Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: a post-hoc efficacy analysis of the START study

It is time to change the way we manage mild asthma: an update in GINA 2019

Asthma is a heterogeneous lung disease, usually characterised by chronic airway inflammation. Although evidence-based treatments are available in most countries, asthma control remains suboptimal, and asthma-related deaths continue to be an ongoing concern. Generally, it is believed that between 50 to 75% of patients with asthma can be considered as having mild asthma.Previous versions of Global Initiative for Asthma (GINA) suggested that mild asthma in adults can be well managed with either reliever medications, for example, short-acting beta2 agonists (SABA) alone or with the additional use of controllers such as regular low-dose inhaled corticosteroids (ICS). Given the low frequency or non-bothersome nature of symptoms in mild asthma, patients' adherence towards their controller medications, especially to ICS is usually not satisfactory. Such patients often rely on SABA alone to relieve symptoms, which may contribute to SABA over-reliance. Overuse of relievers such as SABAs has been associated with poor asthma outcomes, such as exacerbations and even deaths. The new GINA 2019 asthma treatment recommendations represent significant shifts in asthma management at Steps 1 and 2 of the 5 treatment steps. The report acknowledges an emerging body of evidence suggesting the non-safety of SABAs overuse in the absence of concomitant controller medications, therefore does not support SABA-only therapy in mild asthma and has included new off-label recommendations such as symptom-driven (as-needed) low dose ICS-formoterol and "low dose ICS taken whenever SABA is taken".The GINA 2019 report highlights significant updates in mild asthma management and these recommendations represent a clear deviation from decades of clinical practice mandating the use of symptom-driven SABA treatment alone in those with mild asthma. While the new inclusions of strategies such as symptom-driven (as-needed) ICS-formoterol and "ICS taken whenever SABA is taken" are based on several key trials, data in this context are still only emergent data, with clear superiority of as needed ICS-formoterol combinations over maintenance ICS regimens yet to be established for valid endpoints. Nevertheless, current and emerging data position the clinical asthma realm at a watershed moment with imminent changes for the way we manage mild asthma likely in going forward.

Small Airway Dysfunction by Impulse Oscillometry in Symptomatic Patients with Preserved Pulmonary Function

BACKGROUND

Asthma and chronic obstructive pulmonary disease are characterized by persistent airway inflammation and airflow limitation. Early detection of these diseases in patients with respiratory symptoms and preserved pulmonary function (PPF) defined by spirometry is difficult. Impulse oscillometry (IOS) may have better sensitivity than effort-dependent forced expiratory flow between 25% and 75% (FEF_25%-75%) to detect small airway dysfunction (SAD).

OBJECTIVE

To identify SAD in patients with respiratory symptoms and PPF using IOS.

METHODS

Medical records of symptomatic patients without acute or known structural lung diseases were evaluated. Patients had bronchodilator testing and IOS in the outpatient clinic between March 1 and July 31, 2017. Correlations between respiratory symptoms, spirometry, and IOS parameters were determined.

RESULTS

Among 349 patients enrolled to the study, 255 (73.1%) patients met the criteria of PPF. The IOS parameters-difference in resistance at 5 Hz and resistance at 20 Hz , reactance at 5 Hz, resonant frequency (F_res), and area under reactance curve between 5 Hz and resonant frequency-were significantly correlated with FEF_25%-75%. The cutoffs for SAD were difference in resistance at 5 Hz and resistance at 20 Hz greater than 0.07 kPa/(L/s), reactance at 5 Hz less than -0.12 kPa/(L/s), F_res greater than 14.14 Hz, and area under reactance curve between 5 Hz and resonant frequency greater than 0.44 kPa/L. Of the IOS parameters, F_res and reactance at 5 Hz had the highest sensitivity and specificity. When compared with FEF_25%-75%, F_res had greater sensitivity to detect SAD in patients with PPF. Patients with IOS-defined SAD had a significantly higher incidence of wheeze or sputum production than did those defined by FEF_25%-75%.

CONCLUSIONS

Patients with respiratory symptoms and PPF may have SAD, which can be identified with the aid of IOS in addition to spirometry.

Asthma progression and mortality: the role of inhaled corticosteroids

Overall, asthma mortality rates have declined dramatically in the last 30 years, due to improved diagnosis and to better treatment, particularly in the 1990s following the more widespread use of inhaled corticosteroids (ICSs). The impact of ICS on other long-term outcomes, such as lung function decline, is less certain, in part because the factors associated with these outcomes are incompletely understood. The purpose of this review is to evaluate the effect of pharmacological interventions, particularly ICS, on asthma progression and mortality. Furthermore, we review the potential mechanisms of action of pharmacotherapy on asthma progression and mortality, the effects of ICS on long-term changes in lung function, and the role of ICS in various asthma phenotypes.Overall, there is compelling evidence of the value of ICS in improving asthma control, as measured by improved symptoms, pulmonary function and reduced exacerbations. There is, however, less convincing evidence that ICS prevents the decline in pulmonary function that occurs in some, although not all, patients with asthma. Severe exacerbations are associated with a more rapid decline in pulmonary function, and by reducing the risk of severe exacerbations, it is likely that ICS will, at least partially, prevent this decline. Studies using administrative databases also support an important role for ICS in reducing asthma mortality, but the fact that asthma mortality is, fortunately, an uncommon event makes it highly improbable that this will be demonstrated in prospective trials.

Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma

BACKGROUND

In double-blind, placebo-controlled trials, budesonide-formoterol used on an as-needed basis resulted in a lower risk of severe exacerbation of asthma than as-needed use of a short-acting β₂-agonist (SABA); the risk was similar to that of budesonide maintenance therapy plus as-needed SABA. The availability of data from clinical trials designed to better reflect clinical practice would be beneficial.

METHODS

We conducted a 52-week, randomized, open-label, parallel-group, controlled trial involving adults with mild asthma. Patients were randomly assigned to one of three treatment groups: albuterol (100 μg, two inhalations from a pressurized metered-dose inhaler as needed for asthma symptoms) (albuterol group); budesonide (200 μg, one inhalation through a Turbuhaler twice daily) plus as-needed albuterol (budesonide maintenance group); or budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol, one inhalation through a Turbuhaler as needed) (budesonide-formoterol group). Electronic monitoring of inhalers was used to measure medication use. The primary outcome was the annualized rate of asthma exacerbations.

RESULTS

The analysis included 668 of 675 patients who underwent randomization. The annualized exacerbation rate in the budesonide-formoterol group was lower than that in the albuterol group (absolute rate, 0.195 vs. 0.400; relative rate, 0.49; 95% confidence interval [CI], 0.33 to 0.72; P<0.001) and did not differ significantly from the rate in the budesonide maintenance group (absolute rate, 0.195 in the budesonide-formoterol group vs. 0.175 in the budesonide maintenance group; relative rate, 1.12; 95% CI, 0.70 to 1.79; P = 0.65). The number of severe exacerbations was lower in the budesonide-formoterol group than in both the albuterol group (9 vs. 23; relative risk, 0.40; 95% CI, 0.18 to 0.86) and the budesonide maintenance group (9 vs. 21; relative risk, 0.44; 95% CI, 0.20 to 0.96). The mean (±SD) dose of inhaled budesonide was 107±109 μg per day in the budesonide-formoterol group and 222±113 μg per day in the budesonide maintenance group. The incidence and type of adverse events reported were consistent with those in previous trials and with reports in clinical use.

CONCLUSIONS

In an open-label trial involving adults with mild asthma, budesonide-formoterol used as needed was superior to albuterol used as needed for the prevention of asthma exacerbations. (Funded by AstraZeneca and the Health Research Council of New Zealand; Novel START Australian New Zealand Clinical Trials Registry number, ACTRN12615000999538.).

A review of the burden and management of mild asthma in adults - Implications for clinical practice

Mild asthma is present in 50-75% of patients with asthma and is defined by the Global Initiative for Asthma as asthma that can be well controlled with low-intensity treatments (Steps 1 and 2). Despite this definition, 'mild' asthma is often not well controlled in reality, and can have a significant impact on an individual's symptom burden and quality of life. We performed a PubMed literature search to investigate the burden of 'mild' asthma in the lives of patients, including future risk and asthma control, and the current management strategies. While clinical guidelines recommend long-term, daily, low-dose inhaled corticosteroids (ICS) for 'mild' asthma, published data suggest that ICS are often under-prescribed or used intermittently as symptoms arise. Furthermore, patients and physicians tend to overestimate disease control, impacting the accuracy of diagnosing 'mild asthma' and subsequent management. This disconnect may be amplified by miscommunication between patients and physicians, limited objective assessment of control, and differences in guidelines. As with moderate and severe asthma, current evidence supports early initiation of regular ICS in 'mild' asthma to address the underlying inflammation, achieve symptom control and reduce risk of exacerbations. Adherence to ICS treatment is key and can be improved by educating both patients and healthcare professionals. The results of this literature search challenge the term 'mild' asthma and suggest strategies to improve the proactive management of the disease to enable patients to live symptom-free.

The multifaceted roles of FOXM1 in pulmonary disease

Forkhead box M1 (FOXM1), a transcriptional regulator of G1/S and G2/M transition and M phase progression in the cell cycle, plays a principal role in many physiological and pathological processes. A growing number of studies have focused on the relationship between abnormal FOXM1 expression and pulmonary diseases, such as lung cancer, chronic obstructive pulmonary disease (COPD), asthma, acute lung injury (ALI), pulmonary fibrosis, and pulmonary arterial hypertension (PAH). These studies indicate that the FOXM1 regulatory network is a major predictor of poor outcomes, especially in lung cancer, and provide novel insight into various pulmonary diseases. For the first time, this review summarizes the mechanistic relationship between FOXM1 dysregulation and pulmonary diseases, the benefits of targeting abnormal FOXM1 expression, and the questions that remain to be addressed in the future.

Asthma exacerbation prediction: recent insights

PURPOSE OF REVIEW

Asthma attacks are frequent in children with asthma and can lead to significant adverse outcomes including time off school, hospital admission and death. Identifying children at risk of an asthma attack affords the opportunity to prevent attacks and improve outcomes.

RECENT FINDINGS

Clinical features, patient behaviours and characteristics, physiological factors, environmental data and biomarkers are all associated with asthma attacks and can be used in asthma exacerbation prediction models. Recent studies have better characterized children at risk of an attack: history of a severe exacerbation in the previous 12 months, poor adherence and current poor control are important features which should alert healthcare professionals to the need for remedial action. There is increasing interest in the use of biomarkers. A number of novel biomarkers, including patterns of volatile organic compounds in exhaled breath, show promise. Biomarkers are likely to be of greatest utility if measured frequently and combined with other measures. To date, most prediction models are based on epidemiological data and population-based risk. The use of digital technology affords the opportunity to collect large amounts of real-time data, including clinical and physiological measurements and combine these with environmental data to develop personal risk scores. These developments need to be matched by changes in clinical guidelines away from a focus on current asthma control and stepwise escalation in drug therapy towards inclusion of personal risk scores and tailored management strategies including nonpharmacological approaches.

SUMMARY

There have been significant steps towards personalized prediction models of asthma attacks. The utility of such models needs to be tested in the ability not only to predict attacks but also to reduce them.

[New approaches of inhaled steroid asthma management in mild to moderate asthma]

Inhaled corticosteroids (ICS) are the cornerstone of the management of asthma. Daily use allows to reduce mortality, intensity and frequency of exacerbations, to increase the control of symptoms of asthma and the quality of life of asthmatics patients and to reduce the decline of the lung function. A daily use of a weak dose of ICS allows to control the symptoms of asthma of the vast majority of mild to moderate asthmatics patients who account for about 75-80 % of the French asthmatic patients. An add-on strategy with a combination by ICS/LABA allows to decrease by 20 % the risk of an exacerbation compared with a treatment by CSI in monotherapy. "SMART" which consists in using a fixed ICS/LABA combination as a maintenance and reliever therapy had showed better results in the prevention of exacerbations that the use of the same combination associated with a SABA as a reliever therapy. This strategy is recommended by GINA at the same level of proof as the classical treatment. An "on-demand" use of a ICS/LABA combination according to symptoms is clearly less efficacious in terms of control of the symptoms than the classical strategy by ICS/LABA; but both strategies are identical in terms of prevention of exacerbations. The daily dose of ICS is 4 to 5 times less than in the daily ICS group. The clinical effectiveness and cost-effectiveness of a standard asthma self-management plan that advises patients to temporarily quadrupling the dose of ICS in case of asthma worsening can be an alternative and allow to reduce 20 % of clinically important asthma exacerbations.

Two Sides of the Same Coin?-Treatment of Chronic Asthma in Children and Adults

Globally, asthma is one of the most common chronic conditions that affect individuals of all ages. When poorly controlled, it negatively impacts patient's ability to enjoy life and work. At the population level, effective use of recommended strategies in children and adults can reduce symptom burden, improve quality of life and significantly reduce the risk of exacerbation, decline of lung function and asthma-related death. Inhaled corticosteroid as the initial maintenance therapy, ideally started within 2 years of symptom onset, is highly effective in both children and adults and across various degrees of asthma severity. If asthma is not controlled, the choice of subsequent add-on therapies differs between children and adults. Evidence supporting pharmacological approach to asthma management, especially for those with more severe disease, is more robust in adults compared to children. This is, in part, due to various challenges in the diagnosis of asthma, in the recruitment into clinical trials and in the lack of objective outcomes in children, especially those in the preschool age group. Nevertheless, where evidence is emerging for younger children, it seems to mirror the observations in adults. Clinicians need to develop strategies to implement guideline-based recommendations while taking into consideration individual variations in asthma clinical phenotypes, pathophysiology and treatment responses at different ages.

Extent, trends, and determinants of controller/reliever balance in mild asthma: a 14-year population-based study

BACKGROUND

The majority of patients with asthma have the mild form of the disease. Whether mild asthma patients receive appropriate asthma medications has not received much attention in the literature. We examined the trends in indicators of controller/reliever balance.

METHODS

Using administrative health databases of British Columbia, Canada (2000 to 2013), we created a population-based cohort of adolescents/adults with mild asthma using validated case definition algorithms. Each patient-year of follow-up was assessed based on two markers of inappropriate medication prescription: whether the ratio of controller medications (inhaled corticosteroids [ICS] and leukotriene receptor antagonists [LTRA]) to total asthma-related prescriptions was low (cut-off 0.5 according to previous validation studies), and whether short-acting beta agonists (SABA) were prescribed inappropriately according to previously published criteria that considers SABA in relation to ICS prescriptions. Generalized linear models were used to evaluate trends and to examine the association between patient-, disease-, and healthcare-related factors and medication use.

RESULTS

The final cohort consisted of 195,941 mild asthma patients (59.5% female; mean age at entry 29.6 years) contributing 1.83 million patient-years. In 48.8% of patient-years, controller medications were suboptimally prescribed, while in 7.2%, SABAs were inappropriately prescribed. There was a modest year-over-year decline in inappropriate SABA prescription (relative change - 1.3%/year, P < 0.001) and controller-to-total-medications (relative change - 0.5%/year, P < 0.001). Among the studied factors, the indices of type and quality of healthcare (namely respirologist consultation and receiving pulmonary function test) had the strongest associations with improvement in controller/reliever balance.

CONCLUSIONS

Large number of mild asthma patients continue to be exposed to suboptimal combinations of asthma medications, and it appears there are modifiable factors associated with such phenomenon.

Does a Patient-Directed Financial Incentive Affect Patient Choices About Controller Medicines for Asthma? A Discrete Choice Experiment and Financial Impact Analysis

BACKGROUND

In Australia, many patients who are initiated on asthma controller inhalers receive combination inhaled corticosteroid/long-acting beta₂-agonist (ICS/LABA) despite having asthma of sufficiently low severity that ICS-alone would be equally effective and less costly for the government.

METHODS

We conducted a discrete choice experiment (DCE) in a nationally representative sample of adults (n = 792) and parents of children (n = 609) with asthma. Mixed multinomial models were estimated and calibrated to reflect the estimated market shares of ICS-alone, ICS/LABA and no controller. We then simulated the impact of varying patient co-payment on demand and the financial impact on government pharmaceutical expenditure.

RESULTS

Preference for inhaler decreased with increasing costs to the patient or government, increasing chance of a repeat visit to the doctor, and if fewer symptoms were present. Adults preferred high-strength controllers, but parents preferred low-strength inhalers for children (general beneficiaries only). The DCE predicted a higher proportion choosing controller treatment (89%) compared to current levels (57%) at the current co-payment level, with proportionately higher uptake of ICS-alone and a lower average cost per patient [32.73 Australian dollars (AU$) c.f. AU$38.54]. Reducing the co-payment on ICS-alone by 50% would increase its market share to 50%, whilst completely removing the co-payment would only have a small marginal impact on market share, but increased average cost of treatment to the government to AU$41.04 per person.

CONCLUSIONS

Patient-directed financial incentives are unlikely to encourage much switching of medicines, and current levels of under-treatment are not explained by patient preferences. Interventions directed at prescribers are more likely to promote better use of asthma medicines.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Nationwide use of inhaled corticosteroids by South Korean asthma patients: an examination of the Health Insurance Review and Service database

BACKGROUND

Previous studies have found that the prescription rates of inhaled corticosteroid (ICS) were considerably low although it is recommended as the optimal asthma treatment. The aim of this study was to analyze the current status of ICS prescription for asthma patients in the South Korea.

METHODS

We evaluated quality assessment data based on nationwide Health Insurance Review and Service (HIRA) database from July 2013 to June 2014. ICS prescription rates in asthma patients were analyzed by types and specialty of medical institutions. Also, we graded medical institutions by their ICS prescription rate. In addition, ICS prescription rates were calculated by patient gender, age, and insurance type.

RESULTS

This study included 831,613 patients and 16,804 institutions in the analysis. The overall mean ICS prescription rate was 22.58%. Tertiary hospitals had the highest mean prescription rate (84.16%) whereas primary healthcare clinics had the lowest (20.71%). By specialty, internal medicine physicians prescribed ICS more frequently compared to other specialists. Of all, 47.17% of medical institutions prescribed ICS to <10% of asthma patients, while less than 6% of institutions prescribed ICS to >80% of asthma patients. Also, we found that female and patients with age >90 or <20 years exhibited lower ICS prescription rate.

CONCLUSIONS

The ICS prescription rate was found to be inadequate, given the importance of ICS as an asthma treatment. The prescription rates were especially low in primary healthcare clinics, and by specialists in fields other than internal medicine.

Difficult vs. Severe Asthma: Definition and Limits of Asthma Control in the Pediatric Population

Evaluating the degree of disease control is pivotal when assessing a patient with asthma. Asthma control is defined as the degree to which manifestations of the disease are reduced or removed by therapy. Two domains of asthma control are identified in the guidelines: symptom control and future risk of poor asthma outcomes, including asthma attacks, accelerated decline in lung function, or treatment-related side effects. Over the past decade, the definition and the tools of asthma control have been substantially implemented so that the majority of children with asthma have their disease well controlled with standard therapies. However, a small subset of asthmatic children still requires maximal therapy to achieve or maintain symptom control and experience considerable morbidity. Childhood uncontrolled asthma is a heterogeneous group and represents a clinical and therapeutic challenge requiring a multidisciplinary systematic assessment. The identification of the factors that may contribute to the gain or loss of control in asthma is essential in differentiating children with difficult-to-treat asthma from those with severe asthma that is resistant to traditional therapies. The aim of this review is to focus on current concept of asthma control, describing monitoring tools currently used to assess asthma control in clinical practice and research, and evaluating comorbidities and modifiable and non-modifiable factors associated with uncontrolled asthma in children, with particular reference to severe asthma.

Long-Term Trajectories of Mild Asthma in Adulthood and Risk Factors of Progression

BACKGROUND

Most patients with asthma have mild disease. However, the clinical course of mild asthma and risk factors for progression are not well studied.

OBJECTIVE

To examine the long-term trajectories of mild asthma and the effects of early-stage risk factors on the subsequent disease course.

METHODS

From the administrative health data of British Columbia, Canada, we identified patients aged 14 to 45 years with newly diagnosed mild asthma between January 1997 and December 2012. For each follow-up year, we categorized a patient's asthma severity into mild/dormant, moderate, or severe on the basis of the intensity of asthma medications and occurrence of exacerbations. Ordinal logistic regression was used to estimate the probability of severity or all-cause death in the next year as a function of a patient's severity history in the past 3 years and selected baseline risk factors.

RESULTS

The study included 70,829 patients with incident mild asthma (62% women; mean age, 31 years). Over 10 years, 8% of these patients transitioned to moderate or severe asthma. Inappropriate use of rescue medications and older age were the most influential determinants for progression from mild asthma (odds ratios, 1.79; 95% CI, 1.68-1.90; P < .001; 1.24 per 10-year increase in age; 95% CI, 1.22-1.27; P < .001), whereas the presence of allergic rhinitis had no significant effects (odds ratio, 0.95; 95% CI, 0.91-1.00; P = .063).

CONCLUSIONS

Mild asthma remains largely stable over time. However, potentially modifiable factors such as inappropriate use of rescue medications are associated with a worsened prognosis.

New and Anticipated Therapies for Severe Asthma

Asthma is frequently undertreated, resulting in a relatively high prevalence of patients with uncontrolled disease, characterized by the presence of symptoms and risk of adverse outcomes. Patients with uncontrolled asthma have a higher risk of morbidity and mortality, underscoring the importance of identifying uncontrolled disease and modifying management plans to improve control. Several assessment tools exist to evaluate control with various cutoff points and measures, but these tools do not reliably correlate with physiological measures and should be considered a supplement to physiological tests. When attempting to improve control in patients, nonpharmacological interventions should always be attempted before changing or adding pharmacotherapies. Among patients with severe, uncontrolled asthma, individualized treatment based on asthma phenotype and eosinophil presence should be considered. The efficacy of the anti-IgE antibody omalizumab has been well established for patients with allergic asthma, and novel biologic agents targeting IL-5, IL-13, IL-4, and other allergic pathways have been investigated for patients with allergic or eosinophilic asthma. Fevipiprant (a CRT_H2 [chemokine receptor homologous molecule expressed on Th2 cells] antagonist) and imatinib (a tyrosine kinase inhibition) are examples of nonbiologic therapies that may be useful for patients with severe, uncontrolled asthma. Incorporation of new and emerging treatment into therapeutic strategies for patients with severe asthma may improve outcomes for this patient population.

The pediatric asthma yardstick: Practical recommendations for a sustained step-up in asthma therapy for children with inadequately controlled asthma

Current asthma guidelines recommend a control-based approach to management involving assessment of impairment and risk followed by implementation of treatment strategies individualized according to the patient's needs and preferences. However, for children with asthma, achieving control can be elusive. Although tools are available to help children (and families) track and manage day-to-day symptoms, when and how to implement a longer-term step-up in care is less clear. Furthermore, treatment is challenged by the 3 age groups of childhood-adolescence (12-18 years old), school age (6-11 years old), and young children (≤5 years old)-and what works for 1 age group might not be the best approach for another. The Pediatric Asthma Yardstick provides an in-depth assessment of when and how to step-up therapy for the child with not well or poorly controlled asthma. Development of this tool follows others in the Yardstick series, presenting patient profiles and step-up strategies based on current guidance documents, but modified according to newer data and the authors' combined clinical experience. The objective is to provide clinicians who treat children with asthma practical and clinically relevant recommendations for each step-up and each intervention, with the intent of helping practitioners better treat their pediatric patients with asthma, particularly those who do not always respond to recommended therapies.

Asthma

Asthma-one of the most common chronic, non-communicable diseases in children and adults-is characterised by variable respiratory symptoms and variable airflow limitation. Asthma is a consequence of complex gene-environment interactions, with heterogeneity in clinical presentation and the type and intensity of airway inflammation and remodelling. The goal of asthma treatment is to achieve good asthma control-ie, to minimise symptom burden and risk of exacerbations. Anti-inflammatory and bronchodilator treatments are the mainstay of asthma therapy and are used in a stepwise approach. Pharmacological treatment is based on a cycle of assessment and re-evaluation of symptom control, risk factors, comorbidities, side-effects, and patient satisfaction by means of shared decisions. Asthma is classed as severe when requiring high-intensity treatment to keep it under control, or if it remains uncontrolled despite treatment. New biological therapies for treatment of severe asthma, together with developments in biomarkers, present opportunities for phenotype-specific interventions and realisation of more personalised treatment. In this Seminar, we provide a clinically focused overview of asthma, including epidemiology, pathophysiology, clinical diagnosis, asthma phenotypes, severe asthma, acute exacerbations, and clinical management of disease in adults and children older than 5 years. Emerging therapies, controversies, and uncertainties in asthma management are also discussed.

Symbicort® Maintenance and Reliever Therapy (SMART) and the evolution of asthma management within the GINA guidelines

INTRODUCTION

The Global Initiative for Asthma (GINA) annual report summarizes the latest evidence for asthma management. GINA recommends stepwise pharmacological treatment, advocating inhaled corticosteroids (ICS) plus rapid, long-acting β₂-agonists (LABA) delivered in a single inhaler for maintenance and relief at Steps 3 (moderate persistent asthma requiring 1-2 controllers plus as-needed reliever), 4 (severe persistent asthma requiring ≥2 controllers plus as-needed reliever), and 5 (higher level care and/or add-on treatment). Areas covered: Randomized controlled trials and real-world evidence demonstrate that flexibly dosed budesonide/formoterol for maintenance and relief (Symbicort® Maintenance And Reliever Therapy [SMART]) is associated with reductions in severe exacerbations, prolongs time to first exacerbation, and provides fast symptom relief. Expert commentary: SMART provides greater or equal levels of sustained asthma control than similar or higher fixed doses of ICS/LABA plus short-acting β₂-agonist (SABA) as needed or higher ICS plus SABA as needed, with lower overall ICS doses and cost. The simplified dosing strategy may improve adherence and overall asthma control but relies on patient education. Budesonide/formoterol as needed in mild asthma (patients qualifying for regular low-dose ICS) is currently under investigation in two double-blind randomized studies, SYGMA1/2 (NCT02149199/NCT02224157), comparing budesonide/formoterol as needed with budesonide plus SABA and SABA alone.

How should treatment approaches differ depending on the severity of asthma?

INTRODUCTION

Asthma is nowadays regarded as a syndrome of various overlapping phenotypes with defined clinical characteristics, different underlying inflammatory mechanisms, identifiable genetic background, environmental risk factors and possible biomarkers. There are no doubts that due to the diversity of asthma, a 'one size fits all' management of the disease is no longer valid. Areas covered: Nowadays asthma management is based on the control of the disease, and the goals of asthma treatment are defined as good symptom control, decreased future risk of exacerbations, fixed airflow limitation, and side-effects of treatment. Alternative strategies for adjusting asthma treatment such as sputum or exhaled nitric oxide guided protocols have been evaluated and despite some effectiveness, are regarded as impractical in every-day clinical conditions. Further studies in the field of asthma phenotypes/endotypes and biomarkers are warranted with the main goal to define which of those possible subgroups will be useful in clinical practice in regards to the potential allocation of successful treatment. Expert commentary: Despite the availability of guidelines on the diagnosis and management of asthma, it seems that the disease is still not optimally controlled. Addressing unmet needs in every day care, improving education, adherence/compliance and inhalation technique may significantly improve asthma control across all severities of the disease.

Decreased frequency of adenoidectomy by a 12-week nasal budesonide treatment

Objective

There is little evidence on the role of topical budesonide in reducing the frequency of adenoidectomy, although it was reported that topical budesonide can effectively ameliorate the symptoms of adenoid hypertrophy (AH). This study was aimed to investigate the possibility and safety of alternatives to adenoidectomy with a 12-week treatment with nasal budesonide.

Materials and methods

One hundred patients with AH were randomized to receive either a double-blind budesonide (1 mg once daily) or placebo treatment for 2 weeks by transnasal nebulization. A further 12-week open study, budesonide spray (64 μg per nostril at bedtime) was administered to the treatment group. During the final 12 weeks of follow-up, the frequency of adenotonsillectomy, side effects, the degree of nasal obstruction, nasal discharge, and snoring were assessed.

Results

Out of the 100 total enrolled patients, 92 children with AH completed the study. After the 2-week treatment with transnasal budesonide nebulization, the symptoms of AH significantly decreased compared to the control group. Responders (n=26) who had initially improved showed significantly decreased symptoms of AH, and the frequency of adenotonsillectomy during the follow-up (14 and 26 weeks) was compared with that of the control group and non-responders (n=21) who did not respond to the initial 2-week budesonide therapy. The 12-week nasal budesonide treatment did not suppress the growth rate of children’s height or cause other side effects.

Conclusion

AH children who had improved after an initial 2-week budesonide therapy can achieve clinical improvements and decreased frequency of adenoidectomy following the therapy with a 12-week treatment with nasal budesonide.

Risks associated with managing asthma without a preventer: urgent healthcare, poor asthma control and over-the-counter reliever use in a cross-sectional population survey

OBJECTIVES

Overuse of asthma relievers, particularly without anti-inflammatory preventers, increases asthma risks. This study aimed to identify how many reliever-only users have urgent healthcare, explore their attitudes and beliefs about asthma and its treatment, and investigate whether purchasing over-the-counter relievers was associated with worse asthma outcomes than by prescription.

DESIGN AND SETTING

Cross-sectional population-based Internet survey in Australia.

PARTICIPANTS

Of 2686 participants ≥16 years with current asthma randomly drawn from a web-based panel, 1038 (50.7% male) used only reliever medication.

MAIN OUTCOME MEASURES

Urgent asthma-related healthcare; Asthma Control Test (ACT); patient attitudes about asthma and medications; reliever purchase (with/without prescription).

RESULTS

Of 1038 reliever-only participants, 23.3% had required urgent healthcare for asthma in the previous year, and only 36.0% had a non-urgent asthma review. Those needing urgent healthcare were more likely than those without such events to be male (56.5% vs 49.0%, p=0.003) and current smokers (29.4% vs 23.3%, p=0.009). Only 30.6% had well-controlled asthma (ACT ≥20) compared with 71.0% of those with no urgent healthcare (p<0.0001), and 20.8% used relievers regularly to prevent asthma symptoms (vs 5.5% of those without urgent healthcare). Those with urgent healthcare were more frustrated by their asthma and less happy with how they managed it, and they were less confident about their ability to manage worsening asthma, but just as likely as those without urgent healthcare to manage worsening asthma themselves rather than visit a doctor. Reliever-only users purchasing over-the-counter relievers were no more likely than those purchasing relievers by prescription to have uncontrolled asthma (35.9% vs 40.6%, p=0.23) but were less likely to have had a non-urgent asthma review.

CONCLUSIONS

One-quarter of the reliever-only population had needed urgent asthma healthcare in the previous year, demonstrating the importance of identifying such patients. Their attitudes and beliefs suggest opportunities for targeting this population in the community.

The impact of inappropriate use of short acting beta agonists in asthma

BACKGROUND

Inappropriate use of short-acting beta-agonists (SABA) has been associated with increased morbidity and mortality in asthma. However, the extent and pattern of SABA use have changed significantly over recent years. The outcomes in patients who are contemporarily receiving inappropriate doses of SABA have not been evaluated.

METHODS

We used population-based administrative health data from British Columbia (BC), Canada, to create a cohort of asthma patients aged 14 to 55. The exposure of interest was inappropriate use of SABA with any given 12-month period, as defined and validated previously. The primary outcome was asthma-related hospitalization in the following three-month period; secondary outcomes were asthma-related emergency department (ED) visits, asthma-related intensive care unit (ICU) admissions, and asthma-attributable costs.

RESULTS

A total of 343,520 individuals contributed 2,127,592 patient-years of follow up. Of these, in 190,546 patient-years (7.7%) SABAs were used inappropriately. Inappropriate use of SABAs in any given year was associated with a 45% (odds ratio (OR) = 1.45, 95%CI 1.26-1.66) increase in the risk of asthma-related admissions in the following three-month period. Similarly, inappropriate use of SABA was associated with 25% (OR = 1.25, 95% CI 1.18-1.33) increase in the risk of asthma-related ED visits. The association with ICU admissions was not statistically significant. Inappropriate use of SABA was associated with a 6% (relative rate [RR] = 1.06, 95% CI = 1.04-1.08) increase in total-asthma-related costs.

CONCLUSIONS

Inappropriate use of SABA continues to be problematic in a significant minority of asthma patients and is associated with an increased health care utilization and risk of adverse outcomes.

Description of the protocol for the PRACTICAL study: a randomised controlled trial of the efficacy and safety of ICS/LABA reliever therapy in asthma

Introduction

In adult asthma, combination inhaled corticosteroid (ICS)/fast-onset long-acting beta agonist (LABA) used solely as reliever therapy may represent an effective and safe alternative to ICS maintenance and short-acting beta agonist (SABA) reliever therapy.

Objective

To compare the efficacy and safety of ICS/fast-onset LABA reliever therapy with ICS maintenance and SABA reliever therapy in adults with asthma.

Methods and analysis

A 52-week, open-label, parallel group, multicentre, phase III randomised controlled trial with 1:1 randomisation to either budesonide/formoterol Turbuhaler 200/6 µg, one actuation as required for symptom relief, or budesonide Turbuhaler 200 µg, one actuation twice daily and terbutaline Turbuhaler 250 µg, two actuations as required for symptom relief. 890 adults aged 18–75 years with asthma for whom maintenance ICS and SABA reliever therapy is indicated by current guidelines will be recruited in New Zealand. The primary outcome variable is the rate of severe exacerbations per patient per year. This study will investigate a novel treatment regimen that might lead to a paradigm shift in asthma management for adults for whom guidelines currently recommend maintenance ICS and SABA reliever therapy.

Ethics and dissemination

Ethical approval has been granted (15/NTB/178). Study findings will be published according to Iinternational Committee of Medical Journal Editors' recommendations.

Trial registration number

ACTRN12616000377437; Pre-results.

Improving the Efficiency of Respiratory Drug Delivery: A Review of Current Treatment Trends and Future Strategies for Asthma and Chronic Obstructive Pulmonary Disease

Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous airway diseases associated with significant morbidity and mortality. Pharmacological treatment is delivered primarily through the inhalation route using various devices. Optimal disease control is highly dependent upon patient adherence. Both patients with asthma and COPD are prone to exacerbations leading to hospitalization, which can significantly impact quality of life. Poor adherence is a complex and multifactorial problem that does not have one simple solution. However, it is the biggest risk factor for exacerbations and consequently high healthcare utilization. This review discusses the complex and multifactorial obstacles that impact patient adherence as well as the effect on overall treatment outcomes and healthcare utilization. We also critically examined and compared relatively recent improvements in breath-activated pressurized metered dose inhalers, dry powder inhalers, and e-technology in asthma and COPD. Finally, future treatment strategies for better patient compliance such as personalized medicine and the importance of decision-making between patients and physicians were highlighted.

Therapeutic approaches to asthma-chronic obstructive pulmonary disease overlap

INTRODUCTION

Patients with features of both asthma and chronic obstructive pulmonary disease (COPD) ('asthma-COPD overlap') experience greater symptom burden and higher risk of adverse health outcomes than those with asthma or COPD alone. However, virtually no pharmacotherapy studies have been performed in this overlap population, leading to confusion amongst clinicians regarding therapeutic approaches. Areas covered: A pragmatic approach is suggested to identify patients with typical asthma, typical COPD, and those with overlap features. Interim clinical guidance on the treatment of asthma-COPD overlap is provided, acknowledging that these recommendations are based on expert opinion given the paucity of available evidence. Expert commentary: There is an urgent need for new studies in patients with asthma-COPD overlap to evaluate the efficacy and safety of existing pharmacotherapeutic options. Multiple underlying mechanisms are likely to contribute to the development of asthma-COPD overlap and a greater understanding of these mechanisms may allow a personalised approach to therapy in the future.

The SYGMA programme of phase 3 trials to evaluate the efficacy and safety of budesonide/formoterol given 'as needed' in mild asthma: study protocols for two randomised controlled trials

Background

In many patients with mild asthma, the low frequency of symptoms and the episodic nature of exacerbations make adherence to regular maintenance treatment difficult. This often leads to over-reliance on short-acting β₂-agonist (SABA) reliever medication and under-treatment of the underlying inflammation, with poor control of asthma symptoms and increased risk of exacerbations. The use of budesonide/formoterol ‘as needed’ in response to symptoms may represent an alternative treatment option for patients with mild asthma.

Methods/design

The SYmbicort Given as needed in Mild Asthma (SYGMA) programme consists of two 52-week, double-blind, randomised, multicentre, parallel-group, phase 3 trials of patients aged 12 years and older with a clinical diagnosis of asthma for at least 6 months, who would qualify for treatment with regular inhaled corticosteroids (ICS). SYGMA1 aims to recruit 3750 patients who will be randomised to placebo twice daily (bid) plus as-needed budesonide/formoterol 160/4.5 μg, placebo bid plus as-needed terbutaline 0.4 mg, or budesonide 200 μg bid plus as-needed terbutaline 0.4 mg. The primary objective is to demonstrate the superiority of as-needed budesonide/formoterol over as-needed terbutaline for asthma control, as measured by well-controlled asthma weeks; a secondary objective is to establish the noninferiority of as-needed budesonide/formoterol versus maintenance budesonide plus as-needed terbutaline using the same outcome measure. SYGMA2 aims to recruit 4114 patients who will be randomised to placebo bid plus as-needed budesonide/formoterol 160/4.5 μg, or budesonide 200 μg bid plus as-needed terbutaline 0.4 mg. The primary objective is to demonstrate the noninferiority of as-needed budesonide/formoterol over budesonide bid plus as-needed terbutaline as measured by the annualised severe exacerbation rate. In both studies, use of all blinded study inhalers will be recorded electronically using Turbuhaler® Usage Monitors.

Discussion

Given the known risks of mild asthma, and known poor adherence with regular inhaled corticosteroids, the results of the SYGMA programme will help to determine the efficacy and safety of as-needed budesonide/formoterol therapy in mild asthma. Patient recruitment is complete, and completion of the phase 3 studies is planned in 2017.

Trial registration

ClinicalTrials.gov identifiers: NCT02149199 SYGMA1 and NCT02224157 SYGMA2. Registered on 16 May 2014 and 19 August 2014, respectively.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1731-4) contains supplementary material, which is available to authorized users.