websites for public comments by members of both the societies. The reviewers' comments contributed to creating the final version of the guidelines. The key hallmark of the diagnostic approach is the pragmatic concept, which assesses the presence of allergy and eosinophilia in each asthmatic patient. The guidelines define three clinically relevant asthma phenotypes: eosinophilic allergic asthma, eosinophilic nonallergic asthma and noneosinophilic nonallergic asthma. The resulting multifunctional classification describing the severity, level of control and phenotype is the starting point for a comprehensive treatment strategy. The level of control is constantly confronted with the intensity of the common stepwise pharmacotherapy, and the concurrently included phenotyping is essential for phenotype-specific therapy. The concept of the asthma approach with assessing the presence of eosinophilia and allergy provides a way for more precise diagnosis, which is a prerequisite for using widening options of personalized therapy.

The evidence on tiotropium bromide in asthma: from the rationale to the bedside

Severe and poorly controlled asthma still accounts for a great portion of the patients affected. Disease control and future risk management have been identified by international guidelines as the main goals in patients with asthma. The need for new treatment approaches has led to reconsider anticholinergic drugs as an option for asthma treatment. Tiotropium is the first anticholinergic drug that has been approved for children and adults with poorly controlled asthma and is currently considered as an option for steps 4 and 5 of the Global Initiative for Asthma. In large randomized clinical trials enrolling patients with moderate to severe asthma, add-on therapy with tiotropium has demonstrated to be efficacious in improving lung function, decreasing risk of exacerbation and slowing the worsening of disease; accordingly, tiotropium demonstrated to be non inferior compared to long acting beta-agonists in the maintenance treatment along with medium to high inhaled corticosteroids. In view of the numerous ancillary effects acting on inflammation, airway remodeling, mucus production and cough reflex, along with the good safety profile and the broad spectrum of efficacy demonstrated in different disease phenotypes, tiotropium can represent a beneficial alternative in the therapeutic management of poorly controlled asthma. The present extensive narrative review presents the pharmacological and pathophysiological basis that guided the rationale for the introduction of tiotropium in asthma treatment algorithm, with a particular focus on its conventional and unconventional effects; finally, data on tiotropium efficacy and safety. from recent randomized clinical trials performed in all age categories will be extensively discussed.

Long-acting muscarinic antagonists: a potential add-on therapy in the treatment of asthma?

Asthma is a chronic inflammatory disorder of the airways that is a major global burden on both individuals and healthcare systems. Despite guideline-directed treatment, a significant proportion of patients with asthma do not achieve control. This review focuses on the potential use of long-acting anticholinergics as bronchodilators in the treatment of asthma, with results published from clinical trials of glycopyrrolate, umeclidinium and tiotropium. The tiotropium clinical trial programme is the most advanced, with data available from a number of phase II and III studies of tiotropium as an add-on to inhaled corticosteroid maintenance therapy, with or without a long-acting β2-agonist, in patients across asthma severities. Recent studies using the Respimat Soft Mist inhaler have identified 5 µg once daily as the preferred dosing regimen, which has shown promising results in adults, adolescents and children with asthma. Tiotropium Respimat has recently been incorporated into the Global Initiative for Asthma 2015 treatment strategy as a recommended alternative therapy at steps 4 and 5 in adult patients with a history of exacerbations. The increasing availability of evidence from ongoing and future clinical trials will be beneficial in determining where long-acting anticholinergic agents fit in future treatment guidelines across a variety of patient populations and disease severities.

Communication during counseling sessions about inhaled corticosteroids at the community pharmacy

BACKGROUND

Pharmaceutical care is one of the major tasks of pharmacists, which aims to improve patient outcomes. Counseling patients with asthma or chronic obstructive pulmonary disease about their use of inhaled corticosteroids (ICS) might enhance medication adherence and symptom control. Therefore, effective pharmacist-patient communication is very important. In this regard, both affective communication, for handling emotions, and instrumental communication, for exchanging biomedical and lifestyle information, are relevant. Until now, only few studies have explored pharmacist-patient communication, and further insight is needed in this regard. The aim of this study is to investigate how pharmacists and pharmacy technicians communicate about ICS with patients with asthma and/or chronic obstructive pulmonary disease, what topics are discussed by them, and whether pharmacists and pharmacy technicians differ in their communication during counseling sessions.

METHODS

Patients aged ≥18 years who had used ICS for at least 1 year and filled at least two ICS prescriptions in the preceding year were recruited through 12 pharmacies. Participants had one counseling session with a pharmacist or a pharmacy technician, which was video-recorded. The process and content of the provider-patient communication were analyzed using the Roter interaction analysis system, adapted to the pharmaceutical setting.

RESULTS

A total of 169 sessions were recorded and analyzed. The communication appeared largely instrumental. Lifestyle, psychosocial issues, and ICS adherence were not discussed in detail. The pharmacists had longer conversations and more affective talk than the pharmacy technicians.

CONCLUSION

Pharmacists and pharmacy technicians may need to pay more attention to ICS adherence, lifestyle, and psychosocial topics. They differed in their communication; the pharmacists exhibited more affective behavior and discussed medical and therapeutic issues more extensively compared to the pharmacy technicians. Educational courses for pharmacists and pharmacy technicians could focus more on the discussion of adherence, lifestyle, and psychosocial topics with patients.

Tiotropium in asthma: what is the evidence and how does it fit in?

Despite current therapeutic approaches asthma remains uncontrolled in a significant proportion of patients. Short-acting anticholinergic bronchodilators have a very long history of use in asthma, and recent data confirms the importance of acetylcholine as both a bronchoconstrictor and as a regulator of inflammation and remodeling in the lungs. Data from a comprehensive clinical trial programme, as well as use in primary care, show the efficacy and safety of tiotropium in adults with mild to moderate asthma when it is added to ICS and in severe asthma when it is added to high doses of ICS plus LABA, as well as in adolescents. Tiotropium is cost effective and its benefits are not restricted to particular phenotypes, making it a useful addition to the therapeutic options recommended by the Global Initiative for Asthma (GINA) for people with poorly controlled asthma at steps 4 & 5.

Beliefs about inhaled corticosteroids: Comparison of community pharmacists, pharmacy technicians and patients with asthma

OBJECTIVES

To compare pharmacists' and pharmacy technicians' perceptions of patients' beliefs regarding inhaled corticosteroids (ICS) with those of patients and to compare the ICS beliefs of pharmacists and technicians with those of patients with asthma.

METHODS

1269 community pharmacies were approached to fill out an online questionnaire; 1952 patients were sent a questionnaire by post. Beliefs (i.e., necessity and concerns) regarding ICS were measured using (an adapted version of) the Beliefs about Medicines Questionnaire (BMQ-specific). Pharmacists and technicians were instructed to fill out the BMQ for themselves, and to fill it out in the way they thought most of their patients would complete it.

RESULTS

136 pharmacists, 90 pharmacy technicians and 161 patients with asthma completed the questionnaire. Pharmacists and technicians thought patients had more concerns about ICS than patients themselves reported (p < 0.0001). They also thought that patients had stronger beliefs in their personal need for ICS than patients reported (p < 0.01). Pharmacists reported lower levels of concerns than patients (p < 0.05) and both providers attributed a higher level of necessity to ICS than patients did (p < 0.0001).

CONCLUSION

Pharmacists and technicians overestimate the personal need for treatment as well as the concerns patients with asthma have regarding ICS. They also have, to some extent, stronger positive beliefs about ICS than patients. If pharmacists and technicians expect that patients share their positive views about ICS, they might be less likely to elicit and address patients' doubts and concerns about ICS, which might be relevant for effective ICS treatment and subsequent patient outcomes.

Asthma control and exacerbations: two different sides of the same coin

PURPOSE OF REVIEW

Optimal asthma management includes both the control of asthma symptoms and reducing the risk of future asthma exacerbations. Traditionally, treatment has been adjusted largely on the basis of symptoms and lung function and for many patients, this approach delivers both excellent symptom control and reduced risk. However, the relationship between these two key components of the disease may vary between different asthmatic phenotypes and disease severities and there is increasing recognition of the need for more individualized treatment approaches.

RECENT FINDINGS

A number of factors which predict exacerbation risk have been identified including demographic and behavioural features and specific inflammatory biomarkers. Type-2 cytokine-driven eosinophilic airways inflammation predisposes to frequent exacerbations and predicts response to corticosteroids, and the usefulness of sputum eosinophilia as both a marker of exacerbation risk and biomarker for adjustment of corticosteroid treatment has been established for some time. However, attempts to develop surrogate markers, which would be more straightforward to deliver in the clinic, have been challenging.

SUMMARY

Some patients with asthma have persistent symptoms in the absence of type-2 cytokine driven-eosinophilic airways inflammation due to noncorticosteroid responsive mechanisms (T2-low disease). Composite biomarker strategies using easily measured surrogate indicators of type-2 inflammation (such as fractional exhaled nitric oxide, blood eosinophil count and serum periostin levels) may predict exacerbation risk better but it is unclear if they can be used to adjust corticosteroid treatment. Biomarkers will be used to target novel biologic treatments but additionally may be used to optimize corticosteroid treatment dose and act as prognostics for exacerbation risk and potentially other important longer term asthma outcomes.

Predicting frequent asthma exacerbations using blood eosinophil count and other patient data routinely available in clinical practice

PURPOSE

Acute, severe asthma exacerbations can be difficult to predict and thus prevent. Patients who have frequent exacerbations are of particular concern. Practical exacerbation predictors are needed for these patients in the primary-care setting.

PATIENTS AND METHODS

Medical records of 130,547 asthma patients aged 12-80 years from the UK Optimum Patient Care Research Database and Clinical Practice Research Datalink, 1990-2013, were examined for 1 year before (baseline) and 1 year after (outcome) their most recent blood eosinophil count. Baseline variables predictive (P<0.05) of exacerbation in the outcome year were compared between patients who had two or more exacerbations and those who had no exacerbation or only one exacerbation, using uni- and multivariable logistic regression models. Exacerbation was defined as asthma-related hospital attendance/admission (emergency or inpatient) or acute oral corticosteroid (OCS) course.

RESULTS

Blood eosinophil count >400/µL (versus ≤400/µL) increased the likelihood of two or more exacerbations >1.4-fold (odds ratio [OR]: 1.48 (95% confidence interval [CI]: 1.39, 1.58); P<0.001). Variables that significantly increased the odds by up to 1.4-fold included increasing age (per year), female gender (versus male), being overweight or obese (versus normal body mass index), being a smoker (versus nonsmoker), having anxiety/depression, diabetes, eczema, gastroesophageal reflux disease, or rhinitis, and prescription for acetaminophen or nonsteroidal anti-inflammatory drugs. Compared with treatment at British Thoracic Society step 2 (daily controller ± reliever), treatment at step 0 (none) or 1 (as-needed reliever) increased the odds by 1.2- and 1.6-fold, respectively, and treatment at step 3, 4, or 5 increased the odds by 1.3-, 1.9-, or 3.1-fold, respectively (all P<0.05). Acute OCS use was the single best predictor of two or more exacerbations. Even one course increased the odds by more than threefold (OR: 3.75 [95% CI: 3.50, 4.01]; P<0.001), and three or more courses increased the odds by >25-fold (OR: 25.7 [95% CI: 23.9, 27.6]; P<0.001).

CONCLUSION

Blood eosinophil count and several other variables routinely available in patient records may be used to predict frequent asthma exacerbations.

Small airway dysfunction and bronchial asthma control : the state of the art

According to national and international guidelines, achieving and maintaining asthma control is a major goal of disease management. In closely controlled clinical trials, good asthma control can be achieved , with the medical treatments currently available, in the majority of patients , but large population-based studies suggest that a significant proportion of patients in real-life setting experience suboptimal levels of asthma control and report lifestyle limitations with a considerable burden on quality of life. Poor treatment adherence and persistence, failure to use inhalers correctly, heterogeneity of asthma phenotypes and associated co-morbidities are the main contributing factors to poor disease control. Now, it is widely accepted that peripheral airway dysfunction , already present in patients with mild asthma, is a key contributor of worse control. The aim of this paper is to investigate the association between small-airways dysfunction and asthma symptoms/control. We therefore performed a PubMed search using keywords : small airways; asthma (limits applied: Humans, English language) and selected papers with a study population of asthmatic patients, reporting measurement of small-airways parameters and clinical symptoms/control.

The Potential for Poverty to Lower the Self-Efficacy of Adults With Asthma: An Australian Longitudinal Study

PURPOSE

It is known that strong feelings of self-efficacy are linked with better management of asthma. However, it is not known whether the experience of poverty can detrimentally impact the self-efficacy feelings of asthma patients. This paper aims to determine whether falling into income or multidimensional poverty lowers self-efficacy among people diagnosed with asthma.

METHODS

Longitudinal analysis of Waves 7 to 11 (2007 to 2011) of the nationally representative Household, Income and Labour Dynamics in Australia (HILDA) survey using generalized linear models. The analysis was limited to those who had been diagnosed with asthma. The Freedom Poverty Measure was used to identify those in multidimensional poverty.

RESULTS

People with asthma who fell into income poverty had significantly lower self-efficacy scores-23% lower (95% CI: -35.1 to -9.1), after falling into income poverty for 3 or 4 years between 2007 and 2011 compared to those who were never in income poverty. Those who fell into multidimensional poverty also had significantly lower self-efficacy scores-25% lower (95% CI: -42.8 to -2.0), after being in multidimensional poverty for 3 or 4 years between 2007 and 2011 compared to those who were never in poverty.

CONCLUSIONS

Asthmatics who fall into poverty are likely to experience a decline in their feelings of self-efficacy. The findings of this study show that experiencing poverty should be a flag to identify those who may need extra assistance in managing their condition.

Details of development of the resource for adults with asthma in the RAISIN (randomized trial of an asthma internet self-management intervention) study

Background

Around 300 million people worldwide have asthma and prevalence is increasing. Self-management can be effective in improving a range of outcomes and is cost effective, but is underutilised as a treatment strategy. Supporting optimum self-management using digital technology shows promise, but how best to do this is not clear. We aimed to develop an evidence based, theory informed, online resource to support self-management in adults with asthma, called ‘Living well with Asthma’, as part of the RAISIN (Randomized Trial of an Asthma Internet Self-Management Intervention) study.

Methods

We developed Living well with Asthma in two phases.

Phase 1: A low fidelity prototype (paper-based) version of the website was developed iteratively through input from a multidisciplinary expert panel, empirical evidence from the literature, and potential end users via focus groups (adults with asthma and practice nurses). Implementation and behaviour change theories informed this process.

Phase 2: The paper-based designs were converted to a website through an iterative user centred process. Adults with asthma (n = 10) took part in think aloud studies, discussing the paper based version, then the web-based version. Participants considered contents, layout, and navigation. Development was agile using feedback from the think aloud sessions immediately to inform design and subsequent think aloud sessions. Think aloud transcripts were also thematically analysed, further informing resource development.

Results

The website asked users to aim to be symptom free. Key behaviours targeted to achieve this include: optimising medication use (including inhaler technique); attending primary care asthma reviews; using asthma action plans; increasing physical activity levels; and stopping smoking. The website had 11 sections, plus email reminders, which promoted these behaviours. Feedback on the contents of the resource was mainly positive with most changes focussing on clarification of language, order of pages and usability issues mainly relating to navigation difficulties.

Conclusions

Our multifaceted approach to online intervention development underpinned by theory, using evidence from the literature, co-designed with end users and a multidisciplinary panel has resulted in a resource which end users find relevant to their needs and easy to use. Living well with Asthma is undergoing evaluation within a randomized controlled trial.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0177-z) contains supplementary material, which is available to authorized users.

The impact of asthma exacerbations and preventive strategies

OBJECTIVE

To review the pathophysiologic mechanisms underlying asthma exacerbations, the impact of exacerbations, and both current and future treatment strategies to establish asthma control and reduce the risk of future exacerbations.

RESEARCH DESIGN AND METHODS

Relevant adult data were identified via PubMed, with additional references obtained by reviewing bibliographies from selected articles.

RESULTS

Asthma exacerbations or 'attacks' are acute episodes of progressive worsening of symptoms which occur in patients with all degrees of asthma severity and are an important cause of morbidity and mortality. For patients, these asthma attacks constitute a considerable part of the disease burden in terms of both personal suffering and economic impact. Exacerbations are characterized in part by decreases in expiratory flow or lung function. The pathophysiologic mechanism underlying these changes is likely to be different depending on the specific asthma phenotype. Asthma exacerbations are commonly initiated by upper respiratory tract infections and/or environmental allergens, although there are other known factors which increase the risk of a patient developing exacerbations, such as cigarette smoking. Establishing asthma control and reducing the risk of future exacerbations is the main goal of asthma treatment. Inhaled corticosteroids alone or in combination with long-acting β2-agonists, in addition to other step-up strategies such as leukotriene receptor antagonists and theophylline, are recommended. The anti-immunoglobulin E monoclonal antibody omalizumab should also be considered in difficult-to-treat allergic asthma.

CONCLUSIONS

Despite the currently available treatments, many patients with asthma remain symptomatic and experience exacerbations regardless of disease severity. New therapies, including long-acting anticholinergics, anti-cytokines, and chemoattractant receptor-homologous molecules, are under investigation with some promising results. In addition to increased education and use of self-management plans, these novel therapies are essential to help improve asthma control and reduce exacerbation risk.

Long-acting muscarinic antagonist use in adults with asthma: real-life prescribing and outcomes of add-on therapy with tiotropium bromide

Background

Randomized controlled trials indicate that addition of a long-acting muscarinic antagonist (LAMA) such as tiotropium may improve asthma control and reduce exacerbation risk in patients with poorly controlled asthma, but broader clinical studies are needed to investigate the effectiveness of LAMA in real-life asthma care.

Methods

Medical records of adults with asthma (aged ≥18 years) prescribed tiotropium were obtained from the UK Optimum Patient Care Research Database for the period 2001–2013. Patients diagnosed with chronic obstructive pulmonary disease were excluded, but no other clinical exclusions were applied. Two primary outcomes were compared in the year before (baseline) and the year after (outcome) addition of tiotropium: exacerbations (asthma-related hospital emergency department attendance or inpatient admission, or acute oral corticosteroid course) and acute respiratory events (exacerbation or antibiotic prescription with lower respiratory consultation). Secondary outcomes included lung function test results and short-acting β₂ agonist usage. The Wilcoxon signed-rank test was used for variables measured on the interval scale, the marginal homogeneity test for categorized variables, and the paired t-test for lung function indices.

Results

Of the 2,042 study patients, 83% were prescribed an inhaled corticosteroid and 68% a long-acting β₂ agonist during the baseline year; 67% were prescribed both. Comparing baseline and outcome years, the percentage of patients having at least one exacerbation decreased from 37% to 27% (P<0.001) and the percentage having at least one acute respiratory event decreased from 58% to 47% (P<0.001). There were no significant changes in lung function, and usage of short-acting β₂ agonists (in salbutamol/albuterol equivalents) increased from a median (interquartile range) of 274 (110, 548) to 329 (110, 603) μg/day (P=0.01).

Conclusion

In this real-life asthma population, addition of LAMA therapy was associated with significant decreases in the incidence of exacerbations and antibiotic prescriptions for lower respiratory tract infections in the following year.

Efficacy of fluticasone propionate/formoterol fumarate in the treatment of asthma: a pooled analysis

BACKGROUND

Fluticasone propionate and formoterol fumarate have been combined in a single inhaler (fluticasone/formoterol; flutiform(®)) for the maintenance treatment of asthma. This pooled analysis assessed the efficacy of fluticasone/formoterol versus fluticasone in patients who previously received inhaled corticosteroids.

METHODS

Data were pooled from five randomised studies in patients with asthma (aged ≥12 years) treated for 8 or 12 weeks with fluticasone/formoterol (100/10, 250/10 or 500/20 μg b.i.d.; n = 528 delivered via pMDI) or fluticasone alone (100, 250 or 500 μg b.i.d.; n = 527).

RESULTS

Fluticasone/formoterol provided significantly greater increases than fluticasone alone in mean morning forced expiratory volume in 1 second (FEV1) from pre-dose at baseline to 2 hours post-dose at study end (least-squares mean [LSM] treatment difference: 0.146L; p < 0.001) and in pre-dose FEV1 from baseline to study end (LSM treatment difference: 0.048 L; p = 0.043). Compared with fluticasone, fluticasone/formoterol provided greater increases in the percentage of asthma control days (no symptoms, no rescue medication use and no sleep disturbance due to asthma) from baseline to study end (LSM treatment difference: 8.6%; p < 0.001), and was associated with a lower annualised rate of exacerbations (rate ratio: 0.71; p = 0.014).

CONCLUSIONS

In summary, fluticasone/formoterol provides clinically significant improvements in lung function and asthma control measures, with a lower incidence of exacerbations than fluticasone alone.

Is there a rationale and role for long-acting anticholinergic bronchodilators in asthma?

Despite current guidelines and the range of available treatments, over a half of patients with asthma continue to suffer from poor symptomatic control and remain at risk of future worsening. Although a number of non-pharmacological measures are crucial for good clinical management of asthma, new therapeutic controller medications will have a role in the future management of the disease. Several long-acting anticholinergic bronchodilators are under investigation or are available for the treatment of respiratory diseases, including tiotropium bromide, aclidinium bromide, glycopyrronium bromide, glycopyrrolate and umeclidinium bromide, although none is yet licensed for the treatment of asthma. A recent Phase III investigation demonstrated that the once-daily long-acting anticholinergic bronchodilator tiotropium bromide improves lung function and reduces the risk of exacerbation in patients with symptomatic asthma, despite the use of inhaled corticosteroids (ICS) and long-acting β₂-agonists (LABAs). This has prompted the question of what the rationale is for long-acting anticholinergic bronchodilators in asthma. Bronchial smooth muscle contraction is the primary cause of reversible airway narrowing in asthma, and the baseline level of contraction is predominantly set by the level of ‘cholinergic tone’. Patients with asthma have increased bronchial smooth muscle tone and mucus hypersecretion, possibly as a result of elevated cholinergic activity, which anticholinergic compounds are known to reduce. Further, anticholinergic compounds may also have anti-inflammatory properties. Thus, evidence suggests that long-acting anticholinergic bronchodilators might offer benefits for the maintenance of asthma control, such as in patients failing to gain control on ICS and a LABA, or those with frequent exacerbations.

Asthma control and management in 8,000 European patients: the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey

Background:

Asthma is one of the most common chronic diseases in the world, and previous studies have reported low levels of control. Recent developments in the availability and use of online sources of information about asthma might add to patients’ knowledge and help improve control.

Aims:

To investigate whether asthma control has improved by assessing levels of symptoms, exacerbations and Global Initiative for Asthma-defined control in a real-life population of patients who use the Internet and social media, as well as evaluate patient perception of control and attitudes to asthma.

Methods:

Online surveys were conducted among 8,000 patients with asthma (aged 18–50 years, ⩾2 prescriptions in the previous 2 years, use of social media) from 11 European countries.

Results:

Levels of asthma control were low: 45% of respondents had uncontrolled asthma. Acute exacerbations were common: 44% of respondents reported having used oral steroids for asthma in the previous 12 months, 24% had visited an emergency department and 12% had been hospitalised. More than 80% of respondents (overall, and among those with a history of exacerbations) considered their asthma to be controlled. Of those who had an exacerbation requiring oral steroids, 75% regarded their asthma as not serious.

Conclusions:

Asthma control in Europe remains poor; symptoms and exacerbations are common. Many patients regard their asthma as controlled and not serious despite experiencing symptoms and exacerbations. There is a need to assess patients’ control, risk and inhaler technique, and to ensure that patients are prescribed, and take, appropriate treatments.

A Randomized trial of an Asthma Internet Self-management Intervention (RAISIN): study protocol for a randomized controlled trial

Background

The financial costs associated with asthma care continue to increase while care remains suboptimal. Promoting optimal self-management, including the use of asthma action plans, along with regular health professional review has been shown to be an effective strategy and is recommended in asthma guidelines internationally. Despite evidence of benefit, guided self-management remains underused, however the potential for online resources to promote self-management behaviors is gaining increasing recognition. The aim of this paper is to describe the protocol for a pilot evaluation of a website ‘Living well with asthma’ which has been developed with the aim of promoting self-management behaviors shown to improve outcomes.

Methods/Design

The study is a parallel randomized controlled trial, where adults with asthma are randomly assigned to either access to the website for 12 weeks, or usual asthma care for 12 weeks (followed by access to the website if desired). Individuals are included if they are over 16-years-old, have a diagnosis of asthma with an Asthma Control Questionnaire (ACQ) score of greater than, or equal to 1, and have access to the internet. Primary outcomes for this evaluation include recruitment and retention rates, changes at 12 weeks from baseline for both ACQ and Asthma Quality of Life Questionnaire (AQLQ) scores, and quantitative data describing website usage (number of times logged on, length of time logged on, number of times individual pages looked at, and for how long). Secondary outcomes include clinical outcomes (medication use, health services use, lung function) and patient reported outcomes (including adherence, patient activation measures, and health status).

Discussion

Piloting of complex interventions is considered best practice and will maximise the potential of any future large-scale randomized controlled trial to successfully recruit and be able to report on necessary outcomes. Here we will provide results across a range of outcomes which will provide estimates of efficacy to inform the design of a future full-scale randomized controlled trial of the ‘Living well with asthma’ website.

Trial registration

This trial is registered with Current Controlled Trials ISRCTN78556552 on 18/06/13.

Efficacy and safety of fluticasone furoate 100 μg once-daily in patients with persistent asthma: a 24-week placebo and active-controlled randomised trial

Inhaled corticosteroids (ICSs) improve asthma disease control; once-daily ICS administration may have advantages for patients. Our objective was to assess the efficacy and safety of the novel ICS fluticasone furoate (FF) over 24 weeks versus placebo. This was a 24-week double-blind, double-dummy, placebo- and active-controlled study (NCT01159912) of 343 asthma patients (≥12 years) not controlled by their current ICS. Patients were randomised (1:1:1) to FF100 μg, placebo (both administered once-daily [OD] via ELLIPTA™ dry powder inhaler in the evening) or fluticasone propionate (FP) 250 μg (administered twice-daily (BD) via DISKUS™/ACCUHALER™). Primary endpoint was change from baseline in pre-dose evening forced expiratory volume in 1s (FEV1) at Week 24; change from baseline in % rescue-free 24-h periods was a powered secondary endpoint. Adverse events (AEs) were assessed. FF100 μg OD and FP250 μg BD significantly improved pre-dose evening FEV1 compared with placebo at Week 24 (+146 ml [p = 0.009] and +145 ml [p = 0.011], respectively). Percentage of rescue-free 24-h periods was increased with FF100 μg OD (+14.8%) and FP250 μg BD (+17.9%) compared to placebo (both p < 0.001). On-treatment AEs were reported by 53% (FF100 μg OD), 42% (FP250 μg BD) and 40% (placebo) of patients. On-treatment severe asthma exacerbations were lower with FF100 μg OD (3%) and FP250 μg BD (2%) than placebo (7%). There was significant suppression of urinary cortisol at week 24 with FF100 μg OD (p = 0.030) and FP250 μg BD (p = 0.036) relative to placebo. FF100 μg OD, administered in the evening, achieves significant improvements in lung function and rescue inhaler use over 24 weeks, comparable to FP250 μg BD with similar safety profile.

A computerized asthma-specific quality of life: a novel tool for reflecting asthma control and predicting exacerbation

BACKGROUND

Proper assessment of health-related quality of life is essential to achieve and maintain a controlled status in asthmatic patients. We developed our own computerized asthma-specific quality-of-life (cA-QOL) questionnaire based on in-depth interviews with adult asthmatic patients. In this study, we evaluated this cA-QOL in terms of the Asthma Control Test (ACT) score and Global Initiative for Asthma (GINA) guidelines as well as asthma exacerbation, and compared it with the asthma-related quality-of-life questionnaire (AQLQ).

METHODS

We conducted a multicenter, prospective, observational study in 133 adult asthmatic patients recruited from 5 university hospitals in South Korea, who were randomized into 2 groups according to the operating order of the cA-QOL and AQLQ. At every visit (3-month interval), physicians evaluated asthma control status with monitoring spirometry. The self-administered cA-QOL, AQLQ(S) and ACT were completed.

RESULTS

The cA-QOL scores correlated significantly with ACT and AQLQ(S) scores (r = 0.814, p < 0.001; r = 0.900, p < 0.001). The cA-QOL score was significantly lower where the ACT score was <19, in the patients with an uncontrolled asthma status according to the GINA guidelines and in those with asthma exacerbation (p < 0.001, respectively). A multivariate analysis showed that this cA-QOL was a significant parameter associated with an uncontrolled asthma status and asthma exacerbation (p < 0.001, p = 0.045, p = 0.019, respectively).

CONCLUSION

The cA-QOL is a valid tool for reflecting current asthma control status and for assessment to predict the future risk of asthma exacerbation in adult asthmatics.

Eligibility for treatment with omalizumab in Italy and Germany

Omalizumab is an add-on therapy for patients with uncontrolled severe allergic asthma. In Europe, patients must fulfil a number of additional criteria to become eligible for omalizumab therapy, creating a challenge for epidemiology studies to quantify the potential patient pool. Thus, and in the absence of robust data, the number of omalizumab-eligible patients has remained unclear. To assess eligible patient numbers, a chart-audit design approach was employed to measure epidemiology variables based on patient-level data. 770 patient charts were reviewed in designated towns in Germany and Italy, in collaboration with >200 primary care physicians (PCPs) and respiratory specialists (RS). This study sample represents >50% and >70% of local RS in these designated towns of Germany and Italy, respectively. Of patient charts evaluated, 4 patients were currently receiving omalizumab. A further 31 patients (12 PCP; 19 RS) were evaluated as omalizumab-eligible (i.e. fulfilled all product label criteria) but were not receiving the drug. Extrapolating to a national level, this yields >6500 eligible patients in Germany, and >3200 in Italy. Furthermore, this study sample revealed a significant number of PCPs treating uncontrolled severe asthma patients without referral to RS; these patients are not consistently evaluated for FEV1, aero-allergen sensitivity, a qualitative understanding of severe exacerbations, and day and night-time symptoms. This study suggests that significant numbers of omalizumab-naïve severe allergic asthma patients in Germany/Italy are eligible for omalizumab therapy. Despite proven benefits in uncontrolled severe allergic asthma, adjunctive omalizumab therapy is underutilized.

Potential masking of airway eosinophilic inflammation by combination therapy in asthma

Purpose

Long-acting β₂ agonists (LABA) may mask ongoing bronchial inflammation, leaving asthmatic patients at greater risk of severe complications. The aim of this study was to compare the effect of combination therapy using low-dose inhaled corticosteroids (ICS) plus LABA on airway inflammation in asthma to the effect of medium-dose ICS alone.

Methods

Twenty-four patients with asthma not controlled by low-dose (400 µg per day) budesonide alone were enrolled in this prospective crossover study. Patients were randomized into 2 treatment phases: one receiving medium-dose (800 µg per day) budesonide (ICS phase), and the other receiving a combination therapy of low-dose budesonide/formoterol (360 µg/9 µg per day) delivered by a single inhaler (LABA phase). Each treatment phase lasted for 6 week, after which patients were crossed over. Asthma symptoms, lung function, and airway inflammation were compared between the 2 phases.

Results

Twenty-three patients completed the study; adequate sputum samples were collected from 17 patients. Asthma symptoms and lung function remained similar between the 2 phases. However, the mean sputum eosinophil percentage was higher in the LABA phase than in the ICS phase (5.07±3.82% vs. 1.02±1.70%; P<0.01). Sputum eosinophilia (≥3%) was more frequently observed in the LABA phase than in the ICS phase (six vs. two).

Conclusion

Addition of LABA may mask airway eosinophilic inflammation in asthmatic patients whose symptoms are not controlled with low-dose ICS.

Influence of subcutaneous specific immunotherapy on drug costs in children suffering from allergic asthma

Background

Subcutaneous specific immunotherapy (SCIT) is an effective treatment attenuating the progression of allergic asthma. To date, there is a lack of studies investigating the economic consequences of SCIT on health care expenditures.

Methods

A health-economic piggy-back analysis of SCIT was conducted based on a RCT that enrolled 65 children and adolescents with allergic asthma. Patients were allocated into two groups: A group receiving SCIT with a high-dose hypoallergenic house dust mite preparation plus asthma medication and a control group receiving only asthma medication. For both groups asthma control was achieved before the start of the SCIT treatment and was maintained during the study. Both, costs and cost-effectiveness of SCIT with the high-dose hypoallergenic house dust mite preparation were investigated based on total medication costs, incremental medication costs and treatment effects (measured as lung function), respectively. A bootstrap analysis was performed to validate the results.

Results

A steady decline in medication costs could be observed in the SCIT group one year after treatment start compared to the control group. This cost trend became statistically significant 3 years after SCIT started. The calculated potential savings in the SCIT group correlated with an improved lung function. The distribution of the bootstrap results revealed that the probability of SCIT having a superior effectiveness compared to the control group is around 90%.

Conclusion

SCIT with a high-dose hypoallergenic preparation received by children and adolescents suffering from mite induced allergic asthma reduces the allergic medication intake and has cost-saving effects. Additional costs associated with SCIT may be completely compensated by drug cost savings 4 years after end of SCIT. Additionally, SCIT is superior compared to routine care as measured by the lung function that improved in SCIT-treated patients. Trial registration: (EudraCT no. 2004 – 003892 – 35).

Major comorbid conditions in asthma and association with asthma-related hospitalizations and emergency department admissions in adults: results from the German National Health Telephone Interview Survey (GEDA) 2010

BACKGROUND

It remains unclear to what extent asthma in adults is linked to allergic rhinitis (AR), gastroesophageal reflux disease (GERD), and acetylsalicylic acid exacerbated respiratory disease (AERD), and how these comorbidities may affect asthma outcomes in the general population. We therefore aimed to assess the prevalence of these major comorbidities among adults with asthma and examine their impact on asthma exacerbations requiring hospital care.

METHODS

A total of 22,050 adults 18 years and older were surveyed in the German National Health Telephone Interview Survey (GEDA) 2010 using a highly standardized computer-assisted interview technique. The study population comprised participants with self-reported physician-diagnosed asthma, among which the current (last 12 months) prevalence of AR and GERD-like symptoms (GERS), and life-time prevalence of AERD was estimated. Weighted bivariate analyses and logistic regression models were applied to assess the association of each comorbid condition with the asthma outcome (any self-reported asthma-related hospitalization and/or emergency department (ED) admission in the past year).

RESULTS

Out of 1,136 adults with asthma, 49.6% had GERS and 42.3% had AR within the past 12 months; 14.0% met the criteria of AERD, and 75.7% had at least one out of the three conditions. Overall, the prevalence of at least one exacerbation requiring emergency room or hospital admission within the past year was 9.0%. Exacerbation prevalence was higher among participants with comorbidities than among those without (9.8% vs. 8.2% for GERS; 11.2% vs. 7.6% for AR, and 22.2% vs. 7.0% for AERD), but only differences in association with AERD were statistically significant. A strong association between asthma exacerbation and AERD persisted in multivariable logistic regression analyses adjusting for sex, age group, level of body mass index, smoking status, educational attainment, and duration of asthma: odds ratio (OR) = 4.5, 95% confidence interval (CI) = 2.5-8.2.

CONCLUSIONS

Data from this large nation-wide study provide evidence that GERS, AR and AERD are all common comorbidities among adults with asthma. Our data underline the public health and clinical impact of asthma with complicating AERD, contributing considerably to disease-specific hospitalization and/or ED admission in a defined asthma population, and emphasize the importance of its recognition in asthma care.

Safety and feasibility of bronchial thermoplasty in asthma patients with very severe fixed airflow obstruction: a case series

OBJECTIVE

Bronchial thermoplasty (BT) can provide relief for patients with severe, uncontrolled asthma despite maximal medical therapy. However, it is unclear whether BT is safe in patients with very severe airflow obstruction.

METHODS

We performed BT in eight patients with severe asthma as defined by Expert Panel Report 3 (EPR-3) guidelines who were poorly controlled despite step 5 therapy. Data were available on each subject for 1 year prior to and 15-72 weeks following BT.

RESULTS

The mean (±SEM) pre-bronchodilator forced expiratory volume in one second (FEV(1)) prior to BT was 51.8 ± 8.6% of predicted, and the mean (±SEM) number of hospitalizations for asthma in the year prior to BT was 2.9 ± 1.2. No subject had an unexpected severe adverse event due to BT. Among the eight patients with follow-up of at least 15 weeks, there was no significant decline in FEV(1) (p = .4).

CONCLUSION

We suggest that BT may be safe for asthma patients with severe airflow obstruction and higher hospitalization rates than previously reported.

Aspirin-intolerant asthma in the Korean population: prevalence and characteristics based on a questionnaire survey

BACKGROUND

Aspirin-intolerant asthma is a unique clinical syndrome characterized by acute bronchoconstriction following the administration of aspirin and/or non-steroidal anti-inflammatory drugs.

OBJECTIVE

We assessed the prevalence and investigated the demographic and clinical characteristics of adult patients with aspirin-intolerant asthma in Korea.

METHODS

Using an adult asthma cohort (COREA) from 11 university hospitals in Korea, we analyzed the prevalence of aspirin-intolerant asthma, defined as a positive response to the question: "Have you ever experienced dyspnea and cough after taking an aspirin or any NSAID (cold medicine)?" Demographic and clinical characteristics were compared between patients with aspirin-intolerant asthma and aspirin-tolerant asthma.

RESULTS

Aspirin-intolerant asthma was reported in 68 (5.8%) of 1173 adult asthmatics (age 15-84). Patients with aspirin-intolerant asthma had a lower mean age (43.9 ± 13.4 vs. 49.0 ± 15.6, P = 0.003) and a higher prevalence of rhinosinusitis (77.9% vs. 61.7%, P = 0.012) and atopic dermatitis (16.2% vs. 5.7%, P = 0.001) than aspirin-tolerant asthma patients. There were no significant differences in lung function, asthma severity or the use of asthma controllers. However, aspirin-intolerant asthma was associated with greater use of healthcare services over a lifetime and over the past 12 months. Aspirin-intolerant asthma was significantly associated with emergency room visits over the past 12 months (P = 0.029, OR 2.19, 95% CI 1.08-4.42).

CONCLUSION

Based on histories, the prevalence of aspirin-intolerant asthma is 5.8% among adult asthma patients in Korea. Aspirin-intolerant asthma is associated with lower age, higher prevalence of rhinosinusitis and atopic dermatitis, and more frequent exacerbations.