A comparison of the efficacy and safety of inhaled corticosteroids in asthma

The right tools at the right time

Asthma is underdiagnosed and undertreated or inappropriately treated, even though approximately 300 million people worldwide currently have the disease. While asthma in most patients can be controlled using currently available medications, in practice this rarely happens. Despite the wide availability of treatment guidelines, there are clear discrepancies between recommendations and the reality of treatment. There is excessive use of relief medications, particularly among patients with moderate-to-severe persistent asthma, coupled with a marked underuse of inhaled corticosteroids (ICS). This underuse by patients is likely to be related to anxiety about side effects and a misunderstanding about asthma. Many patients overestimate their degree of control and have a perceived lack of need for medication. Early therapeutic intervention, with optimal antiinflammatory therapy and a stepwise approach, has a positive impact on long-term outcomes, achieving suppression of airway inflammation, prompt symptom control, and restoration of pulmonary function. Even at low doses, ICS rapidly improve clinical symptoms and measures of lung function, while their long-term use markedly reduces the frequency and severity of exacerbations and asthma mortality. Although ICS monotherapy achieves successful control of persistent asthma in a significant proportion of patients, add-on therapy with a long-acting beta2-agonist provides control for most patients with moderate-to-severe persistent asthma. Fixed combination inhalers (ICS plus a long-acting beta2-agonist) have become popular, but these have drawbacks and there is the potential for overuse. In conclusion, ICS are the cornerstone of therapy for persistent asthma of all degrees of severity in adults and children, and early therapeutic intervention is recommended for optimal long-term outcome.

Pharmacological management of mild or moderate persistent asthma

Patients with mild persistent asthma rarely see their doctor with symptoms of the disease. Partly as a result of this situation, mild asthma is generally undertreated. Findings of several large randomised clinical trials have shown benefits for this population of regular treatment with low doses of inhaled corticosteroids. Additional drugs are rarely needed, and although leukotriene modifiers are effective, they are less so than inhaled corticosteroids. People with moderate persistent asthma are not well controlled on low doses of inhaled corticosteroids. A combination of this drug and long-acting inhaled beta2 agonists provides improved control compared with doubling of the maintenance dose of inhaled corticosteroids. The combination of budesonide and formoterol has been assessed as both maintenance and reliever treatment. This approach further reduces the risk for severe exacerbations. With these strategies, most individuals can achieve good control of their asthma. For patients who do not achieve asthma control despite taking drugs, measurement of the inflammatory response in the airway in induced sputum could provide further information to guide treatment.

Once-daily ciclesonide in children: efficacy and safety in asthma

OBJECTIVE

To compare the efficacy and safety of once-daily inhaled ciclesonide 40 mug (CIC40), 80 mug (CIC80), and 160 mug (CIC160) with placebo in children with persistent asthma of all severities.

STUDY DESIGN

Overall, 1031 children age 4 to 11 years were randomized into 2 identical double-blinded, placebo-controlled, parallel group studies consisting of a run-in phase followed by 12 weeks of treatment. Both studies were designed to allow for a prespecified integrated analysis. The primary outcome variable was change in forced expiratory volume in 1 second (FEV(1)) percent predicted between baseline and study end; treatment comparisons were assessed using analysis of covariance. Additional endpoints included asthma symptom scores, daily albuterol use, and safety, including hypothalamic-pituitary-adrenal (HPA) axis function.

RESULTS

Baseline characteristics were comparable; 59.4% of patients had moderate asthma, and 24.1% had severe asthma. All ciclesonide doses were associated with greater improvements in baseline to week 12 FEV(1) percent predicted versus placebo (CIC40, 11.97; CIC80, 13.58, P <.05; CIC160, 14.17, P < .01). Significant improvements in asthma symptoms (P < .01) and reductions in albuterol use were reported. Ciclesonide was well tolerated with no effect on HPA axis function.

CONCLUSIONS

In this integrated analysis, ciclesonide was effective and well tolerated in children with persistent asthma.

Modulation of p-glycoprotein and breast cancer resistance protein by some prescribed corticosteroids

Efflux transporters, p-glycoprotein and breast cancer resistance protein (BCRP), located at barrier sites such as the blood-brain barrier may affect distribution of steroids used for treating chronic inflammatory conditions and thus the extent to which they may perturb the hypothalamic-pituitary-adrenal axis. In the present study, six different glucocorticoids were investigated for their possible interactions with these efflux transporters. Beclomethasone dipropionate, mometasone furoate and ciclesonide active principle but not fluticasone propionate or triamcinolone, (all at 0.1 to 10 microM) caused inhibition of efflux, resulting in increased accumulation of mitoxantrone in BCRP-expressing MCF7/MR breast cancer cells and of calcein in p-glycoprotein-expressing SW620/R colon carcinoma cell. At 5 microM the same three increased sensitivity of p-glycoprotein-expressing SW620/R to doxorubicin and stimulated ATPase activity associated with BCRP expressed in bacterial membrane vesicles. Budesonide also stimulated ATPase activity. These data demonstrate the capacity of some clinically used glucocorticoids to interact with efflux transporters.

Initiation, dose reduction, and duration of inhaled corticosteroid therapy

Asthma is characterized by persistent airway inflammation, which is associated with airway hyperresponsiveness and variable airflow obstruction, which accounts for the majority of symptoms experienced by asthmatic patients. Allergen sensitization and inhalation causes airway inflammation, and is likely important in the initiation and persistence of asthma in more than 50% of patients, and while allergen avoidance (or avoidance of other initiating factors, such as occupational sensitizers) can help some patients, it is often difficult to achieve. For this reason, pharmacologic treatment to reduce airway inflammation is currently the cornerstone of therapy for most individuals who have asthma.

Inhaled Corticosteroids Adverse Events In Asthmatic Children: A Review

BACKGROUND: Inhaled corticosteroids (ICS) have an important role in the treatment of chronic asthma in children. The prevalence of asthma symptoms in children varies from 0 to 30 percent in different populations with the highest prevalence occurring in Australia, New Zealand and England. METHODS: A review of the literature and studies about inhaled corticosteroids safety, action and adverse events in children and adults where applicable was done. CONCLUSION: Inhaled corticosteroids are the main stay therapy for persistent asthma in children. Their safety and efficacy is proven from the literature. Proper education of the parents about asthma and inhaled corticosteroids is very important and improve asthma control. Keeping in mind to taper the inhaled corticosteroids to the lowest dose needed to control asthma and using correct inhalation technique by the use of spacers with metered dose inhalers or dry powder inhalers (Turbuhaler and Diskus) will prevent the occurrence of adverse events.

Dry powder inhalers for pulmonary drug delivery

The pulmonary route is an interesting route for drug administration, both for effective local therapy (asthma, chronic obstructive pulmonary disease or cystic fibrosis) and for the systemic administration of drugs (e.g., peptides and proteins). Well-designed dry powder inhalers are highly efficient systems for pulmonary drug delivery. However, they are also complicated systems, the the performance of which relies on many aspects, including the design of the inhaler (e.g., resistance to air flow and the used de-agglomeration principle to generate the inhalation aerosol), the powder formulation and the air flow generated by the patient. The technical background of these aspects, and how they may be tuned in order to obtain desired performance profiles, is reviewed. In light of the technical background, new developments and possibilities for further improvements are discussed.

Safety of inhaled corticosteroids: room for improvement

Inhaled corticosteroids (ICS) are the standard of care in asthma and are widely used in the treatment of patients with chronic obstructive pulmonary disease. High-dose regimens and long-term use of ICS in predisposed individuals may be associated with a variety of side effects, similar to those observed with systemic corticosteroid therapy. Side effects associated with long-term ICS use include reduction in growth velocity, cataracts, glaucoma, osteoporosis, and fractures. Fear of unwanted complications may be of concern in all patients using ICS, particularly in age- and gender-specific populations that are more prone to develop side effects or to reduce treatment adherence because of physical, behavioral, or psychological problems. In addition to concerns about ICS safety, dosing regimens that are difficult to follow may further reduce a patient's ability to comply with treatment. Ciclesonide, a new-generation ICS with unique pharmacokinetic properties, was developed to provide effective anti-inflammatory control for asthma with once-daily administration to improve patient adherence and a high safety profile to reduce the occurrence of local and systemic side effects.

Idealhalers or realhalers? A comparison of Diskus and Turbuhaler

Medication for the treatment of asthma and chronic obstructive pulmonary disease should be given locally by inhalation. There is, however, no such thing as an ideal inhaler, or 'Idealhaler', which has all desired properties with no drawbacks. In this short review, we have compared the relative merits of the two most commonly used dry powder inhalers -- Turbuhaler and Diskus. Clinical effect is related to the amount of inhaled drug that reaches the lungs, and this in turn depends on the amount of fine particles generated at inhalation. Turbuhaler is more than twice as effective as Diskus at generating fine particles, and the higher lung deposition with Turbuhaler is accompanied by a lower variability in lung deposition. Compared with Diskus, the lung deposition with Turbuhaler is affected less by factors such as humidity.

Fluticasone versus placebo for chronic asthma in adults and children

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The use of sterically stabilized liposomes to treat asthma

Asthma is characterized by airway hyperresponsiveness, chronic inflammation, and airway remodeling, which may lead to progressive, irreversible lung damage. Liposomes have been used for the delivery of aerosolized asthma medications into the lungs. This method could facilitate sustained action of steroids while using only a fraction of the dosage and a less frequent dosing interval than conventional therapy. We describe the evaluation of the effect of budesonide encapsulated in sterically stabilized liposomes on lung inflammation and airway hyperreactivity in a mouse model of asthma. We outline the determination of markers implicated in the progression of asthma, including histopathology, eosinophil peroxidase activity in bronchoalveolar lavage, and airway hyperresponsiveness to methacholine. Weekly administration of budesonide in sterically stabilized liposomes results in a significant reduction in the total lung inflammation score, peripheral blood eosinophil counts, and the total serum IgE level, similar to that obtained with daily budesonide. Airway hyperresponsiveness to methacholine challenge decreases significantly in the group treated with weekly budesonide in sterically stabilized liposomes, while it does not decrease in the daily budesonide group.

Evidence for ototopical glucocorticoid-induced decrease in hypothalamic-pituitary-adrenal axis response and liver function

To clarify whether ototopical glucocorticoid treatment is associated with impaired hypothalamic-pituitary-adrenal axis (HPA) activity and altered hepatic metabolism, one commercially available dexamethasone-containing ointment was tested. At present, very little is known about the effects of ototopical glucocorticoid treatment on HPA and liver function. Ten beagle dogs received two daily therapeutic doses of dexamethasone (0.6 mg/ear) in the outer auditory canal for 21 d in a single-blind, placebo-controlled study. Resting cortisol concentrations were assessed before, during, and after treatment using an RIA system. Adrenal function and HPA feedback sensitivity were measured by a standard dose (250 microg) ACTH stimulation test. Serum biochemical and hematological parameters were measured, whether ototopical glucocorticoids affect hepatic function was studied, and blood cell counts were made. Ototopical dexamethasone treatment induced a marked suppression (to about 100%) of resting plasma cortisol concentrations below the placebo effect (P < 0.0001) within the first 11 d, and these remained reduced during the entire treatment period up to d 19. As well, an ACTH stimulation test found a markedly reduced rise in plasma cortisol concentrations (P = 0.0004). Concomitantly, significant increases in serum activities of alkaline phosphatase, gamma-glutamyl transferase, alanine transaminase, and aspartate transaminase were detected. Moreover, we found a significant reduction in differential leukocyte counts of eosinophils and lymphocytes, whereas neutrophils increased. Although cortisol levels and hematological parameters returned to baseline 7 d after treatment cessation, liver enzyme activities remained elevated. In conclusion, these findings suggest that after ototopical application, dexamethasone is sufficiently absorbed from the auditory canal to suppress HPA function as well as to alter metabolic and hemopoietic profiles. Thus, in long-term treatment of otitis externa or media, the systemic adverse suppression of HPA has to be considered in relation to stress exposure, whereas changes in serum enzyme activities may not be interpreted as hepathopathy.

Liposomal methylprednisolone differentially regulates the expression of TNF and IL-10 in human alveolar macrophages

Glucocorticoids (GC) are frequently used for therapy of various inflammatory lung diseases by either systemic or inhalative application. Because the oral application often has various side effects and because the inhalative application is not as potent, new formulations of GCs are required. We evaluated the effect of a liposomal (Lip) formulation of methylprednisolone (MP) on the expression of lipopolysaccharide (LPS)-induced proinflammatory tumor necrosis factor (TNF) and antiinflammatory interleukin-10 (IL-10) in human alveolar macrophages (AM). AM were obtained from bronchoalveolar lavage fluids of patients with various inflammatory lung diseases and precultured 20 h+/-MP, either liposomal or free, and then stimulated with LPS. Cells were harvested for analysis of mRNA levels by real-time reverse transcriptase polymerase chain reaction (RT-PCR); supernatants were used to measure protein concentrations by ELISA. We confirm the suppression of LPS-induced TNF production by an average of factor 7 at the mRNA level and factor 3 at the protein level. On the other hand, we detected a strong increase of the IL-10 production by MP. At the mRNA level, liposomal MP alone led to an 18-fold increase, and the LPS-induced IL-10 mRNA was enhanced by factor 2. At the protein level, MP alone had no effect, but LPS-induced IL-10 was increased by factor 2.5. Our data show that liposomal MP can consistently induce IL-10 and reduce TNF when macrophages are exposed for a prolonged period of time. In all respects, liposomal MP had similar activities as free MP, but liposomes were selectively taken up by monocytes and macrophages and not by lymphocytes in blood and in the lung. This suggests that liposomal glucocorticoids when applied locally in the lung may act efficiently but with less side effects.

Optimizing inhaled corticosteroid therapy in children with chronic asthma

Asthma is the most common chronic illness among children, and inhaled corticosteroids (ICS) are the most effective long-term therapy available for suppressing airway inflammation in persistent asthma. While the primary aim of ICS therapy is good efficacy with minimal side effects, early diagnosis and treatment of asthma can also improve asthma control and normalize lung function, and may prevent irreversible airway injury. Poor patient compliance is a major barrier to treatment. Simplified dosing regimens (e.g., once-daily administration), good inhaler technique, and education of the patient/caregiver should improve patient compliance. Concerns over ICS therapy are often based on the potential for systemic effects associated with oral corticosteroids (e.g., effects on bone mineral density, or growth suppression in children). Since adverse events are associated with high doses of ICS, the dose in all patients should be titrated to the minimum effective dose required to maintain control. Optimal distribution of an ICS in the lungs rather than the systemic compartment is affected by several factors, including the drug's pharmacokinetic profile, inhaler type, inhaler technique, and drug particle size. For young patients unable to use a dry-powder inhaler or pressurized metered-dose inhaler, a nebulizer facilitates drug delivery through passive inhalation; ICS therapy in the form of budesonide inhalation suspension can be given to children with persistent asthma from 12 months of age. In conclusion, selecting a drug with good efficacy and minimal side effects, such as budesonide, together with an easy-to-use delivery system and ongoing patient/caregiver education, is important in optimizing ICS therapy for children with persistent asthma.

Adrenal Suppression with Dry Powder Formulations of Fluticasone Propionate and Mometasone Furoate

Mometasone furoate (MF) and fluticasone propionate (FP) are high potency inhaled corticosteroids. The systemic bioavailability of MF is claimed to be negligible, leading to a minimal potential for systemic adverse effects. We assessed the overnight urinary cortisol/creatinine as the primary outcome of adrenal suppression in 21 patients with persistent asthma (mean FEV1 = 91%). Patients were randomized in a crossover fashion to receive 2 weekly consecutive doubling incremental doses of either FP Accuhaler (500, 1,000, and 2,000 microg/day) or MF Twisthaler (400, 800, and 1,600 microg/day). For the 21 per protocol completed patients, there was significant suppression of overnight urinary cortisol/creatinine with high and medium doses of both drugs-as geometric mean fold suppression (95% confidence interval) from baseline: FP 2,000 microg, 1.85 (1.21-2.82, p = 0.002); FP 1,000 microg, 1.45 (1.07-1.96, p = 0.02); MF 1,600 microg, 1.92 (1.26-2.93, p = 0.001); and MF 800 microg, 1.39 (1.04-1.88, p = 0.02). For secondary outcomes of 8:00 A.M. plasma cortisol, serum osteocalcin, and early morning urinary cortisol/creatinine, there was significant suppression with MF and FP at the highest dose. Our data refute the assertion that MF has negligible systemic bioavailability and a lower potential for systemic adverse effects compared with FP.

Efficacy and safety of mometasone furoate dry powder inhaler vs fluticasone propionate metered-dose inhaler in asthma subjects previously using fluticasone propionate

OBJECTIVE

To compare the efficacy and safety of mometasone furoate dry powder inhaler (DPI) administered once daily in the evening with fluticasone propionate metered-dose inhaler (MDI) administered twice daily.

METHODS

An 8-week, randomized, open-label, parallel-group study compared mometasone furoate DPI, 400 microg every evening (1 puff daily), with fluticasone propionate MDI, two 125-microg puffs twice daily, in 167 adults and adolescents with moderate persistent asthma previously using fluticasone propionate. The primary efficacy variable was the change in forced expiratory volume in 1 second (FEV1) from baseline to the end point. Variables such as response to therapy and subject satisfaction with the inhaler devices were also analyzed.

RESULTS

Improvement in FEV1 was noted at the week 2 visit with both treatments. This improvement was maintained at the 4- and 8-week visits and at the end point for both groups. The mean percent change in FEV1 from baseline to the end point was 4.58% with mometasone furoate DPI and 6.98% with fluticasone propionate MDI (P = .35). At the end point, physicians rated 62% of the mometasone furoate DPI group as "improved" or "much improved" compared with 47% of the fluticasone propionate MDI group (P = .007). A significantly greater proportion of subjects in the mometasone furoate DPI group "liked the inhaler a lot" vs subjects in the fluticasone propionate MDI group (46.8% vs 22.4%; P = .01). Both treatments were well tolerated.

CONCLUSION

Mometasone furoate DPI, 400 microg every evening, provided comparable efficacy as fluticasone propionate MDI, two 125-microg puffs twice daily, in subjects with moderate persistent asthma previously treated with fluticasone propionate.

Topical treatment with aqueous solutions of rofleponide palmitate and budesonide in a pollen-season model of allergic rhinitis

BACKGROUND

Rofleponide palmitate is an esterified glucocorticosteroid pro-drug with a promising pre-clinical profile designed to deliver topical airway treatment for allergic rhinitis and asthma in a novel manner. Thus, the rofleponide palmitate pro-drug is designed to provide topical exposure of the mucosa to the inactive lipophilic drug, which would be locally metabolized to the more hydrophilic and readily cleared drug rofleponide.

OBJECTIVE

To examine whether rofleponide palmitate affects nasal symptoms and peak inspiratory flow (PIF) in a pollen-season model of allergic rhinitis and to compare any such effects with those of another glucocorticosteroid (i.e., budesonide).

METHODS

During the pollen-free season, 40 patients with strictly seasonal allergic rhinitis received topical nasal spray treatment with an aqueous solution of rofleponide palmitate 400 microg and an aqueous solution of budesonide 128 microg once daily for 10 days in a double-blind, placebo-controlled, and crossover study. After 3 days of drug treatment, individualized allergen challenges were given once daily for 7 days while the treatment continued. The washout periods between each of the challenge series were 2 weeks. Nasal symptoms and PIF were recorded in the morning and evening, as well as 10 and 20 min after each allergen challenge. The mean recordings obtained during the last 3 days of the allergen-challenge series, when symptoms were established and when the treatment had lasted for 8-10 days, were used in the analysis.

RESULTS

Both active treatments reduced nasal symptoms and improved nasal PIF compared with placebo (P<0.01-0.001). There was no overall difference in efficacy between rofleponide palmitate 400 microg and budesonide 128 microg.

CONCLUSIONS

Topical treatment with aqueous solutions of rofleponide palmitate attenuates nasal symptoms and improves nasal PIF in allergic rhinitis. The overall efficacy of 400 microg of rofleponide palmitate is similar to that of 128 microg of budesonide in the pollen-season model used in this study.

Oral corticosteroid-sparing effects of inhaled corticosteroids in the treatment of persistent and acute asthma

OBJECTIVE

To review the efficacy and safety of inhaled corticosteroids (ICSs) when used to reduce daily oral corticosteroid (OCS) requirements in patients with severe persistent asthma and periodic requirements in patients with acute asthma exacerbations.

DATA SOURCES

Clinical studies of the OCS-sparing effects of ICSs were located by searching MEDLINE databases from 1966 onward using the terms oral, steroid, and asthma in combination with the generic names for each marketed ICS.

STUDY SELECTION

Studies reporting on the use of ICSs to reduce OCS requirements in patients with persistent and acute asthma are included.

RESULTS

Clinical study results consistently show that ICSs significantly improve asthma control and reduce OCS requirements among adults, children, and infants with persistent asthma. A dose reduction or complete discontinuation of use of OCSs is possible in most patients without loss of asthma control. ICSs also can control asthma during acute asthma exacerbations and reduce the need for short courses of OCSs. With many ICSs, the reductions in OCS use are accompanied by recovery of hypothalamic-pituitary-adrenal axis function, indicating that the safety of asthma therapy is improved when OCS requirements are decreased with ICSs. Of the available ICSs that may reduce OCS needs, budesonide appears to be the most intensively studied.

CONCLUSIONS

ICSs can reduce OCS requirements in adults and children with persistent asthma and during acute asthma exacerbations. The reduced systemic corticosteroid activity associated with ICS treatment improves the overall safety of asthma therapy.

The efficacy and safety of QVAR (hydrofluoroalkane-beclometasone diproprionate extrafine aerosol) in asthma (part 1): an update of clinical experience in adults

In 1999, a robust dose-finding study showed that the chlorofluorocarbon (CFC) -free formulation of beclometasone dipropionate (BDP), QVAR (hydrofluoroalkane-134a BDP), produced equivalent asthma control to CFC-BDP at approximately half the daily dose in adults. Since then, a wealth of clinical and pharmaco-vigilance studies have been undertaken to confirm these results and establish dose-potency ratios with other inhaled corticosteroids (ICS). This review summarises the results of studies performed by the manufacturer that have been published since the last comprehensive review of the efficacy and safety of QVAR in 2000. Long-term comparisons with CFC-BDP have confirmed the durability of the 2:1 daily dosing ratio of CFC-BDP:QVAR in adults. Clinical comparisons with other ICS in both symptomatic and asymptomatic patients have established dose-potency ratios of 2: 1 for budesonide:QVAR and 1:1 for fluticasone:QVAR. Furthermore, QVAR has been associated with benefits on asthma symptomatology and quality of life, compared with other ICS that probably arises from its peripheral deposition in the lung.

Effect of MX-68 on airway inflammation and hyperresponsiveness in mice and guinea-pigs

MX-68 is a newly synthesized antifolate, which is a derivative of methotrexate (MTX). In this paper, the effect of MX-68 on allergic airway responses in mice and guinea-pigs was studied. In the first experiment, antigen-induced airway inflammation and airway hyperresponsiveness (AHR) to acetylcholine in mice were examined and compared with the effects of classical antifolate methotrexate and prednisolone. Mice were sensitized with ovalbumin as an antigen and challenged with ovalbumin inhalation three times. After the last inhalation, AHR and airway inflammation were observed. An increase in Th2 cytokines (IL-4 and IL-5) and a decrease in a Th1 cytokine (IFN-gamma) in the bronchoalveolar lavage fluid (BALF), as well as an elevation of the immunoglobulin level in serum, were observed in sensitized mice. Oral administration of MX-68 had no effect on changes of body weight, but prednisolone reduced body weight during the experiment. The antigen-induced AHR and increases in the number of eosinophils and lymphocytes in BALF were significantly inhibited by MX-68. MX-68 interfered with the elevation of IL-4 and IL-5 levels in BALF, but had no effect on the decrease in IFN-gamma. Moreover, MX-68 significantly inhibited the elevation of serum IgE and IgG levels. In the guinea-pig model for bronchial asthma, biphasic increases in airway resistance (immediate asthmatic response, IAR, and late asthmatic response, LAR), as well as accumulated inflammatory cells in BALF, were observed after repeated antigen challenge. These asthmatic responses and inflammatory signs were significantly decreased by administration of MX-68. These results suggest that MX-68 obviously has an anti-inflammatory effect in an animal model of asthma and would be useful clinically for the treatment of bronchial asthma.

Effectiveness of budesonide administered via dry-powder inhaler versus triamcinolone acetonide administered via pressurized metered-dose inhaler for adults with persistent asthma in managed care settings

BACKGROUND

Clinical studies have demonstrated the efficacy and relative safety of inhaled corticosteroids in the treatment of asthma. However, effectiveness and cost-effectiveness comparisons of available inhaled corticosteroids in real-life clinical settings are lacking.

OBJECTIVE

This study compared the effectiveness and safety of budesonide administered via dry-powder inhaler versus that of triamcinolone acetonide administered via pressurized metered-dose inhaler in the treatment of adult patients with persistent asthma treated in a managed care setting.

METHODS

This was a randomized, open-labe, 52-week study of adult patients (aged >or= 18 years) with persistent asthma enrolled in 25 US health plans. The primary study outcome was mean change from baseline to the end of treatment in symptom-free days. Secondary variables were changes from baseline in number of episode-free days, episode-free days at 52 weeks, forced expiratory volume in 1 second (FEV(1)), forced vital capacity, asthma symptom scores, breakthrough bronchdilator use, patient discontinuations, and health-related quality of life. Patients were issued diaries in which to record use of study medication and concomitant asthma medication use, as well as daytime and nighttime asthma symptom severity. Patients were assessed at weeks 4, 13, 26, 39, and 52. Safety was assessed based on adverse events and changes in laboratory tests, vital signs, and physical examinations.

RESULTS

A total of 945 patients (344 men, 601 women; mean [SD] age, 46.8 [14] years) were enrolled; 631 received budesonide and 314 received triacinolane acetonide. Improvements in all effectiveness variables were observed with both treatments. The mean increase from baseline in the number of symptom-free days per month assessed at month 12 was 7.74 (95% CI, 6.81-8.66) for patients receiving budesonide and 3.78 (95% CI, 2.47-5.09) for patients receiving triamcinoline acetonide ( P<0.001). The estimated annual mean (SD) number symptom-free days for patients receiving budesonide was 141.1 (125.0) over the treatment phase, compared with 99.3 (112.1) for those receiving triamcinolone acetonide (P<0.001). Patients receiving budesonide demonstrated significant improvements (compared with those receiving triamcinolone acetonide) in overall quality of life, daytime and nighttime asthma symptom severity, breakthrough bronchodilator use, and FEV(1) (all P<0.001). Safety measures were similar between groups.

CONCLUSION

In these managed care settings, budesonide inhalation powder administered via dry-powder inhaler was significantly more effective than triamcinolone acetonide administered via pressurized metered-dose inhaler in the treatment of adults with persistent asthma.

Comparison of two budesonide dry powder inhalers in the treatment of asthma in children

The aim of this study was to compare the clinical efficacy, safety, and acceptability of budesonide inhaled from Easyhaler dry powder inhaler (DPI) (Giona Easyhaler, Orion Pharma, Finland) and from Turbuhaler DPI (Pulmicort Turbuhaler, AstraZeneca, Sweden) in the treatment of asthma in children. The 6-month, randomised, double-blind, double-dummy, parallel-group study was conducted in 229 completed, asthmatic children (5-10 years), who were symptomatic at study entry. For the first 2 months, children inhaled budesonide 2 x 200 microg b.i.d. (high-dose treatment period). Thereafter, the daily dose of inhaled budesonide was 2 x 100 microg for 4 months (low-dose treatment period). The study was carried out at 32 centers in Finland, Sweden, Norway, and Denmark. During the high-dose treatment period, the initially symptomatic patients improved in both treatment groups and the achieved control was maintained during the low-dose treatment period. An improvement was seen in the efficacy outcome parameters in the initially symptomatic patients in both treatment groups. Also, there were no differences in the number of asthma exacerbations between the treatments. The urinary free cortisol/creatinine (UCC) ratios were significantly lower in the Turbuhaler group compared to the Easyhaler group after the high-dose treatment period. In addition, there was a slight but statistically significant slower growth rate in the Turbuhaler group after the 6- month treatment period compared with the Easyhaler group. Pulmicort Turbuhaler and Giona Easyhaler are equally effective in the treatment of asthma in children aged 5-10 years old. Budesonide inhaled from Turbuhaler showed slightly greater systemic effects than budesonide inhaled from Easyhaler. The majority of children and parents preferred Easyhaler to Turbuhaler.

The role of budesonide in adults and children with mild-to-moderate persistent asthma

Asthma, a chronic and potentially life-threatening disease of the airways, affects patients of all ages. Inhaled corticosteroids (ICS) are the recommended first-line therapy for patients with persistent asthma. To review the clinical efficacy and tolerability data available on budesonide in the treatment of mild-to-moderate persistent asthma, a MEDLINE database search was performed for 1996-2003 using the following key words: budesonide, inhaled corticosteroid, efficacy, safety, systemic. When administered once or twice daily, budesonide effectively controls asthma in children, adolescents, and adults with mild-to-moderate asthma. Budesonide can be delivered effectively via a dry powder inhaler (Pulmicort Turbuhaler) in patients aged > or = 6 years or as an inhalation suspension (Pulmicort Respules) in children as young as 12 months. With over 20 years' clinical exposure, budesonide has been demonstrated to be well tolerated in the treatment of chronic asthma in patients as young as 12 months. Specifically, at doses required to treat mild or moderate persistent asthma, budesonide does not affect hypothalamic-pituitary-adrenal axis function, bone mineral density, cataract formation, or final adult height. As Pulmicort Turbuhaler, budesonide is the only ICS to achieve a Food and Drug Administration pregnancy category B rating. Early intervention with budesonide is recommended in asthma management: maximum benefit from therapy is reported in patients treated within 2 years of disease recognition. Budesonide is effective and well tolerated in the control of mild-to-moderate persistent asthma in patients aged 12 months and older. There is no evidence for variation in efficacy in population subgroups.

Preclinical properties of budesonide: translation to the clinical setting

BACKGROUND

Since the introduction of inhaled corticosteroids (ICSs) nearly 30 years ago, the management of asthma has been transformed. It is now understood that asthma is primarily a disease of chronic inflammation, even in its milder forms, and that to delay treatment may lead to deterioration in lung function. International treatment guidelines for asthma recommend early intervention with a potent ICS, with the greatest benefit observed when treatment is started within 2 years of the onset of symptoms. Each of the currently available ICSs has distinct physical and pharmacokinetic properties and is delivered via different devices.

OBJECTIVE

This article brings together the findings and concepts presented in this supplement. It provides an overview of budesonide's predicted clinical efficacy and tolerability in patients with asthma based on its physical properties and pharmacokinetic and pharmacodynamic characteristics.

CONCLUSIONS

Budesonide's physical properties and pharmacokinetic and pharmacodynamic profiles help predict its clinical efficacy and tolerability when used as early intervention in asthma. Study results indicate that lung deposition of budesonide is increased by delivery via dry-powder inhaler, enhancing the drug's efficacy in patients with newly diagnosed mild persistent asthma. The preclinical, clinical, and safety data support budesonide's predicted performance in the clinical setting.

Therapeutic margin of budesonide in patients with mild to severe asthma

BACKGROUND

The therapeutic margin of a drug is the difference between the optimal effective dose and the dose at which unacceptable adverse effects occur. This margin is particularly important in the case of therapies that are used long term for the control of chronic illnesses, such as inhaled corticosteroids (ICSs) in the treatment of asthma. Because data from controlled clinical studies indicate that the available ICSs have similar clinical efficacy, the safety profile is central to differentiating between them on the basis of their therapeutic margins. The main safety concern with long-term use and high doses of ICSs is systemic exposure that could result in such unwanted effects as cortisol suppression, a reduction in the final adult height of pediatric patients, and decreased bone mineral density.

OBJECTIVE

This article reviews data from clinical trials, including long-term prospective studies, to compare the therapeutic margin of budesonide with those of other second-generation ICSs and to determine whether there are variations in the therapeutic margin with different delivery devices, severities of disease, or patient age.

RESULTS

Based on the tolerability data for budesonide from short-term (6-12 wk) and long-term (1-9 y) studies in patients with mild to moderate persistent asthma, the dose-response and dose-tolerability curves for budesonide delivered by dry-powder inhaler can be plotted in parallel. The margin between these curves-the therapeutic margin-is favorable and consistent in pediatric and adult patients and at all degrees of asthma severity. Fewer tolerability data are available for other ICSS.

CONCLUSION

Whereas budesonide has clinical efficacy similar to that of other currently available ICSs, it has a good safety profile-and hence a favorable therapeutic margin-that is supported by long-term clinical data. Budesonides favorable therapeutic margin is probably a result of its pharmacokinetic and physical properties.

Expected characteristics of an ideal, all-purpose inhaled corticosteroid for the treatment of asthma

BACKGROUND

Inhaled corticosteroids (ICSs) are well established as the mainstay of asthma therapy. A number of ICSs are now available, each with unique pharmacokinetic/pharmacodynamic profiles and physical characteristics.

OBJECTIVE

This article reviews the key characteristics of an ideal ICS and uses examples of existing agents to indicate the extent to which therapies reach these goals.

RESULTS

Improved therapeutic efficacy in an ICS may be offset by an increase in systemic effects. The ideal characteristics of an ICS include optimal clinical efficacy and no toxicity in combination with a convenient and easy-to-use inhaler device. To achieve this optimal profile, an ICS should have the following: a high affinity for and potency at the glucocorticoid receptor; prolonged retention in the lung; minimal or no oral bioavailability (ie, high first-pass inactivation); and rapid, complete systemic inactivation. The formulation and type of inhaler device are also important considerations: they should provide deposition in the lung in both large and small airways with no absorption effects outside the lung. ICSs should be evaluated for administration with several different delivery devices to ensure ease of use by patients of all ages with different asthma severities. An ICS that can be administered QD is also likely to improve patient adherence by simplifying the treatment regimen.

CONCLUSION

An ideal ICS should have a large therapeutic margin, be used safely and effectively for long periods, be administered QD, be suitable for use in patients of all ages and asthma severities, and offer both control and prevention of asthma symptoms and exacerbations.

Review of the unique properties of budesonide

BACKGROUND

The aim of inhaled corticosteroid (ICS) therapy for asthma is to attain high therapeutic activity in the airways while keeping the risk of systemic adverse effects relatively low. However, the physicochemical and pharmacokinetic properties of various ICSs affect this ratio, thereby influencing their ability to fulfill the requirements of an ideal agent.

OBJECTIVE

This article reviews the physical and pharmacokinetic properties of budesonide, outlining how they, safety data, and use of different inhalation devices enable budesonide to meet many of the clinical requirements of an ideal ICS for the treatment of asthma.

RESULTS

ICS efficacy is influenced by lipophilicity, lung deposition, and retention in airway tissue, whereas the rate of elimination determines systemic activity. Budesonide is retained in the airways to a greater extent than other ICSs because of an esterification process that increases its lipophilicity. The prolonged retention of budesonide in the airways may contribute to its efficacy when administered QD. In addition to a pressurized metered-dose inhaler, budesonide is available as a dry-powder inhaler and in nebulized form, which can be used by asthma patients aged > or =6 months.

CONCLUSIONS

When combined with delivery devices suitable for a spectrum of patient groups, the physical and pharmacokinetic properties of budesonide lend it many of the characteristics of an ideal ICS, including favorable efficacy and tolerability profiles.

The effect of inhaled corticosteroids on the urinary calcium to creatinine ratio in childhood asthma

BACKGROUND

The use of inhaled corticosteroids (ICS) via spacers in childhood asthma is increasing. However, concern has been raised about its long-term impact. Hypercalciuria is a known adverse effect of treatment with systemic corticosteroids. The urinary calcium to creatinine ratio (UCa:Cr) is a simple, reliable and non-invasive tool for evaluation of hypercalciuria.

AIM

To determine whether ICS can induce hypercalciuria in children with asthma.

SETTING

Outpatient clinic in a referral hospital.

METHODS

The UCa:Cr was determined in 25 children aged 3-6 years with mild-to-moderate persistent asthma before and after a 2-month course of inhaled budesonide 400 micrograms/day via an aerochamber. Children who had received oral corticosteroids, diuretics, antibiotics or theophylline were excluded.

STATISTICS

Paired Student's t-test and Fisher's exact test.

RESULTS

The mean UCa:Cr was similar in the children with asthma before and after 2 months' administration of budesonide (0.10 +/- 0.10 and 0.11 +/- 0.08, respectively; p = 0.601). The numbers of hypercalciuric children were two and five, respectively (p = 0.417). In 68% of patients, the UCa:Cr increased and in 16% the increase indicated hypercalciuria (UCa:Cr > 0.2).

CONCLUSIONS

Although the treatment of childhood asthma with budesonide 400 micrograms/day via an aerochamber does not appear to be associated with hypercalciuria, the existence of a subgroup of patients in whom ICS may induce hypercalciuria is plausible. This needs to be further evaluated in a larger study.

Safety of the newer inhaled corticosteroids in childhood asthma

Inhaled corticosteroids (ICS) remain a vital part of the management of persistent asthma, but concerns have been raised about their potential adverse effects in children. This review examines the safety data on three new ICS - fluticasone propionate, mometasone, and extrafine beclomethasone in hydrofluoroalkane (HFA-134a) propellant (QVAR The use of tradenames is for product identification purposes only and does not imply endorsement. formulation) in relation to the older corticosteroids. Topical adverse effects such as thrush and dysphonia are rare, but dental erosion is a possibility with powder forms of ICS because of their low pH. Thus, it is important to stress mouth rinsing after administration and maintaining good dental hygiene to minimize this risk. Biochemical adrenal suppression can be readily demonstrated, particularly with high doses of all ICS. The clinical relevance of this was uncertain in the past, but there have now been >50 reported cases of acute adrenal crises in children receiving ICS, most of whom were on fluticasone propionate. In order to minimize the risk of symptomatic adrenal suppression, it is important to back-titrate the ICS dose and alert families of children receiving high-dose ICS of this potential adverse effect. A pediatric endocrine opinion should be sought if adrenal suppression is suspected. The older ICS cause temporary slowing of growth velocity, but the limited data available do not show any significant compromise of final adult height. The effect on growth of fluticasone propionate may not be as great as with the older ICS, but the studies have been short term and only used low doses of fluticasone propionate. There have been case reports of growth suppression in children receiving high doses of fluticasone propionate. The limited studies performed on the effect of ICS on bone mineral density in children did not show any adverse effects, but there may be an increased risk of fractures. Hydrofluoroalkane beclomethasone (QVAR) is essentially the same drug as chlorofluorocarbon beclomethasone, but with double the lung deposition owing to the smaller particle size. Thus, it could be expected that any adverse effects seen with chlorofluorocarbon beclomethasone would be the same with hydrofluoroalkane beclomethasone. However, some of the published data, particularly in adults, suggest that hydrofluoroalkane beclomethasone may be less systemically active than chlorofluorocarbon beclomethasone, even at equipotent doses. As yet, there are no long-term data on mometasone, but initial studies in adults suggest there may be less suppression of the hypothalamic-pituitary-adrenal axis, although further studies are required, particularly in children.ICS will remain a cornerstone in the management of persistent pediatric asthma, provided that the diagnosis of asthma is secure. It is very important to use ICS appropriately and to ensure the lowest possible doses are used to achieve symptom control, thus minimizing the risk of serious adverse effects.

Pharmaceutical characteristics that influence the clinical efficacy of inhaled corticosteroids

BACKGROUND

Inhaled corticosteroids (ICSs) are the most effective therapy for the management of persistent asthma. The aim of ICS therapy is to achieve a high anti-inflammatory effect in the airways with a concomitant low risk of unwanted local and systemic effects. Direct estimates of clinical efficacy and potency based on studies in humans are difficult to interpret.

OBJECTIVE

To examine the challenges of using alternative estimates of ICS efficacy and potency, including pharmaceutical characteristics.

DATA SOURCES AND STUDY SELECTION

Articles published from 1990 to 2002 on the potency, efficacy, and tolerability of ICSs were identified using MEDLINE and in-house databases and were then reviewed. Search terms included inhaled corticosteroid, budesonide, fluticasone, beclomethasone, mometasone, and potency.

RESULTS

Differences among ICSs can be readily shown using preclinical measures, such as glucocorticoid receptor binding or skin blanching tests. However, pharmaceutical (delivery and pharmacokinetic) differences of ICSs can have a greater impact on clinical efficacy than in vitro potency differences. For example, the unique esterification of budesonide in the airways prolongs its local activity and may contribute positively to its efficacy and therapeutic index. Although comparative clinical trials suggest 6-fold differences in potencies among ICSs, there is currently no evidence to support differences in efficacy when they are administered at equipotent dosages.

CONCLUSIONS

Greater preclinical potency of an ICS does not imply greater clinical efficacy. Pharmacokinetic factors can have a significant impact on relative clinical efficacy.

Lung deposition and systemic availability of fluticasone Diskus and budesonide Turbuhaler in children

Pharmacokinetic studies can be used to measure lung dose of inhaled drugs. The aim of this study was to compare the lung deposition of budesonide (BUD) inhaled from Turbuhaler (AstraZeneca, Lund, Sweden) and fluticasone propionate (FP) inhaled from Diskus (GlaxoSmithKline, London, UK) and to assess if the study design used for pharmacokinetic studies can be simplified. Plasma levels of BUD and FP were measured for 21 hours on five separate days in 15 patients aged 8 to 14 years: (1) Intravenous infusion of 200 microg BUD, (2) intravenous infusion of 200 microg fluticasone dipropionate, (3) inhalation of 800 microg BUD via Turbuhaler, (4) inhalation of 750 microg FP via Diskus, and (5) inhalation of BUD and FP on the same day. Charcoal was ingested to eliminate drug uptake from the gastrointestinal tract. The mean lung deposition of drug after Turbuhaler and Diskus inhalation was 30.8 and 8.0% when BUD and fluticasone were administered on separate days and 29.5% (BUD) and 7.6% (fluticasone) when the two drugs were inhaled on the same day. Lung deposition is four times higher in children after inhalation from Turbuhaler than after inhalation from Diskus. Pharmacokinetic studies with BUD and FP can be simplified because the two treatments can be administered on the same day.

Effects of budesonide inhalation suspension compared with cromolyn sodium nebulizer solution on health status and caregiver quality of life in childhood asthma

OBJECTIVE

To compare the effects of 2 nebulizable controller asthma medications on caregiver and pediatric quality of life.

METHODS

In this 52-week, randomized trial, children aged 2 to 6 years with mild to moderate persistent asthma received budesonide inhalation suspension 0.5 mg (total daily dose) once or twice daily (n = 168) or cromolyn sodium nebulizer solution 20 mg 4 times daily (n = 167) for 8 weeks, with dosage adjustment thereafter at the investigators' discretion. The Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), Compliance/Caregiver Satisfaction Questionnaire (CCSQ), Modified Child Health Questionnaire-Parent Form 50 (CHQ-PF50), and Functional Status-II(R) (FS-II[R]) Questionnaire were administered at baseline and weeks 8, 28, and 52. Global assessments of ease of asthma management and child health status were obtained from caregivers and physicians at the end of the study.

RESULTS

Improvements from baseline in domain-specific (activities and emotional function) and total PACQLQ scores were greater at each time point (weeks 8, 28, and 52) for caregivers of patients treated with budesonide compared with caregivers of patients receiving cromolyn sodium. Only the budesonide group met the criterion for a clinically important improvement (>or=0.5 unit change) in all PACQLQ domains by week 8, which was maintained at weeks 28 and 52. Moreover, improvements surpassed the criterion for moderate clinical importance (1.0 unit change) in all PACQLQ domains for the budesonide group, but this level of improvement was only achieved in the activities domain (at week 28) for the cromolyn sodium group. Based on the CCSQ, budesonide resulted in greater caregiver satisfaction, treatment convenience, ease of use, and compliance compared with cromolyn sodium. Thus, 90.7% of caregivers in the budesonide group were "completely or very satisfied" compared with 53.4% in the cromolyn sodium group. Over half (54.6%) of caregivers in the budesonide group rated budesonide "highly or very convenient" compared with 23% for cromolyn sodium; 77% rated budesonide "extremely or very easy" to use compared with 47% for cromolyn. Adherence with daily medication regimens was reported for 76% of children in the budesonide group compared with 57% in the cromolyn sodium group. Child health status, as indicated by mean FS-II(R) scores, showed improvements from baseline in both groups at weeks 8, 28, and 52. There was a trend for these improvements to be superior in the budesonide group. Additionally, budesonide was superior to cromolyn sodium in caregiver and physician global assessments. At the end of the study, 76% of caregivers of children receiving budesonide reported asthma management to be "a great deal easier" compared with the start of the study, and 74% rated the overall health status of their child as "much better now than 1 year ago." In contrast, only 29% and 37% of caregivers whose children received cromolyn sodium provided these respective ratings.

CONCLUSIONS

Budesonide inhalation suspension improved the quality of life for caregivers of children with asthma. Caregivers of children treated with budesonide had significantly fewer limitations in daily activities and emotional functioning compared with caregivers of children treated with cromolyn sodium nebulizer solution. The improvements in caregiver quality of life occurred earlier with budesonide compared with cromolyn sodium. Only caregivers in the budesonide group had a clinically important mean change from baseline in all PACQLQ domains by week 8. These benefits were maintained at week 52. Children treated with budesonide inhalation suspension and cromolyn sodium experienced improvements in health status, assessed using the FS-II(R). The greatest differences between treatments were seen in the disease-specific portion of the FS-II(R), which relates impairments in functional status to the child's illness. Caregiver and physician global assessment indicated significantly better overall child health after 1 year of treatment with budesonide, supporting an improvement in health status. Clinical trials in children 4 to 16 years of age with asthma have demonstrated greater effectiveness of inhaled corticosteroids versus cromolyn sodium on several clinical measures of efficacy. Measures of asthma control in this study, reported in detail elsewhere [Leflein et al. Pediatrics 2002;109:866-872], also have shown greater improvements with budesonide therapy. Treatment with budesonide inhalation suspension resulted in a significantly lower mean rate of asthma exacerbations, significantly longer times to first asthma exacerbation, significantly longer times to first additional use of chronic asthma therapy, and significant improvements in asthma symptom scores and breakthrough medication use compared with cromolyn sodium therapy. Additionally, children receiving budesonide inhalation suspension experienced more symptom-free days and episode-free days compared with children receiving cromolyn sodium. Safety profiles were similar between the 2 treatment groups. Budesonide inhalation suspension was associated with significantly greater caregiver satisfaction, convenience, ease of use, and compliance compared with cromolyn sodium nebulizer solution. This greater caregiver satisfaction and quality of life may be related to the greater asthma control achieved in children treated with budesonide therapy compared with cromolyn sodium. In addition, the convenience of once- or twice-daily dosing with budesonide inhalation suspension, compared with 3- or 4-times-daily dosing of cromolyn sodium, may decrease caregiver burden and enhance the willingness of caregivers to adhere to treatment regimens prescribed for their young children with asthma. This effect on caregiver adherence could further improve treatment effectiveness. This is the first clinical trial comparing the effects of a nebulized corticosteroid with that of an alternative nebulized therapy on quality of life in young children with asthma and their families. Compared with nebulized cromolyn sodium, budesonide inhalation suspension not only provides better overall child health status and asthma management, but greater caregiver quality of life and greater caregiver satisfaction, convenience, ease of use, and compliance.

Role of budesonide as maintenance therapy for children with asthma

Asthma is a chronic inflammatory disease of the airways. Inhaled corticosteroids are recognized as the preferred long-term control medication for persistent asthma based on their anti-inflammatory properties and significant evidence of efficacy. Inhaled budesonide is the most carefully characterized inhaled corticosteroid for childhood asthma. It is available for administration in children down to six months of age and to date has an excellent safety profile.

Reduction in oral corticosteroid use with mometasone furoate dry powder inhaler improves health-related quality of life in patients with severe persistent asthma

Severe persistent asthma can have a substantial impact on a patient's health-related quality of life (HRQL), both as a result of symptoms and from side effects of treatment. The HRQL impact of two doses (400 and 800 microg twice daily) of mometasone furoate dry powder inhaler (MF DPI) was compared with placebo in patients with severe persistent asthma previously maintained on oral steroids as a component of a previously published randomized, 12-week, double-blind, placebo-controlled, multicenter trial. A 9-month open-label extension (OLE), with all patients treated with MF DPI, followed. Patients 12 years of age or older completed a generic HRQL measure, the Medical Outcomes Trust Short Form-36 (SF-36), and an asthma-specific measure, the Marks Asthma Quality of Life Questionnaire (AQLQ-M), at baseline, at endpoint (last evaluable visit) of the double-blind phase (EODBP), and after the first 3 months of the OLE. Of 132 patients enrolled in the study, 128 provided HRQL data at baseline and at EODBP. Mean SF-36 scores at baseline showed significant HRQL impairment compared with U.S. general population norms. With treatment, the reduction in oral corticosteroid (OCS) requirements of the MF-DPI-treated groups was accompanied by significant (p < 0.05) improvement over placebo in the physical domain of HRQL (SF-36 physical component summary score and the physical function subscale) at EODBP. MF-DPI-treated patients also showed significant improvements at EODBP in each of the four subscales of the AQLQ-M (p<0.05). From EODBP to the OLE 3-month endpoint, patients treated with MF DPI twice daily maintained, or improved, SF-36 scores in most domains. Symptomatic improvement and reduction in OCS use with MF DPI were accompanied by significant improvement in HRQL in patients with severe persistent asthma. These improvements were maintained during the 3-month period of the OLE in which HRQL was evaluated.

Efficacy and safety of budesonide inhalation powder (Pulmicort Turbuhaler) during 52 weeks of treatment in adults and children with persistent asthma

BACKGROUND

Inhaled corticosteroids are the agents of choice for treating persistent asthma.

OBJECTIVE

To evaluate the long-term efficacy and safety of budesonide inhalation powder (Pulmicort Turbuhaler) in patients with mild to severe persistent asthma.

METHODS

Patients (n=1133) received open-label budesonide (dose range, 100-800 microg b.i.d.) for 52 weeks following 2 weeks to 5 months of treatment in one of four double-blind, placebo-controlled studies. Patients, identified before the double-blind studies, included adults (n=249) not receiving corticosteroids, adults (n=384) and children (n=356) previously maintained on inhaled corticosteroids, and adults (n=144) previously maintained on oral corticosteroids.

RESULTS

Mean forced expiratory volume in 1 sec was 68.2% of predicted normal (n=1133) at baseline (mean from two visits before randomization), 74.4% (n=1132) at the end of double-blind treatment, 81.3% (n=971) at week 52, and 80.1% (n=1125) at last observation (including patients who discontinued early). Sixty-four patients maintained on oral corticosteroids before double-blind treatment entered the open-label study off oral corticosteroids, 58 of whom (91%) remained oral corticosteroid-free throughout the study. There was no evidence of basal or cosyntropin-stimulated hypothalamic-pituitary-adrenal axis function suppression, and the most commonly occurring adverse events were respiratory infection, sinusitis, and pharyngitis.

CONCLUSIONS

During this 52-week, open-label study, budesonide maintained the improved pulmonary function and decreased oral corticosteroid use observed during previous double-blind treatment and was well tolerated, supporting its long-term use in adults and children with mild to severe persistent asthma.

Long-term outcomes in paediatric asthma

Over the years the aims of asthma management have changed markedly from effective prednisolone treatment of symptoms and exacerbations towards more use of continuous prophylactic treatment. With our new understanding of the disease and its management definition of the aims of treatment and assessment of optimal asthma control have become much more complex. Even in times of evidence-based medicine our asthma management is based upon findings of effects on various outcomes in somewhat short-term (<1 year) controlled studies. However, assumptions about long-term effects upon the basis of findings in such studies should be made with great caution. Good examples of this are studies which assess the risk of systemic effects and clinical adverse effects of inhaled corticosteroids. From such studies it has become clear that systemic effects detected in short-term trials may have no predictive value of long-term adverse effects. Thus steroid-induced changes in lower leg growth rates assessed by knemometry do not predict long-term statural growth. Moreover, steroid-induced changes in statural growth over 1 year are not predictive of effects upon attained adult height. In contrast, reduced growth caused by uncontrolled asthma disease also seems to affect attained adult height adversely. These findings suggest that long-term outcomes should play a larger role when future asthma management strategies are decided. Some important long-term outcomes of asthma management in children include cure or remission of the disease, prevention of complications of the disease (airway remodelling, adverse effects upon growth/adult height, peak bone mineral density, physical impairment and psychosocial development) or its pharmacological management (adverse effects upon adult height, peak bone mineral density). More controlled long-term studies (several years) are needed to provide a better understanding of how these outcomes are best achieved.

Effect of ciclesonide on allergen challenge in subjects with bronchial asthma

BACKGROUND

The aim of this clinical trial was to investigate whether repeated inhalation of the new inhaled steroid ciclesonide reduces the early-phase (EAR) and late-phase (LAR) reactions after allergen challenge in patients with mild allergic asthma. Also, this study provides further data on safety and tolerance of ciclesonide.

METHODS

The study was designed as a double-blind placebo-controlled randomized crossover trial. Following a baseline period, patients were randomized to either of two treatment sequences (ciclesonide/placebo, placebo/ciclesonide) each of which lasted for one week and were separated by 3-5 weeks from the alternate treatment sequence. Patients received 800 micro g ciclesonide twice daily by means of a Cyclohaler. At the end of each treatment patients were subjected to an allergen challenge.

RESULTS

Thirteen asthmatic patients (mean FEV1 of 91% predicted) who experienced an EAR and LAR after allergen challenge participated in the study. The time-average FEV1 decreases 0-2 h (2-12 h) after allergen challenge as measure of the EAR (LAR) were significantly reduced (P < 0.05, one-sided) from 0.426 L to 0.233 L (EAR) and from 0.443 L to 0.213 L (LAR), respectively. Thus, the study results suggest that ciclesonide significantly lowered the extent of EAR and LAR compared to placebo. Ciclesonide was well tolerated and no drug-related adverse events were reported. Cortisol excretion in 24-h urine showed no significant difference between ciclesonide and placebo.

CONCLUSIONS

The study supports the efficacy and safety of ciclesonide.

Efficacy of liposomal budesonide in experimental asthma

BACKGROUND

Inhaled corticosteroids, such as budesonide, attenuate the inflammatory response in asthma. However, patient noncompliance and side effects of available inhaled corticosteroids limit their use. Liposomes are currently used in medicine to deliver a variety of drugs.

OBJECTIVE

The objective of our study was to determine whether weekly therapy with budesonide encapsulated in sterically stabilized (stealth) liposomes would be comparable to daily budesonide therapy in reducing allergic inflammation.

METHODS

Ovalbumin-sensitized C57/Black 6 mice received aerosolized (1) budesonide encapsulated in stealth or conventional liposomes, administered weekly, (2) budesonide (without liposomes), administered either daily or weekly, or (3) empty stealth liposomes, administered weekly. All treatment groups were compared with sensitized untreated or unsensitized mice. Histopathologic examination of the lung tissues and measurements of eosinophil peroxidase activity, peripheral blood eosinophil counts, and total serum IgE levels were done weekly for 4 weeks.

RESULTS

Weekly therapy with budesonide encapsulated in stealth liposomes was as effective as daily budesonide therapy in decreasing lung inflammation and lowering eosinophil peroxidase activity, peripheral blood eosinophils, and total serum IgE levels. In none of the other groups was there a significant decrease in the inflammatory parameters evaluated.

CONCLUSION

We conclude that weekly therapy with budesonide encapsulated in stealth liposomes is as effective as daily budesonide in reducing markers of lung inflammation in experimental asthma. This novel strategy offers an effective alternative to standard daily budesonide therapy in asthma and has the potential to reduce toxicity and improve compliance.

[Cortisone therapy today]

Five decades of experimental and clinical experience have changed corticoid therapy thoroughly. Corticoides have two modes of action. The first is a genomic effect through which anti-inflammatory proteins are formed which inhibit pro-inflammatory cytokines. This effect is initiated even by small doses, but is of late onset. The use of high doses initiates non-genomic effects through alterations of the cell membrane; these effects are found early after initiation of treatment. The risk of adverse corticoid effects are extremely rare when modern application forms and therapy regimens are used: Very high doses for a short time in case of acute states of illness, very low doses in long-term therapy of chronic illnesses, and the use of topical substances wherever this is possible. As for the dose regimen, one should start with an initial dose which suffices to treat the acute state, and subsequently reduce the dosage after the first positive results are obtained. In long-term therapy a daily dose of 5 mg prednisolone should not be exceeded; usually even lower doses are sufficient. These very low doses can only be reached by reducing in steps of one half to one milligram over very long periods of time. During long-term therapy osteoporosis prophylaxis is mandatory. Due to these new therapeutic concepts treatment of rheumatoid arthritis with corticoids is experiencing a revival. Low-dose corticoid therapy is of lower risk than nonsteroidal antirheumatic treatment and slows down disease progression, i.e. joint destruction is significantly inhibited. Corticoids have also undergone a new development in the treatment of asthma. Previously used only in acute systemic therapy, they have now been established in basic therapy, i.e. long term therapy using special topic applications.

Cost-effectiveness analysis of inhaled corticosteroids in asthma: a review of the analytical standards

PURPOSE

To determine whether published cost-effectiveness studies on inhaled corticosteroids (ICS) in asthma adhered to basic analytical standards as defined in health economic textbooks and in guidelines assessing and comparing efficacy and safety.

METHODS

Original cost-effectiveness studies published between 1990 and 2000 in general medical or economic journals were reviewed to assess the adherence to five fundamental methodological principles: (1) design of the study, (2) choice of perspective and corresponding costs, (3) choice of outcome measure, (4) marginal cost analysis, and (5) sensitivity analysis and discussion about external validity. For each principle, the studies were ranked as high, medium or low quality.

RESULTS

Most of the 18 studies included were ranked medium on the first two principles. The studies adhered to a higher degree to the remaining three principles. Only three studies were high ranked in all five principles. The number of principles fulfilled increased over time. Studies comparing pharmaceutical products from competing companies were typically short-term studies, designed for other purposes than health economic analyses, and, in general, did not use therapeutically equivalent dosing.

CONCLUSIONS

Attention should be drawn to the study design, the weak correspondence between perspective and costs, and especially to the impact of bias in health economic results when comparing different doses of ICSs.

Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom

BACKGROUND

Until recently, only two cases of acute adrenal crisis associated with inhaled corticosteroids (ICS) had been reported worldwide. We identified four additional cases and sought to survey the frequency of this side effect in the United Kingdom.

METHODS

Questionnaires were sent to all consultant paediatricians and adult endocrinologists registered in a UK medical directory, asking whether they had encountered asthmatic patients with acute adrenal crisis associated with ICS. Those responding positively completed a more detailed questionnaire. Diagnosis was confirmed by symptoms/signs and abnormal hypothalamic-pituitary-adrenal axis function test results.

RESULTS

From an initial 2912 questionnaires, 33 patients met the diagnostic criteria (28 children, five adults). Twenty-three children had acute hypoglycaemia (13 with decreased levels of consciousness or coma; nine with coma and convulsions; one with coma, convulsions and death); five had insidious onset of symptoms. Four adults had insidious onset of symptoms; one had hypoglycaemia and convulsions. Of the 33 patients treated with 500-2000 micro g/day ICS, 30 (91%) had received fluticasone, one (3%) fluticasone and budesonide, and two (6%) beclomethasone.

CONCLUSIONS

The frequency of acute adrenal crisis was greater than expected as the majority of these patients were treated with ICS doses supported by British Guidelines on Asthma Management. Despite being the least prescribed and most recently introduced ICS, fluticasone was associated with 94% of the cases. We therefore advise that the licensed dosage of fluticasone for children, 400 micro g/day, should not be exceeded unless the patient is being supervised by a physician with experience in problematic asthma. We would also emphasise that until adrenal function has been assessed patients receiving high dose ICS should not have this therapy abruptly terminated as this could precipitate adrenal crisis.

Budesonide/formoterol in a single inhaler versus inhaled corticosteroids alone in the treatment of asthma

The aim of this study was to evaluate the efficacy (expressed as effect on lung function) and tolerability of Symbicort (budesonide/formoterol in a single inhaler) in children with asthma. This was a double-blind, double-dummy, randomized, parallel-group, multicenter trial. After a 2-4-week run-in period, 286 asthmatic children (177 boys, 109 girls; mean age, 11 years; mean forced expiratory volume in 1 sec (FEV(1)), 75% predicted normal), previously treated with inhaled corticosteroids (average dose 548 microg/day), were randomized to 12 weeks' treatment with either budesonide/formoterol 80/4.5 microg, two inhalations twice daily (n = 148), or an equivalent dose of budesonide 100 microg, two inhalations twice daily (n = 138). Efficacy variables included morning and evening peak expiratory flow (PEF), spirometery, asthma symptoms, and use of rescue medication (beta(2)-agonists). Serial FEV(1) assessments were carried out on a subgroup of children (budesonide/formoterol, n = 41; budesonide, n = 40) at randomization and at week 12. Relative to baseline, morning PEF (primary variable) increased to a significantly greater extent with budesonide/formoterol than with budesonide alone (7.22% predicted normal vs 3.45% predicted normal; P < 0.001). Evening PEF also increased significantly with budesonide/formoterol (6.13% predicted normal vs. 2.73% predicted normal; P < 0.001), as did mean FEV(1) and serial FEV(1) measured over 12 hr (both P < 0.05). Similar improvements in asthma symptoms and rescue medication use were observed in both groups. The two treatment groups were similar in terms of their adverse-event profile and rates of discontinuation. Budesonide/formoterol in a single inhaler provided rapid improvements in PEF and FEV(1) compared to inhaled budesonide alone. These improvements were sustained throughout the study period. Budesonide/formoterol was well-tolerated in children with moderate persistent asthma.

The use of inhaled corticosteroids in adult asthma

Inhaled corticosteroids modify some but not all features of airway inflammation seen in asthma. ICS remain the most effective class of medications currently available to treat persistent asthma and result in few clinically relevant adverse effects when used in low-moderate doses. ICS activity is enhanced when used in combination with LABA and, to a lesser degree, LTRAs. ICS are well tolerated in adults. Daily doses of ICS may not be required to exceed 200 micrograms of FP equivalents. From an economic standpoint, ICS provide health care savings because of reductions in asthma hospitalization. The impact of early introduction of ICS in the disease course of asthma remains unresolved. The use of ICS in patients whose asthma is mild, with essentially normal lung function, and infrequent symptoms also remains unstudied. For the time being, ICS remain the first line of asthma treatment for adults with persistent disease.