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.

Allergic rhinitis and other comorbidities associated with asthma control in Thailand

Background

Asthma and allergic rhinitis (AR) can coexist and cause disabilities. This study aimed to assess the association between AR, asthma control, asthma-related quality of life, and other comorbidities.

Methods

A cross-sectional study was conducted in adults with asthma in six hospitals in Thailand. The outcomes were association of asthma control assessed by the asthma control test (ACT), AR, and asthma comorbidities. Not-well-controlled asthma was defined as ACT scores ≤22. The severity of AR was determined by visual analog scale (VAS). Severe AR was defined as VAS ≥5. Asthma-related quality of life (AQLQ), comorbidities, and total IgE were recorded.

Results

A total of 682 asthmatic patients were included. Median (IQR) age was 58.0 (47.0-64.0) years. 69.9% were female. Not-well-controlled asthma was present in 44.7%. The prevalence of AR was 86.1%. Moderate/severe persistent AR was diagnosed in 21.7% and severe AR was diagnosed in 30.2% of the patients. Inhaled corticosteroid-containing regimens were prescribed in 97.7% of patients. Intranasal corticosteroid and antihistamine were prescribed in 65.7 and 31.7%, respectively. Patients with not-well-controlled asthma had higher body mass index, VAS scores, proportions of pollution exposure, aeroallergen sensitization, severe AR, nasal polyp, urticaria, food allergy, gastroesophageal reflux disease, depression and anxiety, peptic ulcer, and asthma exacerbations, but younger age, lower AQLQ scores, and lower FEV1. Correlation was found between AR severity and ACT (r = -0.461, p < 0.001), AQLQ (r = -0.512, p < 0.001), and total IgE (r = 0.246, p < 0.023). Multiple regression analysis revealed that ACT, AQLQ, and percentage of FEV1/FVC were significantly associated with severe AR.

Conclusion

Allergic rhinitis is prevalent in Thai asthmatic patients. AR severity is associated with asthma control, quality of life, and pulmonary function. Comprehensive care is essential for patients with uncontrolled asthma, particularly when coexisting with conditions.

Randomized, Double-Blind, Placebo-Controlled Trial of Vitamin D Supplementation in the Build-up Phase of House Dust Mite-Specific Immunotherapy

PURPOSE

Vitamin D (VitD) is an immunomodulatory molecule capable of alleviating allergic symptoms. However, the effectiveness of allergen-specific immunotherapy (AIT) is not commonly evidenced in the early build-up phase. The aim of the study was to determine the potential of VitD supplementation in this treatment phase.

METHODS

Thirty-four house dust mite (HDM)-allergic adult patients treated with subcutaneous AIT were randomized to receive VitD2 60,000 IU/week or placebo for 10 weeks and followed up for 10 weeks. The primary endpoints were the symptom-medication score (SMS) and the treatment response rate. The secondary endpoints were eosinophil count and levels of plasma IL-10, Der p 2-specific IgG4, and dysfunctional regulatory T (CRTH2⁺ Treg) cells.

RESULTS

Of 34 patients, 15 in each group completed the study. Patients with VitD deficiency receiving a VitD supplement showed significantly lower mean change SMS than the placebo group in weeks 10 (mean difference -54.54%, P = 0.007) and 20 (mean difference -42.69%, P = 0.04). The percentage of treatment responders reached 78% and 50% in the VitD and placebo groups, respectively, and the effect remained in week 20 (89% and 60%). No significant difference was observed for the tested immunological read-outs, with the exception of the frequency of CRTH2⁺ Treg cells, which was remarkably reduced in the VitD-treated patients. Moreover, improvement in SMS was correlated to the number of CRTH2⁺ Treg cells. Our in vitro experiment indicated that VitD downregulated activation markers, whereas it improved the function of CRTH2⁺ Treg cells.

CONCLUSIONS

VitD supplementation in the build-up phase of AIT could relieve symptoms and decrease Treg cell dysfunction, especially in patients with VitD deficiency.

Risk of Adverse Events of Live-Attenuated COVID-19 Vaccination Among Atopic Patients

PURPOSE

Atopic patients have more risk of adverse drug reactions. COVID-19 vaccination is very important in the current situation. We still do not have data about risks of adverse effects from vaccine in atopic patients. The goal of our study was to evaluate atopic risks and adverse effects of live-attenuated Oxford/AstraZeneca COVID-19 vaccination.

PATIENTS AND METHODS

Data was collected using a prospective descriptive cohort study from participants 18 years old and above who came to the Outpatient Department, Panyananthaphikkhu Chonprathan Medical Center for live-attenuated COVID-19 vaccination between March and December 2021. The sample size was 3016 individuals. The information about adverse reactions at 6, 2, 72 hours and 7.30 and 60 days after each live-attenuated Oxford/AstraZeneca COVID-19 vaccination was collected by telephone. Participants with history of severe allergic reaction to vaccine components were excluded.

RESULTS

There were 732 atopic patients and 2284 non-atopic patients. Atopic patients included 556 with allergic rhinitis, 83 with asthma, 23 with urticaria and 73 with food allergies. The underlying diseases of hypertension, hyperlipidemia and hyperthyroidism were more common in non-allergic patients, with p-value <0.001, <0.001 and 0.042, respectively. Atopic patients developed significantly more fever, nausea and vomiting, skin rash (urticaria), and local reaction than non-atopic patients, with p-values of <0.001, 0.018, <0.001 and <0.001, respectively.

CONCLUSION

Atopic patients had more risk of adverse reactions to live-attenuated Oxford/AstraZeneca COVID-19 vaccination. No life-threatening adverse reaction was seen. Physicians should screen atopic risks in people who are getting vaccinated. Atopic patients should be knowledgeable about their risk and how to monitor clinical reactions by themselves.

Dietary Factors Associated with Asthma Development: A Narrative Review and Summary of Current Guidelines and Recommendations

Asthma is a complex disease, caused by a combination of genetic and environmental factors. The prevalence of asthma is increasing too rapidly to be attributable to genetic factors alone. Thus, environmental factors are becoming increasingly recognized as the cause of asthma. Modifying these environmental factors may be a simple approach for asthma prevention. To date, dietary intervention is an interesting modifiable factor because it can be implemented at the population level. The modification of systemic inflammation, oxidation, and microbial composition might be a mechanistic basis for prevention. This review summarizes the mechanistic basis and evidence from clinical studies on the association between dietary factors and asthma development. We also summarize the recommendations from many organizations and regional guidelines to assist the practicing physician to improve patient care.

Allergic Rhinitis: What Do We Know About Allergen-Specific Immunotherapy?

Allergic rhinitis (AR) is an IgE-mediated disease that is characterized by Th2 joint inflammation. Allergen-specific immunotherapy (AIT) is indicated for AR when symptoms remain uncontrolled despite medication and allergen avoidance. AIT is considered to have been effective if it alleviated allergic symptoms, decreased medication use, improved the quality of life even after treatment cessation, and prevented the progression of AR to asthma and the onset of new sensitization. AIT can be administered subcutaneously or sublingually, and novel routes are still being developed, such as intra-lymphatically and epicutaneously. AIT aims at inducing allergen tolerance through modification of innate and adaptive immunologic responses. The main mechanism of AIT is control of type 2 inflammatory cells through induction of various functional regulatory cells such as regulatory T cells (Tregs), follicular T cells (Tfr), B cells (Bregs), dendritic cells (DCregs), innate lymphoid cells (IL-10⁺ ILCs), and natural killer cells (NKregs). However, AIT has a number of disadvantages: the long treatment period required to achieve greater efficacy, high cost, systemic allergic reactions, and the absence of a biomarker for predicting treatment responders. Currently, adjunctive therapies, vaccine adjuvants, and novel vaccine technologies are being studied to overcome the problems associated with AIT. This review presents an updated overview of AIT, with a special focus on AR.

CoronaVac COVID-19 Vaccine-Induced Anaphylaxis: Clinical Characteristics and Revaccination Outcomes

Anaphylaxis to CoronaVac, an inactivated vaccine against COVID-19, is extremely rare. We report 12 cases of anaphylaxis after CoronaVac administration, focusing on clinical characteristics and management outcomes. Skin test and graded vaccine challenge were successfully performed in our cases and might be considered if an inactivated vaccine is the only remaining option.

Chlorhexidine Allergy: Current Challenges and Future Prospects

Chlorhexidine is a synthetic bisbiguanide antiseptic and was introduced in healthcare use in 1954. Allergy to chlorhexidine has been increasingly reported particularly in the perioperative and medical procedural settings. The hypersensitivity reactions range from mild cutaneous reactions to anaphylaxis or death. There are many products and medical devices containing chlorhexidine that sometimes lack standardized labeling. With the various routes of chlorhexidine exposure, accidental or recurrent reactions in chlorhexidine-allergic patients have been reported. Therefore, we aim to review the most recent evidence in clinical manifestations, diagnostic methods, management, and preventive measures with a focus on the unique features of chlorhexidine allergy.

Venipuncture Rate of Liver Function Tests for Patients being Treatment with Statin in Clinical Practice: A Therapeutic Dilemma

BACKGROUND

Statin or 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors are hypolipidemic agent. Its main functionality is to reduce cholesterol. The low-density lipoprotein cholesterol is the major cause of myocardial infarction. The adverse effect of this medication is hepatotoxicity. Doctors always request patient on statin treatment to obtain blood by venipuncture for liver function tests (LFTs) frequently. There are no researches studying the rate and expenditure of venipuncture for LFTs in patients being treated with statin.

OBJECTIVE

To study unnecessary rate on venipuncture for LFTs in patients being treatment with statin at an outpatient clinic.

MATERIAL AND METHOD

Retrospective cohort study. Data are collected from medical records that being treatment with statin at an outpatient clinic, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University between March 1, 2012 and March 1, 2014. The 441 patients are divided into two groups. The first group is treated with the appropriate venipuncture for LFTs and the second group is treated with unnecessary venipuncture for LFTs. The expenditure for both groups are used to calculate and compare costs.

RESULTS

The number of unnecessary venipuncture in the LFTs group is 308 samples (69.84%). The sample proportions are 85.06% come from staff (262 samples) and 14.94% come from interns (46 samples). The number of appropriate venipuncture for LFTs is 133 samples (30.16%). The sample proportions are 77.44% come from staff (103 samples) and 22.56% come from interns (30 samples). The expenditure of the unnecessary venipuncture for LFTs had a statistically significant difference from the appropriate venipuncture for LFTs [75,500 vs. 4,400 baht (THB)] (p<0.05).

CONCLUSION

The expenditure for the unnecessary venipuncture LFTs in patient being treated with statin at the outpatient clinic is statistically higher than the appropriate venipuncture (p<0.05).