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González-Díaz SN, Ansotegui IJ, Macouzet-Sánchez C, Acuña-Ortega N, de la Cruz-de la Cruz C. Doxofylline as a steroid-sparing treatment in Mexican children with asthma. J Asthma 2024; 61:574-583. [PMID: 38153316 DOI: 10.1080/02770903.2023.2294909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/10/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE The aim of this pilot study was to assess the efficacy of doxofylline as an ICS-sparing agent in the treatment of Mexican children with asthma. METHODS 10-week, open-label, crossover, pilot study, we examined the steroid-sparing effect of doxofylline in Mexican children with asthma. Patients aged 6-16 years treated with inhaled corticosteroids (ICS) for at least 8 wk before enrollment were divided randomly into two groups at the baseline visit. Group A (n = 31) received doxofylline (18 mg/kg/day) plus standard-dose budesonide (D + SDB) for the first 4-week period followed by doxofylline plus reduced-dose budesonide (D + RDB) for the second 4-week period. Group B (n = 30) received D + RDB followed by D + SDB. Clinical outcomes assessed included lung function (forced expiratory volume; in 1 s, FEV1), fractional exhaled nitric oxide (FeNO), asthma control, number of exacerbations and use of rescue medication (salbutamol). RESULTS It was shown that combined use of doxofylline and ICS may allow children with asthma to reduce their daily dose of ICS while maintaining lung function and improving asthma control (p = 0.008). There were few asthma exacerbations and only one patient required treatment with systemic corticosteroids. Rescue medication use decreased significantly in patients receiving D + SDB during the first 4-week period. CONCLUSIONS Our results suggest that doxofylline may be a steroid-sparing treatment in asthma, but longer-term, controlled studies are needed to confirm these observations.
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Affiliation(s)
- Sandra Nora González-Díaz
- Regional Center of Allergy and Clinical Immunology, University Hospital "Dr Jose Eleuterio Gonzalez", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Ignacio J Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Erandio-Bilbao, Spain
| | - Carlos Macouzet-Sánchez
- Regional Center of Allergy and Clinical Immunology, University Hospital "Dr Jose Eleuterio Gonzalez", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Natalhie Acuña-Ortega
- Regional Center of Allergy and Clinical Immunology, University Hospital "Dr Jose Eleuterio Gonzalez", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Carlos de la Cruz-de la Cruz
- Regional Center of Allergy and Clinical Immunology, University Hospital "Dr Jose Eleuterio Gonzalez", Autonomous University of Nuevo León, Monterrey, Mexico
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Salam RA, Khan MH, Meerza SSA, Das JK, Lewis-Watts L, Bhutta ZA. An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents. Nat Med 2024; 30:290-301. [PMID: 38195753 DOI: 10.1038/s41591-023-02737-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 11/27/2023] [Indexed: 01/11/2024]
Abstract
Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.
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Affiliation(s)
- Rehana A Salam
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Maryam Hameed Khan
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Saqlain Ali Meerza
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Jai K Das
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Laura Lewis-Watts
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.
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3
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Sekerel BE, Nell H, Laki I, Pak T, Contreras E, Kolarz A, D'Andrea P, Manga V, Jain M, Vaidya S, Valentin M, Sen B. Efficacy, Safety, and Systemic Exposure of Once-Daily Indacaterol Acetate in Pediatric Asthma: A Randomized, Double-Blind, Controlled Dose-Finding Study. Clin Drug Investig 2023; 43:719-728. [PMID: 37682405 PMCID: PMC10514176 DOI: 10.1007/s40261-023-01300-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Indacaterol acetate (IND), a long-acting β2-agonist in combination with mometasone furoate (MF), an inhaled corticosteroid (ICS), is being explored as a once-daily (od) treatment for asthma in children. This study examined the efficacy, safety, and systemic exposure of IND 75 µg and IND 150 µg in children with persistent asthma. METHODS In this Phase IIb, multicenter, randomized, double-blind, parallel-group study, pediatric patients (aged ≥ 6 to < 12 years) with persistent asthma were randomized (1:1) to receive either IND 75 µg od or IND 150 µg od via Breezhaler® in combination with ICS background therapy. The primary endpoint was change from baseline in pre-dose trough forced expiratory volume in one second (FEV1) after two weeks of treatment. RESULTS In total, 80 patients received IND 75 µg (n = 39) or IND 150 µg (n = 41). The study met its primary endpoint; both doses demonstrated improvements in pre-dose trough FEV1 from baseline to Day 14 (mean change [Δ]: 212 mL, IND 75 µg; 171 mL, IND 150 µg). The secondary spirometry parameters (post-dose FEV1 after 1-h, post-dose forced vital capacity; morning and evening peak expiratory flow) also improved. Overall, 36.1% in IND 75 μg group and 25% patients in IND 150 μg group achieved a decrease from baseline in Pediatric Interviewer-administered Asthma Control Questionnaire score of ≥ 0.5 units. A dose-dependent increase in plasma IND concentration was noted between the two groups. Both IND doses demonstrated an acceptable safety profile. CONCLUSIONS Once-daily IND 75 μg and IND 150 μg via Breezhaler® in combination with background ICS therapy provided substantial bronchodilation in children with asthma and were well tolerated. Taken together, these clinical and systemic exposure findings support IND 75 μg as the most appropriate dose for evaluation in Phase III trials in combination with MF in pediatric asthma. TRIAL REGISTRATION ClinicalTrials.gov (NCT02892019; 08-Sep-2016).
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Affiliation(s)
- Bulent Enis Sekerel
- Pediatric Allergy and Asthma Division, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Haylene Nell
- Tiervlei Trial Centre, Karl Bremer Hospital, Cape Town, South Africa
| | - Istvan Laki
- Department of Pediatric Pulmonology, Institute of Pulmonology, Törökbálint, Hungary
| | - Tatiana Pak
- LLC PiterClinica, Saint-Petersburg, Russian Federation
| | - Edgar Contreras
- Médico Neumólogo e Internista, Director del Centro de Investigaciones de Latinoamerica, Guatemala City, Guatemala
| | | | - Peter D'Andrea
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Volkan Manga
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Monish Jain
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Soniya Vaidya
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
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Beasley R, Bruce P, Houghton C, Hatter L. The ICS/Formoterol Reliever Therapy Regimen in Asthma: A Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:762-772.e1. [PMID: 36639054 DOI: 10.1016/j.jaip.2023.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
The Global Initiative for Asthma recommends that low-dose inhaled corticosteroid (ICS)/formoterol be preferred to short-acting beta2-agonists as reliever therapy in adolescents and adults with asthma, across the range of asthma severity. This recommendation represents the most fundamental change in asthma management for many decades. In this commentary, we review the rationale for combination ICS/formoterol therapy, the evidence on which this recommendation has been made, the limitations in the evidence, the practical issues relevant to the implementation of ICS/formoterol reliever-based regimens in clinical practice, and the emerging evidence for the efficacy and safety of combination ICS/salbutamol reliever therapy regimens.
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Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand; Capital and Coast District Health Board, Wellington, New Zealand; Victoria University of Wellington, Wellington, New Zealand.
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand; Victoria University of Wellington, Wellington, New Zealand
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Chryseriol attenuates the progression of OVA-induced asthma in mice through NF-κB/HIF-1α and MAPK/STAT1 pathways. Allergol Immunopathol (Madr) 2023; 51:146-153. [PMID: 36617834 DOI: 10.15586/aei.v51i1.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/18/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Asthma is a hackneyed chronic inflammatory disease of the airway. Chryseriol (CSR) is a kind of flavonoid, and has the effect of bronchiectasis, indicating its potential application for treating respiratory diseases. However, the functions of CSR in asthma have not been reported till now. MATERIALS AND METHODS The histopathologic changes of the lung tissues were assessed by hematoxylin and eosin staining. The cell apoptosis was identified through terminal deoxynucleotidyl transferase-mediated dUTP nick end labelling assay. Total numbers of eosinophils, neutrophils, and macrophages were assessed under microscope. The levels of interleukin (IL)-1β, IL-4, IL-5, and IL-13 were detected by enzyme-linked-immunosorbent serologic assay. The airway hyper-responsiveness (AHR) was evaluated by the whole body plethysmography. The levels of methane dicarboxylic aldehyde, superoxide dismutase, glutathione S-transferase, and glutathione in lung homogenates were confirmed by using corresponding commercial kits. The protein expressions were examined by Western blot analysis. RESULTS The ovalbumin (OVA) was utilized to establish asthma mouse model. At first, it was revealed that CSR treatment reduced lung injury in OVA-stimulated mice. Moreover, cell apoptosis was enhanced after OVA stimulation but was attenuated by CSR treatment. In addition, CSR treatment decreased the infiltration of inflammatory cells and the production of inflammatory factors in OVA-treated mice. Further investigations demonstrated that CSR treatment relieved AHR in OVA-stimulated mice. The oxidative stress was strengthened in OVA-treated mice, but these effects were relieved by CSR treatment. Lastly, it was discovered that CSR treatment retarded nuclear factor kappa B (NF-κB)/hypoxia-inducible factor 1 alpha (HIF-1α) and p38 mitogen-activated protein kinase (MAPK)/signal transducer and activator of transcription 1 (STAT1) pathways in OVA-triggered asthma mice. CONCLUSION Our findings proved that CSR attenuated the progression of OVA-induced asthma in mice through inhibiting NF-κB/HIF-1α and MAPK/STAT1 pathways. This work might highlight the functions of CSR in the treatment of asthma.
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Yamada S, Fujisawa T, Nagao M, Matsuzaki H, Motomura C, Odajima H, Nakamura T, Imai T, Nagakura KI, Yanagida N, Mitomori M, Ebisawa M, Kabashima S, Ohya Y, Habukawa C, Tomiita M, Hirayama M. Risk Factors for Lung Function Decline in Pediatric Asthma under Treatment: A Retrospective, Multicenter, Observational Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101516. [PMID: 36291452 PMCID: PMC9600699 DOI: 10.3390/children9101516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/27/2022] [Accepted: 09/30/2022] [Indexed: 11/17/2022]
Abstract
Background: Childhood asthma is a major risk for low lung function in later adulthood, but what factors in asthma are associated with the poor lung function during childhood is not known. Objective: To identify clinical factors in children with asthma associated with low or declining lung function during the treatment. Methods: We enrolled children with asthma who had been treated throughout three age periods, i.e., 6−9, 10−12, and 13−15 years old, at seven specialized hospitals in Japan. Clinical information and lung function measurements were retrieved from the electronic chart systems. To characterize the lung function trajectories during each age period, we evaluated the forced expiratory volume 1 (FEV1) with % predicted values and individual changes by the slope (S) from linear regression. We defined four trajectory patterns: normal (Group N) and low (Group L), showing %FEV1 ≥80% or <80% throughout all three periods; upward (Group U) and downward (Group D), showing S ≥ 0 or S < 0%. Logistic regression analysis was performed to compare factors associated with the unfavorable (D/L) versus favorable (N/U) groups. Results: Among 273 eligible patients, 197 (72%) were classified into Group N (n = 150)/U (n = 47), while 76 (28%) were in Group D (n = 66)/L (n = 10). A history of poor asthma control, long-acting beta2 agonist use, and a lower height Z-score during 13−15 years were associated with an unfavorable outcome (Group D/L). Conversely, inhaled corticosteroid (ICS) use during 10−12 years and high-dose ICS use during 13−15 years were associated with a favorable outcome (Group N/U). Conclusion: We identified several factors that are associated with unfavorable lung function changes in pediatric asthma. Attention should be paid to the possible relationship between yearly changes in lung function and poor asthma control, use of ICS (and its dose) and use of LABA.
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Affiliation(s)
- Shingo Yamada
- Allergy Center, National Hospital Organization Mie National Hospital, Tsu 514-0125, Japan
| | - Takao Fujisawa
- Allergy Center, National Hospital Organization Mie National Hospital, 357 Ozato-kubota, Tsu 514-0125, Japan
- Correspondence: ; Tel.: +81-59-232-2531
| | - Mizuho Nagao
- Allergy Center, National Hospital Organization Mie National Hospital, Tsu 514-0125, Japan
| | - Hiroshi Matsuzaki
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka 811-1394, Japan
| | - Chikako Motomura
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka 811-1394, Japan
| | - Hiroshi Odajima
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka 811-1394, Japan
| | - Toshinori Nakamura
- Department of Pediatrics, Showa University School of Medicine, Tokyo 142-8666, Japan
| | - Takanori Imai
- Department of Pediatrics, Showa University School of Medicine, Tokyo 142-8666, Japan
| | - Ken-ichi Nagakura
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Sagamihara 252-0392, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Sagamihara 252-0392, Japan
| | - Masatoshi Mitomori
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Sagamihara 252-0392, Japan
| | - Motohiro Ebisawa
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Sagamihara 252-0392, Japan
| | - Shigenori Kabashima
- Allergy Center, National Center for Child Health and Development, Tokyo 157-8535, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo 157-8535, Japan
| | - Chizu Habukawa
- Department of Pediatric Allergy, National Hospital Organization Minami Wakayama Medical Center, Tanabe 656-8558, Japan
| | - Minako Tomiita
- Center of Pediatric Allergy and Rheumatology, National Hospital Organization Shimoshizu National Hospital, Yotsukaido 284-0003, Japan
| | - Masahiro Hirayama
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
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Papadopoulos NG, Miligkos M, Xepapadaki P. A Current Perspective of Allergic Asthma: From Mechanisms to Management. Handb Exp Pharmacol 2021; 268:69-93. [PMID: 34085124 DOI: 10.1007/164_2021_483] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Asthma is a result of heterogenous, complex gene-environment interactions with variable clinical phenotypes, inflammation, and remodeling. It affects more than 330 million of people worldwide throughout their educational and working lives, while exacerbations put a heavy cost/burden on productivity. Childhood asthma is characterized by a predominance of allergic sensitization and multimorbidity, while in adults polysensitization has been positively associated with asthma occurrence. Despite significant improvements in recent decades, asthma management remains challenging. Recently, a group of specialists suggested that the term "asthma" should be preferably used as a descriptive term for symptoms. Moreover, type 2 inflammation has emerged as a pivotal disease mechanism including overlapping endotypes of specific IgE production, while type 2-low asthma includes several disease endotypes. Optimal asthma control requires both appropriate pharmacological interventions, tailored to each patient, as well as trigger avoidance measures. Regular monitoring for maintenance of symptom control, preservation of lung function, and detection of treatment-related adverse effects are warranted. Allergen-specific immunotherapy and the advent of new targeted therapies for patients with difficult to control asthma offer diverse treatment options. The current review summarizes up-to-date knowledge on epidemiology, definitions, diagnosis, and current therapeutic strategies.
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Affiliation(s)
- Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece. .,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
| | - Michael Miligkos
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
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Mosnaim G, Bizik BK, Wilson C, Bensch G. Efficacy and safety of add-on tiotropium in the management of uncontrolled asthma: a patient case series. J Asthma 2021; 59:1231-1236. [PMID: 33974467 DOI: 10.1080/02770903.2021.1914648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Despite the availability of various treatment options, a large proportion of patients with asthma have uncontrolled asthma in the United States. Consequently, the economic burden of suboptimal asthma control is anticipated to substantially grow in the next 20 years, adversely impacting patients' quality of life. Therefore, there is an urgent need for effective treatments to achieve and maintain asthma control. The Global Initiative for Asthma recommends tiotropium as a controller medication for patients with asthma aged ≥6 years, based on evidence from several randomized controlled trials. However, more real-world data on the effectiveness of tiotropium are required to establish a broad picture of its use in everyday clinical practice. METHODS Herein, we present 3 case reports of patients diagnosed with uncontrolled or fixed obstructive asthma not responding to inhaled corticosteroids (ICS) or ICS + long-acting β2-agonists (LABAs) and/or leukotriene receptor antagonists (LTRAs). RESULTS All 3 patients were prescribed tiotropium, irrespective of their age. Tiotropium improved lung function and quality of life, as indicated by the forced expiratory volume in 1 s/forced vital capacity ratio and the Asthma Control Test score. Furthermore, the addition of tiotropium reduced the use of rescue medication. CONCLUSIONS Hence, the results from these case reports highlight that tiotropium could be an effective and safe add-on treatment option for patients across a range of age groups with uncontrolled or fixed obstructive asthma receiving prior ICS or ICS + LABA and/or LTRA therapy.
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Affiliation(s)
- Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University HealthSystem, IL, USA
| | | | - Christy Wilson
- Piedmont Healthcare Department of Pulmonary, Critical Care and Sleep Medicine, GA, USA
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Cividini S, Sinha I, Donegan S, Maden M, Culeddu G, Rose K, Fulton O, Hughes DA, Turner S, Tudur Smith C. EstablishINg the best STEp-up treatments for children with uncontrolled asthma despite INhaled corticosteroids (EINSTEIN): protocol for a systematic review, network meta-analysis and cost-effectiveness analysis using individual participant data (IPD). BMJ Open 2021; 11:e040528. [PMID: 33550231 PMCID: PMC7925932 DOI: 10.1136/bmjopen-2020-040528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Asthma affects millions of children worldwide-1.1 million children in the UK. Asthma symptoms cannot be cured but can be controlled with low-dose inhaled corticosteroids (ICSs) in the majority of individuals. Treatment with a low-dose ICS, however, fails to control asthma symptoms in around 10%-15% of children and this places the individual at increased risk for an asthma attack. At present, there is no clear preferred treatment option for a child whose asthma is not controlled by low-dose ICS and international guidelines currently recommend at least three treatment options. Herein, we propose a systematic review and individual participant data network meta-analysis (IPD-NMA) aiming to synthesise all available published and unpublished evidence from randomised controlled trials (RCTs) to establish the clinical effectiveness of pharmacological treatments in children and adolescents with uncontrolled asthma on ICS and help to make evidence-informed treatment choices. This will be used to parameterise a Markov-based economic model to assess the cost-effectiveness of alternative treatment options in order to inform decisions in the context of drug formularies and clinical guidelines. METHODS AND ANALYSIS We will search in MEDLINE, the Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, NICE Technology Appraisals and the National Institute for Health Research (NIHR) Health Technology Assessment series for RCTs of interventions in patients with uncontrolled asthma on ICS. All studies where children and adolescents were eligible for inclusion will be considered, and authors or sponsors will be contacted to request IPD on patients aged <18. The reference lists of existing clinical guidelines, along with included studies and relevant reviews, will be checked to identify further relevant studies. Unpublished studies will be located by searching across a range of clinical trial registries, including internal trial registers for pharmaceutical companies. All studies will be appraised for inclusion against predefined inclusion and exclusion criteria by two independent reviewers with disagreements resolved through discussion with a third reviewer. We will perform an IPD-NMA-eventually supplemented with aggregate data for the RCTs without IPD-to establish both the probability that a treatment is best and the probability that a particular treatment is most likely to be effective for a specific profile of the patient. The IPD-NMA will be performed for each outcome variable within a Bayesian framework, using the WinBUGS software. Also, potential patient-level characteristics that may modify treatment effects will be explored, which represents one of the strengths of this study. ETHICS AND DISSEMINATION The Committee on Research Ethics, University of Liverpool, has confirmed that ethics review is not required. The dissemination plan consists of publishing the results in an open-access medical journal, a plain-language summary available for parents and children, dissemination via local, national and international meetings and conferences and the press offices of our Higher Education Institutions (HEIs). A synopsis of results will be disseminated to NICE and British Thoracic Society/Scottish Intercollegiate Guidelines Network (SIGN) as highly relevant to future clinical guideline updates. PROSPERO REGISTRATION NUMBER CRD42019127599.
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Affiliation(s)
- Sofia Cividini
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Ian Sinha
- Alder Hey Children's Foundation NHS Trust, Liverpool, UK
| | - Sarah Donegan
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Michelle Maden
- Liverpool Reviews and Implementation Group (LRIG), University of Liverpool, Liverpool, UK
| | - Giovanna Culeddu
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Katie Rose
- Alder Hey Children's Foundation NHS Trust, Liverpool, UK
| | | | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Stephen Turner
- Department of Child Health, University Court of the University of Aberdeen, Aberdeen, UK
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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Zielen S, Reichert G, Donath H, Trischler J, Schulze J, Eickmeier O, Eckrich M, Blumchen K. Tiotropium as an Add-on Treatment Option for Severe Uncontrolled Asthma in Preschool Patients. J Asthma Allergy 2021; 14:23-30. [PMID: 33469318 PMCID: PMC7813466 DOI: 10.2147/jaa.s274544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/23/2020] [Indexed: 11/23/2022] Open
Abstract
Background Toddlers with asthma suffer disproportionally more than school-aged children from exacerbations with emergency visits and hospital admissions despite inhaled corticosteroid (ICS) treatment. A recent trial for children ≤5 years showed tolerability of tiotropium and potential to reduce asthma-related events. Methods We conducted a retrospective analysis of electronic outpatient records (2017‒2019) of children <6 years treated with ICS plus long-acting β2-agonists (LABAs) plus tiotropium as an add-on for uncontrolled severe asthma. The primary endpoint was a comparison of systemic corticosteroid (SCS) prescriptions 6 months before and after ICS/LABA/tiotropium start. Secondary endpoints included physician visits, hospitalisations and antibiotic prescriptions. We compared outcomes with children without asthma matched for age, sex, season and screening date. Results Compared with a mean 2.42 (95% CI: 1.75, 3.36) SCS courses per patient within 6 months prior to ICS/LABA/tiotropium, 0.74 (95% CI: 0.25, 1.08) SCS courses per patient were prescribed within 6 months after starting ICS/LABA/tiotropium (P<0.001). Physician visits dropped from 9.23 (95% CI: 7.15, 12.72) to 5.76 (95% CI: 3.10, 7.70) per patient (P<0.01). Nineteen hospitalisations were recorded 6 months before ICS/LABA/tiotropium compared with one hospitalisation after (P<0.01). A mean 1.79 antibiotic courses (95% CI: 1.22, 2.23) per patient were prescribed before ICS/LABA/tiotropium compared with 0.74 (95% CI: 0.22, 1.00) after ICS/LABA/tiotropium (P<0.001). Hospitalisation rates for patients at observation end were not statistically different from healthy controls before/after matching. Interpretation Our retrospective study showed that adding tiotropium to ICS/LABA is a new treatment option for patients with severe preschool asthma; however, larger confirmatory studies are needed.
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Affiliation(s)
- Stefan Zielen
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic Fibrosis, University Hospital Frankfurt, Frankfurt, Germany
| | - Gianna Reichert
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic Fibrosis, University Hospital Frankfurt, Frankfurt, Germany
| | - Helena Donath
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic Fibrosis, University Hospital Frankfurt, Frankfurt, Germany
| | - Jordis Trischler
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic Fibrosis, University Hospital Frankfurt, Frankfurt, Germany
| | - Johannes Schulze
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic Fibrosis, University Hospital Frankfurt, Frankfurt, Germany
| | - Olaf Eickmeier
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic Fibrosis, University Hospital Frankfurt, Frankfurt, Germany
| | - Martin Eckrich
- Group Practice Dres. Med. Martin Eckrich and Matthias Gründler, Offenbach am Main, Germany
| | - Katharina Blumchen
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic Fibrosis, University Hospital Frankfurt, Frankfurt, Germany
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11
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Donath H, Kluge S, Sideri G, Trischler J, Jerkic SP, Schulze J, Zielen S, Blumchen K. Hospitalization, Asthma Phenotypes, and Readmission Rates in Pre-school Asthma. Front Pediatr 2020; 8:562843. [PMID: 33330266 PMCID: PMC7716437 DOI: 10.3389/fped.2020.562843] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/13/2020] [Indexed: 01/19/2023] Open
Abstract
Objective: Children with pre-school asthma suffer disproportionally more often from severe asthma exacerbations with emergency visits and hospital admissions compared to school children. Despite this high disease burden, there are only a few reports looking at this particular severe asthma cohort. Similarly, there is little real-life research on the distribution of asthma phenotypes and personalized treatment at discharge in this age group. Patients and Methods: Retrospective analysis of the electronic charts of all children aged 1-5 years with asthma hospitalizations (ICD J45) at the Frankfurt University between 2008 and 2017. An acute severe asthma exacerbation was defined as dyspnea, oxygen demand, and/or systemic steroid therapy. Age, gender, duration of hospitalization, asthma phenotype, treatment, and readmission rate were analyzed. Results: Of 572 patients, 205 met the definition of acute severe asthma. The phenotypic characterization showed 56.1% had allergic asthma, 15.2% eosinophilic asthma and 28.7% non-allergic asthma. Of these patients, 71.7% were discharged with inhaled corticosteroids (ICS) or ICS + long-acting-beta-agonists (LABA), 15.1% with leukotriene antagonists (LTRA) and 7.3% salbutamol on demand. The rate of emergency presentations (emergency department and readmission) within 12 months after discharge was high (n = 42; 20.5%). No phenotype tailored treatment was detectable. Neither the number of eosinophils (>300/μl) nor the treatment at discharge had an effect on emergency visits and readmission rate. Conclusion: Despite protective therapy with ICS, ICS + LABA, or LTRA, the readmission rate was high. Thus, current care and treatment strategies should be reevaluated continuously, in order to better control asthma in pre-school children and prevent hospitalization.
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Affiliation(s)
| | | | | | | | | | | | - Stefan Zielen
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
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12
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Comparing LAMA with LABA and LTRA as add-on therapies in primary care asthma management. NPJ Prim Care Respir Med 2020; 30:50. [PMID: 33177503 PMCID: PMC7658210 DOI: 10.1038/s41533-020-00205-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023] Open
Abstract
The Global Initiative for Asthma recommends a stepwise approach to adjust asthma treatment to the needs of individual patients; inhaled corticosteroids (ICS) remain the core pharmacological treatment. However, many patients remain poorly controlled, and evidence-based algorithms to decide on the best order and rationale for add-on therapies are lacking. We explore the challenges of asthma management in primary care and review outcomes from randomised controlled trials and meta-analyses comparing the long-acting muscarinic antagonist (LAMA) tiotropium with long-acting β2-agonists (LABAs) or leukotriene receptor antagonists (LTRAs) as add-on to ICS in patients with asthma. In adults, LAMAs and LABAs provide a greater improvement in lung function than LTRAs as add-on to ICS. In children, results were positive and comparable between therapies, but data are scarce. This information could aid decision-making in primary care, supporting the use of add-on therapy to ICS to help improve lung function, control asthma symptoms and prevent exacerbations.
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13
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Al-Turki A, Salvator A, Bai S, Sheikh SI. Comparison of Two Therapies on Asthma Control in Children. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2020; 33:127-135. [PMID: 35922029 PMCID: PMC9353977 DOI: 10.1089/ped.2020.1196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/26/2020] [Indexed: 06/15/2023]
Abstract
Background: Childhood asthma carries significant morbidity. Aim/Objectives: Aim of the study was to compare efficacy of 2 commonly used therapies for asthma control in children with asthma. Methods: This was a 1-year, prospective cohort study at a tertiary care children's hospital. Patients were referred by their primary care physicians (PCPs) for asthma control. All patients were on low-dose inhaled corticosteroids (ICSs) at baseline. They were either switched to medium-dose ICS (ICS group) or medium-dose ICS and long-acting beta agonist (ICS+LABA group). Results were compared over time and between both groups. Results: Our cohort included 163 children (ages 2-18 years) with mean age of 5.62 ± 3.61 years. Mean Asthma Control Test (ACT) score at baseline was 15.9 ± 5.4. Mean ACT and percent predicted forced expiratory volume in one second improved (P < 0.0001 for both) in both groups. Median emergency department visits, short courses of oral steroids, and unscheduled PCP visits for acute asthma significantly decreased (P < 0.001 for all) in both groups. Similarly, days/month with wheezing, nighttime cough, and missed school days significantly decreased in both groups (P < 0.001 for all). Patients in ICS group were more likely to fail to achieve asthma control compared to patients in ICS+LABA group. Conclusion: Our study suggests that in children with uncontrolled asthma on low-dose ICS, switching to either medium-dose ICS or medium-dose ICS+LABA resulted in better symptom control, ACT improvement, and less asthma exacerbations over time. ICS+LABA had the additional benefit of less risk of treatment failure when compared to medium-dose ICS.
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Affiliation(s)
- Anas Al-Turki
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ann Salvator
- Biostatistics Resource at Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Shasha Bai
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Biostatistics Resource at Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Shahid I. Sheikh
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
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14
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Vogelberg C, Goldstein S, Graham L, Kaplan A, de la Hoz A, Hamelmann E. A comparison of tiotropium, long-acting β 2-agonists and leukotriene receptor antagonists on lung function and exacerbations in paediatric patients with asthma. Respir Res 2020; 21:19. [PMID: 31931792 PMCID: PMC6958672 DOI: 10.1186/s12931-020-1282-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/05/2020] [Indexed: 11/10/2022] Open
Abstract
Diagnosing and treating asthma in paediatric patients remains challenging, with many children and adolescents remaining uncontrolled despite treatment. Selecting the most appropriate pharmacological treatment to add onto inhaled corticosteroids (ICS) in children and adolescents with asthma who remain symptomatic despite ICS can be difficult. This literature review compares the efficacy and safety of long-acting β2-agonists (LABAs), leukotriene receptor antagonists (LTRAs) and long-acting muscarinic antagonists (LAMAs) as add-on treatment to ICS in children and adolescents aged 4-17 years.A literature search identified a total of 29 studies that met the inclusion criteria, including 21 randomised controlled trials (RCTs) of LABAs versus placebo, two RCTs of LAMAs (tiotropium) versus placebo, and four RCTs of LTRA (montelukast), all as add-on to ICS. In these studies, tiotropium and LABAs provided greater improvements in lung function than LTRAs, when compared with placebo as add-on to ICS. Although exacerbation data were difficult to interpret, tiotropium reduced the risk of exacerbations requiring oral corticosteroids when added to ICS, with or without additional controllers. LABAs and LTRAs had a comparable risk of asthma exacerbations with placebo when added to ICS. When adverse events (AEs) or serious AEs were analysed, LABAs, montelukast and tiotropium had a comparable safety profile with placebo.In conclusion, this literature review provides an up-to-date overview of the efficacy and safety of LABAs, LTRAs and LAMAs as add-on to ICS in children and adolescents with asthma. Overall, tiotropium and LABAs have similar efficacy, and provide greater improvements in lung function than montelukast as add-on to ICS. All three controller options have comparable safety profiles.
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Affiliation(s)
- Christian Vogelberg
- Department of Pediatric Pulmonology and Allergy, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
| | - Stanley Goldstein
- Allergy and Asthma Care of Long Island, Rockville Centre, New York, USA
| | - LeRoy Graham
- Pediatric Pulmonology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada
| | - Alberto de la Hoz
- TA Respiratory/Biosimilars Medicine, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Eckard Hamelmann
- Klinik für Kinder und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld, and Allergy Center of the Ruhr University, Bochum, Germany
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15
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Abstract
Pediatric asthma, the most common chronic disease of childhood, remains a significant burden to the health care system. Although there are guidelines for the management of pediatric asthma, there remain several controversies about how best to manage asthma in the primary care setting, and how to prevent asthma exacerbations and subsequent emergency department visits and hospitalizations. In this article, we address four of these controversies: use of written asthma treatment plans, the role of long-acting beta-agonists, spirometry and peak flow measurements in disease management, and engagement of school nurses in the health care team. We provide suggestions and guidance related to these topics for the pediatric primary care provider. [Pediatr Ann. 2019;48(3):e128-e134.].
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16
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Chung LP, Paton JY. Two Sides of the Same Coin?-Treatment of Chronic Asthma in Children and Adults. Front Pediatr 2019; 7:62. [PMID: 30915319 PMCID: PMC6421287 DOI: 10.3389/fped.2019.00062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/18/2019] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - James Y Paton
- School of Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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17
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Kaur S, Singh V. Asthma and Medicines - Long-Term Side-Effects, Monitoring and Dose Titration. Indian J Pediatr 2018; 85:748-756. [PMID: 29306991 DOI: 10.1007/s12098-017-2553-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/22/2017] [Indexed: 01/30/2023]
Abstract
Asthma is a major pediatric respiratory morbidity requiring long-term management. A thorough knowledge of long-term medication side-effects in children is, thus, essential for every physician dealing with childhood asthma. Establishing diagnosis and initiating treatment is just a beginning of the journey. Ongoing monitoring is an essential component of comprehensive asthma management programme. Monitoring includes not only assessment of asthma control but also checking for adherence to treatment, technique of inhaler device use, associated co-morbities, if any, and potential environmental exposure. Various tools - both subjective and objective - are available for assessment of asthma control. However, evidence for their optimum use in different settings and patient groups is lacking and monitoring has to be customized depending on available resources and individual patient characteristics. Patient education is an important component of long-term asthma therapy. The ultimate aim is to achieve optimum asthma control i.e., achieve and maintain control of clinical symptoms, decrease future risk to patients (risk of exacerbations, progressive loss of lung function and development of fixed airflow obstruction, adverse effects of medications) and enabling the child to lead a life without restrictions, at lowest possible dose of drugs. This article reviews the side-effects of medications used for long-term management of asthma and discusses current literature on asthma monitoring and dose titration in pediatric population to help the asthma therapist not only prescribe the drugs rationally but also help the family make right choices for treatment.
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Affiliation(s)
- Satnam Kaur
- Department of Pediatrics, Vardhman Mahavir Medical College and Associated Safdarjung Hospital, New Delhi, India
| | - Varinder Singh
- Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India.
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18
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Benefits and Risks of Long-Term Asthma Management in Children: Where Are We Heading? Drug Saf 2017; 40:201-210. [PMID: 27928727 DOI: 10.1007/s40264-016-0483-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
International guidelines provide recommendations for a stepwise approach to the management of asthma in children 0-4 years old, 5-11 years old, and adolescents who are treated as adults. Therapy is aimed at two domains of control: current impairment and future risk. The long-term controller medications, inhaled corticosteroids (ICSs), ICSs in combination with long-acting β2 agonists, leukotriene receptor antagonists, and immunomodulators, exhibit different efficacies for these domains. The risk:benefit ratios of the available medications need to be carefully assessed. This review briefly presents the benefits and the potential risks of available asthma medications in children to assist the practitioner in the optimal use of asthma medications. Specifically, the systemic activity of the ICSs and how to minimize their effects on growth and adrenal activity are reviewed as well as other potential adverse effects. Dosing strategies such as intermittent therapy are also assessed.
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Abstract
Evidence is emerging on the use of long-acting muscarinic antagonists (LAMAs) in the management of asthma. Tiotropium bromide (Spiriva® Respimat®) is the only LAMA approved in children and adolescents. As the use of tiotropium becomes more common in clinical practice, it is necessary to review the existing data to identify patients who may benefit from the addition of this medication to their daily asthma regimen. This review discusses recent evidence on the safety and efficacy of tiotropium bromide in the management of asthma in children and adolescents. Current data support that tiotropium bromide has a bronchodilator effect, as evident by improvements in acute lung function compared with placebo; however, data are not yet available to present a stepwise approach or identify phenotypes that would benefit from the addition of tiotropium bromide. Well-designed studies are needed to compare the different step-up options to tiotropium bromide and provide an evidence-based stepwise approach for the management of asthma in children. Furthermore, study design should include identification of phenotypes that might experience a better clinical response to tiotropium bromide compared with other adjunct medications.
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Affiliation(s)
- Hengameh H Raissy
- Department of Pediatrics, MSC10 5590, Clinical and Translational Science Center, University of New Mexico, School of Medicine, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
| | - H William Kelly
- Pediatrics UNMHSC, 9828 Guadalupe Trail NW, Albuquerque, NM, 87114-2009, USA
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20
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Vitale C, Maglio A, Pelaia C, Vatrella A. Long-term treatment in pediatric asthma: an update on chemical pharmacotherapy. Expert Opin Pharmacother 2017; 18:667-676. [PMID: 28387160 DOI: 10.1080/14656566.2017.1317747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Asthma is the most common chronic disease in childhood, affecting approximately 10% of all children, and is the leading cause of hospitalization in developed countries. In this paper we aimed to review the evidence on chemical pharmacotherapy for long-term treatment of pediatric asthma, according to the latest updates. Area covered: Long-term treatment, essential for controlling symptoms and reducing future risks including exacerbations and decline in lung function, includes control agents such as inhaled corticosteroids, long-acting beta2-adrenergic agonists, and leukotriene modifiers. More recent strategies based on the use of a biological drug such as omalizumab, which is a monoclonal antibody directed against immunoglobulin E (IgE), can be considered in selected patients with severe asthma. Expert opinion: In the near future, the challenge of childhood asthma treatment will be to improve the chemical drugs that already exist as well as to carefully characterize the several different asthma subtypes, with special regard to children with severe disease. A better definition of patient features, made possible by the current advanced knowledge of the pathobiology of severe asthma, can ultimately allow the identification of specific phenotypes and endotypes of severe asthma, aimed to personalize pharmacological treatment.
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Affiliation(s)
- Carolina Vitale
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| | - Angelantonio Maglio
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| | - Corrado Pelaia
- b Department of Medical and Surgical Sciences, Section of Respiratory Diseases , University "Magna Graecia" of Catanzaro , Catanzaro , Italy
| | - Alessandro Vatrella
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
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21
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Chauhan BF, Jeyaraman MM, Singh Mann A, Lys J, Abou‐Setta AM, Zarychanski R, Ducharme FM. Addition of anti-leukotriene agents to inhaled corticosteroids for adults and adolescents with persistent asthma. Cochrane Database Syst Rev 2017; 3:CD010347. [PMID: 28301050 PMCID: PMC6464690 DOI: 10.1002/14651858.cd010347.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Asthma management guidelines recommend low-dose inhaled corticosteroids (ICS) as first-line therapy for adults and adolescents with persistent asthma. The addition of anti-leukotriene agents to ICS offers a therapeutic option in cases of suboptimal control with daily ICS. OBJECTIVES To assess the efficacy and safety of anti-leukotriene agents added to ICS compared with the same dose, an increased dose or a tapering dose of ICS (in both arms) for adults and adolescents 12 years of age and older with persistent asthma. Also, to determine whether any characteristics of participants or treatments might affect the magnitude of response. SEARCH METHODS We identified relevant studies from the Cochrane Airways Group Specialised Register of Trials, which is derived from systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, the Allied and Complementary Medicine Database (AMED), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the trial registries clinicaltrials.gov and ICTRP from inception to August 2016. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) of adults and adolescents 12 years of age and older on a maintenance dose of ICS for whom investigators added anti-leukotrienes to the ICS and compared treatment with the same dose, an increased dose or a tapering dose of ICS for at least four weeks. DATA COLLECTION AND ANALYSIS We used standard methods expected by Cochrane. The primary outcome was the number of participants with exacerbations requiring oral corticosteroids (except when both groups tapered the dose of ICS, in which case the primary outcome was the % reduction in ICS dose from baseline with maintained asthma control). Secondary outcomes included markers of exacerbation, lung function, asthma control, quality of life, withdrawals and adverse events. MAIN RESULTS We included in the review 37 studies representing 6128 adult and adolescent participants (most with mild to moderate asthma). Investigators in these studies used three leukotriene receptor antagonists (LTRAs): montelukast (n = 24), zafirlukast (n = 11) and pranlukast (n = 2); studies lasted from four weeks to five years. Anti-leukotrienes and ICS versus same dose of ICSOf 16 eligible studies, 10 studies, representing 2364 adults and adolescents, contributed data. Anti-leukotriene agents given as adjunct therapy to ICS reduced by half the number of participants with exacerbations requiring oral corticosteroids (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.29 to 0.86; 815 participants; four studies; moderate quality); this is equivalent to a number needed to treat for additional beneficial outcome (NNTB) over six to 16 weeks of 22 (95% CI 16 to 75). Only one trial including 368 participants reported mortality and serious adverse events, but events were too infrequent for researchers to draw a conclusion. Four trials reported all adverse events, and the pooled result suggested little difference between groups (RR 1.06, 95% CI 0.92 to 1.22; 1024 participants; three studies; moderate quality). Investigators noted between-group differences favouring the addition of anti-leukotrienes for morning peak expiratory flow rate (PEFR), forced expiratory volume in one second (FEV1), asthma symptoms and night-time awakenings, but not for reduction in β2-agonist use or evening PEFR. Anti-leukotrienes and ICS versus higher dose of ICSOf 15 eligible studies, eight studies, representing 2008 adults and adolescents, contributed data. Results showed no statistically significant difference in the number of participants with exacerbations requiring oral corticosteroids (RR 0.90, 95% CI 0.58 to 1.39; 1779 participants; four studies; moderate quality) nor in all adverse events between groups (RR 0.96, 95% CI 0.89 to 1.03; 1899 participants; six studies; low quality). Three trials reported no deaths among 834 participants. Results showed no statistically significant differences in lung function tests including morning PEFR and FEV1 nor in asthma control measures including use of rescue β2-agonists or asthma symptom scores. Anti-leukotrienes and ICS versus tapering dose of ICSSeven studies, representing 1150 adults and adolescents, evaluated the combination of anti-leukotrienes and tapering-dose of ICS compared with tapering-dose of ICS alone and contributed data. Investigators observed no statistically significant difference in % change from baseline ICS dose (mean difference (MD) -3.05, 95% CI -8.13 to 2.03; 930 participants; four studies; moderate quality), number of participants with exacerbations requiring oral corticosteroids (RR 0.46, 95% CI 0.20 to 1.04; 542 participants; five studies; low quality) or all adverse events (RR 0.95, 95% CI 0.83 to 1.08; 1100 participants; six studies; moderate quality). Serious adverse events occurred more frequently among those taking anti-leukotrienes plus tapering ICS than in those taking tapering doses of ICS alone (RR 2.44, 95% CI 1.52 to 3.92; 621 participants; two studies; moderate quality), but deaths were too infrequent for researchers to draw any conclusions about mortality. Data showed no improvement in lung function nor in asthma control measures. AUTHORS' CONCLUSIONS For adolescents and adults with persistent asthma, with suboptimal asthma control with daily use of ICS, the addition of anti-leukotrienes is beneficial for reducing moderate and severe asthma exacerbations and for improving lung function and asthma control compared with the same dose of ICS. We cannot be certain that the addition of anti-leukotrienes is superior, inferior or equivalent to a higher dose of ICS. Scarce available evidence does not support anti-leukotrienes as an ICS sparing agent, and use of LTRAs was not associated with increased risk of withdrawals or adverse effects, with the exception of an increase in serious adverse events when the ICS dose was tapered. Information was insufficient for assessment of mortality.
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Affiliation(s)
- Bhupendrasinh F Chauhan
- Children’s Hospital Research Institute of ManitobaBiology of Breathing GroupWinnipegCanada
- University of ManitobaCollege of PharmacyWinnipegMBCanada
- University of ManitobaKnowledge Synthesis Platform, George and Fay Yee Centre for Healthcare InnovationWinnipegCanada
- University of MontrealDepartment of PaediatricsMontrealCanada
| | - Maya M Jeyaraman
- University of ManitobaKnowledge Synthesis Platform, George and Fay Yee Centre for Healthcare InnovationWinnipegCanada
| | - Amrinder Singh Mann
- University of ManitobaKnowledge Synthesis Platform, George and Fay Yee Centre for Healthcare InnovationWinnipegCanada
| | - Justin Lys
- University of ManitobaKnowledge Synthesis Platform, George and Fay Yee Centre for Healthcare InnovationWinnipegCanada
| | - Ahmed M Abou‐Setta
- University of ManitobaKnowledge Synthesis Platform, George and Fay Yee Centre for Healthcare InnovationWinnipegCanada
| | - Ryan Zarychanski
- University of ManitobaKnowledge Synthesis Platform, George and Fay Yee Centre for Healthcare InnovationWinnipegCanada
- University of ManitobaCommunity Health SciencesWinnipegMBCanadaR3A 1R9
- CancerCare ManitobaDepartment of Haematology and Medical OncologyWinnipegCanadaR3E 0V9
- University of ManitobaDepartment of Internal MedicineWinnipegCanada
| | - Francine M Ducharme
- University of MontrealDepartment of PaediatricsMontrealCanada
- CHU Sainte‐JustineResearch CentreMontrealCanada
- University of MontrealDepartment of Social and Preventive MedicineMontrealCanada
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22
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Paton J, Bindels P, McMurray A, Biggins J, Nantanda R, Østergaard MS. A young child with a history of wheeze. NPJ Prim Care Respir Med 2017; 27:19. [PMID: 28303014 PMCID: PMC5434789 DOI: 10.1038/s41533-017-0020-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/03/2017] [Accepted: 02/14/2017] [Indexed: 12/12/2022] Open
Abstract
The parents of a 3-year old boy are anxious about their son who has recurring episodes of wheezing. They are frustrated that no one seems to be able to give them answers to their questions and would like a referral to a specialist. Does their son have asthma and what is the prognosis; how can the recurrent wheezing be managed and can the risk of asthma be reduced; are there lifestyle changes that could improve the environment and avoid triggers? Communication and support from the family practice team were essential. Listening to the parents' concerns, explaining the diagnostic uncertainty, being realistic about what drug treatments could achieve, and providing practical advice on inhaler use and trigger avoidance reassured the parents that there was a strategy for managing their son's wheeze. The specialist referral was postponed.
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Affiliation(s)
- James Paton
- School of Medicine Dentistry & Nursing, Child Health, College of Medical, Veterinary, and Life Sciences, Queen Elizabeth University Hospital, University of Glasgow, Zone 1, Ground Floor, Office Block, Glasgow, UK.
| | - Patrick Bindels
- Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Ann McMurray
- Department of Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Sciennes Road, Edinburgh, EH9 1LF, Scotland, UK
| | - Jodie Biggins
- Patient and Public Involvement Group, Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Rebecca Nantanda
- Makerere University Lung Institute Makerere University College of Health Sciences, Kampala, Uganda
| | - Marianne Stubbe Østergaard
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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23
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Isozaki A, Inage E, Yagi H, Arakawa H. CQ1 Which is more effective for improved long-term management of bronchial asthma with inhaled corticosteroids (ICS) in pediatric patients, increasing the dose of ICS or addition of inhaled long-acting β 2 agonists to ICS (ICS/LABA) ? ACTA ACUST UNITED AC 2017. [DOI: 10.3388/jspaci.31.200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Atsushi Isozaki
- Division of Pediatrics, Center for Allergy and Immune Disease, Yokohama City Minato Red Cross Hospital
| | | | - Hisako Yagi
- Department of Pediatrics, Gunma University Graduate School of Medicine
| | - Hirokazu Arakawa
- Department of Pediatrics, Gunma University Graduate School of Medicine
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Chauhan B. Long-acting beta agonists do not increase serious asthma-related event risk. J Pediatr 2017; 180:291-294. [PMID: 28010799 DOI: 10.1016/j.jpeds.2016.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Nixon J, Newbold P, Mustelin T, Anderson GP, Kolbeck R. Monoclonal antibody therapy for the treatment of asthma and chronic obstructive pulmonary disease with eosinophilic inflammation. Pharmacol Ther 2016; 169:57-77. [PMID: 27773786 DOI: 10.1016/j.pharmthera.2016.10.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Eosinophils have been linked with asthma for more than a century, but their role has been unclear. This review discusses the roles of eosinophils in asthma and chronic obstructive pulmonary disease (COPD) and describes therapeutic antibodies that affect eosinophilia. The aims of pharmacologic treatments for pulmonary conditions are to reduce symptoms, slow decline or improve lung function, and reduce the frequency and severity of exacerbations. Inhaled corticosteroids (ICS) are important in managing symptoms and exacerbations in asthma and COPD. However, control with these agents is often suboptimal, especially for patients with severe disease. Recently, new biologics that target eosinophilic inflammation, used as adjunctive therapy to corticosteroids, have proven beneficial and support a pivotal role for eosinophils in the pathology of asthma. Nucala® (mepolizumab; anti-interleukin [IL]-5) and Cinquair® (reslizumab; anti-IL-5), the second and third biologics approved, respectively, for the treatment of asthma, exemplifies these new treatment options. Emerging evidence suggests that eosinophils may contribute to exacerbations and possibly to lung function decline for a subset of patients with COPD. Here we describe the pharmacology of therapeutic antibodies inhibiting IL-5 or targeting the IL-5 receptor, as well as other cytokines contributing to eosinophilic inflammation. We discuss their roles as adjuncts to conventional therapeutic approaches, especially ICS therapy, when disease is suboptimally controlled. These agents have achieved a place in the therapeutic armamentarium for asthma and COPD and will deepen our understanding of the pathogenic role of eosinophils.
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Affiliation(s)
| | | | | | - Gary P Anderson
- Lung Health Research Centre, University of Melbourne, Melbourne, Victoria, Australia
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Kuo HC, Yang YL, Ho SC, Guo MMH, Jiang JH, Huang YH. General anesthesia exposure in early life reduces the risk of allergic diseases: A nationwide population-based cohort study. Medicine (Baltimore) 2016; 95:e4269. [PMID: 27428241 PMCID: PMC4956835 DOI: 10.1097/md.0000000000004269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
General anesthesia (GA) has been used for second line treatment strategy for status asthmaticus in pediatric patients. The association between GA in children and risk of followed-up allergic diseases is unclear. This study aims to assess the risk of allergic diseases after GA in children.We did a nationwide retrospective cohort study by analyzing data from the National Health Insurance Research Database (NHIRD) in Taiwan. The subsequent risks for allergic diseases, including asthma (ICD-9: 493.X), allergic rhinitis (AR; ICD-9 CM code 477.X), and atopic dermatitis (AD; ICD-9-CM code 691.X), were compared between exposure to GA and none before 1 year of age throughout the follow-up period using the Cox proportional hazards model.Insurance claims data for 32,742 children younger than 1 year old from all insured children in the NHIRD. Of those, 2358 subjects were exposed to GA; 414 and 1944 children exposed to mask and intubation ventilation, respectively, served as the study cohort, whereas the remaining 30,384 children made up the comparison cohort. Children in the GA group were at a lower risk of developing asthma, AR and AD, with adjusted hazard ratios of 0.67 (0.62-0.72, 95%CI), 0.72 (0.68-0.77, 95%CI), 0.60 (0.56-0.64, 95%CI), respectively.Children who were exposed to GA in early life before 1 year of age had reduced risk of subsequently developing allergic diseases such as asthma, AD, and AR, when compared with general population.
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Affiliation(s)
- Ho-Chang Kuo
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
- Kawasaki Disease Center, Kaohsiung Chang Gung Memorial Hospital, Taiwan University
| | - Ya-Ling Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Shu-Chen Ho
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University
| | - Mindy Ming-Huey Guo
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
- Kawasaki Disease Center, Kaohsiung Chang Gung Memorial Hospital, Taiwan University
| | - Jyun-Hong Jiang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
- Kawasaki Disease Center, Kaohsiung Chang Gung Memorial Hospital, Taiwan University
- Correspondence: Ying-Hsien Huang, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Taiwan, #123 Ta-Pei Road, Niaosung, Kaohsiung, Taiwan (e-mail: )
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