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Antila MA, Souza-Machado A, Gregório MG, Cruz ÁA, Angelini L, Beekman MJHI, Zonzin GA, Rabahi MF. Overprescription of short-acting β2 agonists: reflections from the SABINA study in Brazil. J Bras Pneumol 2024; 50:e20230174. [PMID: 38422337 PMCID: PMC11095926 DOI: 10.36416/1806-3756/e20230174] [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: 03/30/2023] [Accepted: 11/28/2023] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE To assess prescription patterns for short-acting b2 agonists (SABAs) and other asthma medications in asthma patients treated by specialists and participating in the SABA use IN Asthma (SABINA) study in Brazil. METHODS This was an observational, cross-sectional study conducted at five sites in different regions of Brazil. The primary endpoints were to record SABA prescriptions and obtain data on over-the-counter (OTC) SABA purchases at the pharmacy. RESULTS Data on 218 asthma patients were analyzed. Of those 218 patients, 80.3% were prescribed SABAs in addition to their maintenance therapy, with a mean of 11.2 SABA canisters in the previous 12 months. Of those patients, 71.4% were prescribed ≥ 3 canisters and 42.2% were prescribed ≥ 10 canisters. None of the patients were prescribed SABA monotherapy. A total of 14.2% of the patients reported purchasing SABAs OTC at a pharmacy without a prescription. Of those, 48.4% purchased ≥ 3 SABA canisters. A fixed-dose combination of an inhaled corticosteroid and a long-acting b2 agonist was prescribed to 95.0% of the patients. In the year before the study visit, 45.0% of the patients received at least one course of oral corticosteroid burst treatment. Asthma was well controlled in 43.1% of the patients, partly controlled in 34.9%, and uncontrolled in 22.0%. Patients reported a mean of 1.1 severe asthma exacerbations, with 49.1% experiencing 1 or more severe exacerbations. CONCLUSIONS Overprescription and OTC purchases of SABAs are common in Brazil, possibly leading to the need for courses of oral corticosteroids. The health care community should collaborate to implement evidence-based recommendations and promote health education to improve asthma management in Brazil.
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Affiliation(s)
| | - Adelmir Souza-Machado
- . Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil
- . Fundação ProAR, Brasil
| | | | - Álvaro A Cruz
- . Fundação ProAR, Brasil
- . Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador (BA) Brasil
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Paoli CJ, Linder J, Gurjar K, Thakur D, Wyckmans J, Grieve S. Effectiveness of Single-Tablet Combination Therapy in Improving Adherence and Persistence and the Relation to Clinical and Economic Outcomes. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:8-22. [PMID: 38500521 PMCID: PMC10948140 DOI: 10.36469/001c.91396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 03/20/2024]
Abstract
Background: Single-tablet combination therapies (STCTs) combine multiple drugs into one formulation, making drug administration more convenient for patients. STCTs were developed to address concerns with treatment adherence and persistence, but the impact of STCT use is not fully understood across indications. Objectives: We conducted a systematic literature review (SLR) to examine STCT-associated outcomes across 4 evidence domains: clinical trials, real-world evidence (RWE), health-related quality of life (HRQoL) studies, and economic evaluations. Methods: Four SLRs were conducted across the aforementioned domains. Included studies compared STCTs as well as fixed-dose combinations ([FDCs] of non-tablet formulations) with the equivalent active compounds and doses in loose-dose combinations (LDCs). Original research articles were included; case reports, case series, and non-English-language sources were excluded. Databases searched included EconLit, Embase, and Ovid MEDLINE® ALL. Two independent reviewers assessed relevant studies and extracted data. Conflicts were resolved with a third reviewer or consensus-based discussion. Results: In all, 109 studies were identified; 27 studies were identified in more than one SLR. Treatment adherence was significantly higher in patients receiving FDCs vs LDCs in 12 of 13 RWE studies and 3 of 13 clinical trials. All 18 RWE studies reported higher persistence with FDCs. In RWE studies examining clinical outcomes (n = 17), 14 reported positive findings with FDCs, including a reduced need for add-on medication, blood pressure control, and improved hemoglobin A1C. HRQoL studies generally reported numerical improvements with STCTs or similarities between STCTs and LDCs. Economic outcomes favored STCT use. All 6 cost-effectiveness or cost-utility analyses found FDCs were less expensive and more efficacious than LDCs. Four budget impact models found that STCTs were associated with cost savings. Medical costs and healthcare resource use were generally lower with FDCs than with LDCs. Discussion: Evidence from RWE and economic studies strongly favored STCT use, while clinical trials and HRQoL studies primarily reported similarity between STCTs and LDCs. This may be due to clinical trial procedures aimed at maximizing adherence and HRQoL measures that are not designed to evaluate drug administration. Conclusions: Our findings highlight the value of STCTs for improving patient adherence, persistence, and clinical outcomes while also offering economic advantages.
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Affiliation(s)
- Carly J Paoli
- Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey, USA
| | - Jörg Linder
- Janssen-Cliag of Johnson & Johnson, Neuss, Germany
| | | | | | - Julie Wyckmans
- Janssen Pharmaceutical Companies of Johnson & Johnson, Basel, Switzerland
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Roche N, Yorgancıoğlu A, Cruz AA, Garcia G, Lavoie KL, Abhijith PG, Verma M, Majumdar A, Chatterjee S. Systematic literature review of traits and outcomes reported in randomised controlled trials of asthma with regular dosing of inhaled corticosteroids with short-acting β 2-agonist reliever, as-needed ICS/formoterol, or ICS/formoterol maintenance and reliever therapy. Respir Med 2024; 221:107478. [PMID: 38008385 DOI: 10.1016/j.rmed.2023.107478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/17/2023] [Accepted: 11/19/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION Asthma treatments based solely on diagnostic label do not benefit patients equally. To identify patient traits that may be associated with improved treatment response to regular inhaled corticosteroid (ICSs) dosing with short-acting β2-agonist reliever or ICS/formoterol-containing therapy, a systematic literature review (SLR) was conducted. METHODS Searches of databases including MEDLINE and Embase identified randomised controlled trials (RCTs) of patients with asthma, aged ≥12 years, published 1998-2022, containing ≥1 regular ICS dosing or ICS/formoterol-containing treatment arm, and reporting patient traits and outcomes of interest. Relevant data was extracted and underwent a feasibility assessment to determine suitability for meta-analysis. RESULTS The SLR identified 39 RCTs of 72,740 patients and 90 treatment arms, reporting 11 traits and 11 outcomes. Five patient traits (age, body mass index, FEV1, smoking history, asthma control) and five outcomes (exacerbation rate, lung function, asthma control, adherence, time to first exacerbation) were deemed feasible for inclusion in meta-analyses due to sufficient comparable reporting. Subgroups of clinical outcomes stratified by levels of patient traits were reported in 16 RCTs. CONCLUSION A systematic review of studies of regular ICS dosing with SABA or ICS/formoterol-containing treatment strategies in asthma identified consistent reporting of five traits and outcomes, allowing exploration of associations with treatment response. Conversely, many other traits and outcomes, although being potentially relevant, were inconsistently reported and limited subgroup reporting meant analyses of treatment response for subgroups of traits was not possible. We recommend more consistent measurement and reporting of clinically relevant patient traits and outcomes in respiratory RCTs.
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Affiliation(s)
- Nicolas Roche
- Pneumology, AP-HP Centre Université Paris Cité, Hôpital Cochin, Paris, France
| | | | - Alvaro A Cruz
- ProAR and Universidade Federal da Bahia, Salvador, Brazil
| | | | - Kim L Lavoie
- University of Quebec at Montreal (UQAM), Montreal, Canada; Montreal Behavioural Medicine Centre, CIUSSS-NIM, Hopital du Sacre-Coeur de Montreal, Montreal, Canada
| | - P G Abhijith
- GSK, Global Medical Affairs, General Medicine, Amsterdam, the Netherlands
| | - Manish Verma
- GSK, Global Medical Affairs, General Medicine, Mumbai, India.
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Yu Y, Cao W, Xiao Y, Li A, Huang H, Liu K, Hu L, Hou X, Xiang L, Wang X. Budesonide/formoterol maintenance and reliever therapy in childhood asthma: Real-world effectiveness and economic assessment. Pediatr Pulmonol 2023; 58:3406-3415. [PMID: 37818789 DOI: 10.1002/ppul.26647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/18/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION The study aims to compare the real-world effectiveness and economy of the budesonide/formoterol reliever and maintenance therapy (SMART) with fixed-dose inhaled corticosteroids (ICS)/long-acting b-agonist (LABA) or ICS alone plus as-needed, short-acting β2 agonists (SABA) in pediatric patients. METHODS The outpatient data warehouse of a hospital in China was used. A total of 103 patients under 18 years old in the SMART group and 63 patients in the control group were included from January 1, 2020 to December 31, 2021. The effectiveness was assessed using asthma attacks and lung function at baseline, 6 months and 12 months follow-up. Cost-effectiveness analysis was performed with a three-state Markov model from the healthcare system perspective. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to check the robustness of the results. RESULTS The SMART regimen was more effective than other strategies in reducing the risk of mild and severe attacks in the real-life management of childhood asthma. Patients in both groups showed significant improvement in lung function at 6 and 12 months in contrast to baseline. Compared with other strategies, the forced expiratory volume in 1 s (FEV1 ) level in the SMART group was markedly improved at 6 months. The total cost of outpatient service using the SMART regimen was lower than that of other strategies, while the drug costs were similar in different groups. Incremental cost-effectiveness analysis results showed that using the SMART regimen reduced the total cost by approximately CNY 10,516.11 per year with a 0.12 quality-adjusted life year (QALYs) increase. Sensitive analyses supported that the SMART regimen was the dominant choice at the willingness-to-pay threshold of CNY 85,698, per capita GDP in China. CONCLUSIONS Collectively, our findings indicate that the real-world effectiveness and economy of the SMART regimen are superior to the traditional strategies in pediatric asthma patients.
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Affiliation(s)
- Yuncui Yu
- Clinical Research Center, National Clinical Research Center for Respiratory Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wang Cao
- Clinical Research Center, National Clinical Research Center for Respiratory Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yue Xiao
- National Health Development Research Center, National Health Commission, Beijing, China
| | - Ang Li
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Huijie Huang
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Kejun Liu
- National Health Development Research Center, National Health Commission, Beijing, China
| | - Lihua Hu
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoling Hou
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Li Xiang
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoling Wang
- Clinical Research Center, National Clinical Research Center for Respiratory Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Ibrahim Arif S, Amer YS, Adnan Alkamal T, Abdulrahman Binsaeed M, Ibrahim Arif B, Dhaifallah Albaqami M, Bakri Alfahed O. Patient response to the management during the acute presentation of cough variant Asthma: Retrospective cohort study. Saudi J Biol Sci 2023; 30:103875. [PMID: 38058763 PMCID: PMC10696240 DOI: 10.1016/j.sjbs.2023.103875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 10/26/2023] [Accepted: 11/10/2023] [Indexed: 12/08/2023] Open
Abstract
The clinical improvement after assessing patients with cough variant asthma in outpatient clinics, and therapy success varied depending on the subjective improvement. Cough could be controlled within appropriate time and subsequent management can consist of inhaled corticosteroids. In this study we used the cough improvement, the only available clinical response, as a predictable factor to determine the effect of different modalities of treatment among patients with cough variant asthma. Retrospective observational analysis was performed in Saudi Arabia's King Saud University Medical City, on the presentation, diagnosis, course of therapy, and responsiveness to oral and inhaled steroids in patients with cough variant asthma. All patients who visited the clinic on multiple occasions with persistent, acute coughing without being pre-screened between September 2021 and September 2022 included based on medical records. Cough resembles cough variant asthma is the term used to describe a cough without a diagnosed etiology. To identify patients eligible for CVA treatment, iindividuals having GERD-associated cough, allergic rhinitis, bronchial asthma, smokers and atopic cough was excluded. For the examination of these findings, IBM SPSS version 28 (Armonk, NY, USA) was employed. As a result of using budesonide-formoterol inhaler, most patients (86.3 %) showed improvement in their cough symptoms (with 95 %CI: 78.3 to 94.9). There was a significant yet weak positive correlation between the frequency of cough symptoms before and after using budesonide-formoterol (r = 0.318, P value < 0.001). The understanding of treatment response and patient selection for budesonide-formoterol inhaler therapy, providing clinicians with valuable information to optimize patient care.
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Affiliation(s)
- Samir Ibrahim Arif
- Family Medicine Center, King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Yasser S. Amer
- CPG and Quality Research Unit, Quality Management Department, Pediatrics Department, King Saud University Medical City, Riyadh, Saudi Arabia
- Research Chair for Evidence-Based Health Care and Knowledge Translation, King Saud University Medical City, Riyadh, Saudi Arabia
| | | | | | - Bandar Ibrahim Arif
- Intern, Clinical Pharmacy, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Meshari Dhaifallah Albaqami
- Nursing Services Department, Occupational Health and Safety Clinic King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ousama Bakri Alfahed
- Family Medicine Center, King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia
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Nannini LJ, Neumayer NS, Brandan N, Fernández OM, Flores DM. Asthma-related hospitalizations after implementing SABA-free asthma management with a maintenance and anti-inflammatory reliever regimen. Eur Clin Respir J 2022; 9:2110706. [PMID: 35959199 PMCID: PMC9361757 DOI: 10.1080/20018525.2022.2110706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Overreliance on short-acting β2-agonists (SABA) has been a common feature of asthma management globally for at least 30 years. However, given the evidence against the long-term use of SABA, including potentially increased risk of exacerbations, emergency room visits, overall healthcare resource utilization, and mortality, the latest Global Initiative for Asthma report no longer recommends SABA only therapy. Since 2014, we implemented an ICS-containing reliever strategy at our asthma center at the G Baigorria Hospital in Argentina; we only administered budesonide/formoterol via a single inhaler device across the spectrum of asthma severity and completely eliminated the use of SABA therapy. In this article, we compare hospitalization data from our center, previously reported in the EAGLE study (when inhaled corticosteroids plus as-needed SABA was administered) for the years 1999 and 2004 with data from 2017 to 2018 (when budesonide/formoterol in a single inhaler device was administered as maintenance and/or anti-inflammatory reliever therapy [MART/AIR] without any SABA) from our center, to assess the impact of two distinct asthma management strategies on asthma-related hospitalizations. MART/AIR regimens in our SABA-free center reduced asthma hospitalizations from 9 (1999 and 2004) to 1 (2017 and 2018) (Fisher's exact test, p = 0.031; odds ratio = 0.11; 95% confidence interval [CI] = 0.013-0.98); the hospitalization rate was reduced by 92% (1.47% in 1999 and 2004 to 0.12% in 2017 and 2018). Our data provide preliminary real-world evidence that MART/AIR with budesonide/formoterol simultaneously with SABA elimination across asthma severities is an effective asthma management strategy for reducing asthma-related hospitalizations.
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Affiliation(s)
- L J Nannini
- Pulmonary Section, Hospital E Perón, Universidad Nacional Rosario, Granadero Baigorria, Argentina.,Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Granadero Baigorria, Argentina
| | - N S Neumayer
- Pulmonary Section, Hospital E Perón, Universidad Nacional Rosario, Granadero Baigorria, Argentina
| | - N Brandan
- Pulmonary Section, Hospital E Perón, Universidad Nacional Rosario, Granadero Baigorria, Argentina
| | - O M Fernández
- Pulmonary Section, Hospital E Perón, Universidad Nacional Rosario, Granadero Baigorria, Argentina
| | - D M Flores
- Pulmonary Section, Hospital E Perón, Universidad Nacional Rosario, Granadero Baigorria, Argentina
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Comparative efficacy of inhalers in mild-to-moderate asthma: systematic review and network meta-analysis. Sci Rep 2022; 12:5949. [PMID: 35396495 PMCID: PMC8993836 DOI: 10.1038/s41598-022-09941-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/24/2022] [Indexed: 12/03/2022] Open
Abstract
The comparative effectiveness of different inhaler therapies in mild-to-moderate asthma remains unclear. To assess this, we performed a systematic review and network meta-analysis of randomized controlled trials on the use of inhalers for mild-to-moderate asthma by searching PubMed, Cochrane, and Embase. A total of 29 trials including 43,515 patients and 12 types of inhaler therapies were included. For the prevention of severe and moderate-to-severe exacerbations, inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) as maintenance and reliever (SMART) showed the highest rank for effectiveness. As-needed ICS/LABA or short-acting β2-agonist (SABA) was similar to low-dose ICS and superior to as-needed SABA or LABA for the prevention of severe and moderate-severe exacerbations. As for lung function (FEV1), low-dose ICS/LABA had the highest rank; as-needed ICS/LABA was inferior to regular low-dose ICS but superior to placebo. Higher-dose ICS had a superior effect on the Asthma Control Questionnaire (ACQ) scores, and as-needed ICS/LABA and as-needed SABA or LABA had lower ranks in p-rankogram than did the regular use of low-dose ICS. As-needed ICS with LABA or SABA was more effective than a similar dose of regular ICS for preventing exacerbation in mild-to-moderate asthma. As-needed ICS showed some weakness in improving lung function and controlling asthma symptoms.
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8
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Buendía JA, Patiño DG. SMART therapy in adolescent and adults patients with moderate persistent asthma: a cost-utility analysis. J Asthma 2021; 59:2367-2374. [PMID: 34913809 DOI: 10.1080/02770903.2021.2019266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recent asthma guidelines, recommends for persistent asthma as first alternative low dose inhaled budesonide-formoterol maintenance and reliever over fixed combination of low doses inhaled corticosteroids - long-acting beta-agonist, or fixed-dose inhaled corticosteroids. Concerns arise as to which of the proposed alternatives has the best possible cost-effectiveness profile. This study aimed to assess the health and economic consequences of SMART, fixed combination, and fixed-dose inhaled corticosteroids in patients with moderate-severe persistent asthma. METHODS A probabilistic Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with persistent asthma. Total costs and QALYs of SMART, fixed combination, and fixed-dose inhaled corticosteroids were calculated over a lifetime horizon. Multiple sensitivity analyses were conducted. Cost-effectiveness was evaluated at a willingness-to-pay value of $19,000. RESULTS The model suggests a potential gain of 1.27 and 1.34 QALYs per patient per year on SMART respect to fixed combination and fixed-dose ICS respectively. We observed a reduction of US$4 in total discounted cost per person-year on SMART with respect to fixed combination and US$0.1 respect to fixed-dose ICS. In the deterministic and probabilistic sensitivity analyses, our base-case results were robust to variations of all assumptions and parameters. CONCLUSION SMART therapy was found to be cost-effective regarding fixed combination and fixed-dose inhaled corticosteroids. This evidence supports the use of SMART therapy in Colombia and must to be replicated in others middle-income countries.
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Affiliation(s)
- Jefferson Antonio Buendía
- Research group in Pharmacology and Toxicology "INFARTO", Department of Pharmacology and Toxicology, University of Antioquia, Medellín, Colombia
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9
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Rogliani P, Beasley R, Cazzola M, Calzetta L. SMART for the treatment of asthma: A network meta-analysis of real-world evidence. Respir Med 2021; 188:106611. [PMID: 34536699 DOI: 10.1016/j.rmed.2021.106611] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/04/2021] [Indexed: 11/17/2022]
Abstract
A large proportion of asthmatic patients are treated with protocols resulting from data obtained by randomized controlled trials (RCTs) for which they would not have been eligible. Therefore, the aim of this study was to undertake a quantitative synthesis on real-world evidence comparing single inhaled corticosteroid (ICS)/formoterol maintenance and reliever therapy (SMART) and maintenance ICS/long-acting β2-adrenoceptor agonist (LABA) + as-needed short-acting β2-adrenoceptor agonist (SABA). A network meta-analysis of real-world studies was performed to compare SMART with ICS/LABA + as-needed SABA therapies in asthmatic patients. The surface under the cumulative ranking curve analysis was used to rank efficacy. The posterior probability distribution was reported as 95% credible interval (95%CrI). Data of 11,360 asthmatic patients were extracted from 6 studies. SMART including an ICS at medium-dose (MD) was more effective than MD ICS/LABA FDC + as-needed SABA (RR 0.54 95%CrI 0.42-0.69; P < 0.001) and low-dose (LD) SMART (RR 0.82 95%CrI 0.70-0.95; P < 0.05) against severe asthma exacerbation. MD SMART improved the Asthma Control Questionnaire score more than MD ICS/LABA FDC + as-needed SABA (delta effect -0.33 95%CrI -0.62 to -0.01; P < 0.05). The efficacy rank was: MD SMART > LD SMART > ICS + LABA free combination + as-needed SABA > ICS/LABA FDC + as-needed SABA > MD ICS/LABA FDC + as-needed SABA. The findings of this network meta-analysis of real-world evidence, and concordance with the effect estimates resulting from previous meta-analyses of RCTs, suggest that SMART may represent the preferred therapeutic option to reduce the risk of severe exacerbation in adults with moderate to severe asthma.
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Affiliation(s)
- Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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10
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Zhang S, King D, Rosen VM, Ismaila AS. Impact of Single Combination Inhaler versus Multiple Inhalers to Deliver the Same Medications for Patients with Asthma or COPD: A Systematic Literature Review. Int J Chron Obstruct Pulmon Dis 2020; 15:417-438. [PMID: 32161454 PMCID: PMC7049753 DOI: 10.2147/copd.s234823] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/24/2020] [Indexed: 01/23/2023] Open
Abstract
With increasing choice of medications and devices for asthma and chronic obstructive pulmonary disease (COPD) treatment, comparative evidence may inform treatment decisions. This systematic literature review assessed clinical and economic evidence for using a single combination inhaler versus multiple inhalers to deliver the same medication for patients with asthma or COPD. In 2016, Embase, PubMed and the Cochrane library were searched for publications reporting studies in asthma or COPD comparing a single-inhaler combination medicine with multiple inhalers delivering the same medication. Publications included English-language articles published since 1996 and congress abstracts since 2013. Clinical, economic and adherence endpoints were assessed. Of 2031 abstracts screened, 18 randomized controlled trials (RCTs) in asthma and four in COPD, nine retrospective and three prospective observational studies in asthma, and four observational studies in COPD were identified. Of these, five retrospective and one prospective study in asthma, and two retrospective studies in COPD reported greater adherence with a single inhaler than multiple inhalers. Nine observational studies reported significantly (n=7) or numerically (n=2) higher rates of adherence with single- versus multiple-inhaler therapy. Economic analyses from retrospective and prospective studies showed that use of single-inhaler therapies was associated with reduced healthcare resource use (n=6) and was cost-effective (n=5) compared with multiple-inhaler therapies. Findings in 18 asthma RCTs and one prospective study reporting lung function, and six RCTs reporting exacerbation rates, showed no significant differences between a single inhaler and multiple inhalers. This was in contrast to several observational studies reporting reductions in healthcare resource use or exacerbation events with single-inhaler treatment, compared with multiple inhalers. Retrospective and prospective studies showed that single-inhaler use was associated with decreased healthcare resource utilization and improved cost-effectiveness compared with multiple inhalers. Lung function and exacerbation rates were mostly comparable in the RCTs, possibly due to study design.
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Affiliation(s)
- Shiyuan Zhang
- Value Evidence and Outcomes, GlaxoSmithKline plc, Collegeville, PA, USA
| | - Denise King
- Value Evidence and Outcomes, GlaxoSmithKline plc, Brentford, UK
| | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GlaxoSmithKline plc, Collegeville, PA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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11
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Beasley R, Braithwaite I, Semprini A, Kearns C, Weatherall M, Harrison TW, Papi A, Pavord ID. ICS-formoterol reliever therapy stepwise treatment algorithm for adult asthma. Eur Respir J 2020; 55:55/1/1901407. [PMID: 31919194 DOI: 10.1183/13993003.01407-2019] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/05/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand .,Capital and Coast District Health Board, Wellington, New Zealand
| | - Irene Braithwaite
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
| | - Alex Semprini
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
| | - Ciléin Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
| | - Mark Weatherall
- Capital and Coast District Health Board, Wellington, New Zealand.,University of Otago Wellington, Wellington, New Zealand
| | - Tim W Harrison
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Alberto Papi
- Respiratory Medicine Unit, Dept of Medical Sciences, Università di Ferrara, Ferrara, Italy
| | - Ian D Pavord
- Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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Dose-response relationship of ICS/fast-onset LABA as reliever therapy in asthma. BMC Pulm Med 2019; 19:264. [PMID: 31883519 PMCID: PMC6935489 DOI: 10.1186/s12890-019-1014-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 11/27/2019] [Indexed: 11/30/2022] Open
Abstract
Background and objective The dose-response relationship of inhaled corticosteroid (ICS)/fast-onset long acting beta agonist (LABA) reliever therapy has not been formally addressed. The objective of this retrospective analysis is to ascertain from the available evidence whether ICS/fast-onset LABA administered as reliever therapy has a different dose-response relationship than maintenance fixed dose ICS/fast-onset LABA therapy in reducing risk of severe exacerbations. Methods A systematic literature review was undertaken to identify randomised controlled trials (RCTs) in which randomised treatments included either i) budesonide/formoterol reliever monotherapy versus budesonide/formoterol fixed dose maintenance with short acting beta agonist (SABA) reliever therapy, or ii) budesonide/formoterol reliever therapy in addition to budesonide/formoterol maintenance versus higher fixed dose maintenance budesonide/formoterol with SABA as reliever therapy. Eligible studies were reviewed to allow determination of the relative potency and efficacy of the comparator regimens to reduce the risk of a severe exacerbation. Results The one RCT of budesonide/formoterol reliever monotherapy showed a 4.6-fold (95% CI 2.9 to 7.3) greater potency than budesonide/formoterol fixed dose maintenance plus SABA reliever therapy in reducing the risk of severe exacerbations. In the one RCT that compared budesonide/formoterol maintenance and reliever therapy with higher fixed dose maintenance budesonide/formoterol plus SABA reliever therapy, there was an additional 26% (95% CI 4 to 42%) reduction in severe exacerbation risk with the addition of budesonide/formoterol reliever therapy to maintenance budesonide/formoterol, despite a 25% lower total budesonide/formoterol dose. Conclusion The limited available evidence suggests that budesonide/formoterol reliever therapy has greater potency and efficacy than budesonide/formoterol fixed dose maintenance plus SABA reliever therapy in reducing the risk of a severe exacerbation. This is an important concept which has the potential to guide clinical practice in asthma, although the small number of studies available highlights the need for further research to better define these pharmacological properties.
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Desjardin A, Garcia G. [New approaches of inhaled steroid asthma management in mild to moderate asthma]. Presse Med 2019; 48:293-302. [PMID: 30954316 DOI: 10.1016/j.lpm.2019.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Amaury Desjardin
- CHU de Caen Normandie, service de pneumologie, 14000 Caen, France; CH de Lisieux, service de pneumologie, 14100 Lisieux, France
| | - Gilles Garcia
- Université Paris-Sud, faculté de médecine, 94270 Le Kremlin-Bicêtre, France; Centre chirurgical Marie-Lannelongue, Inserm U999, LabEx LERMIT, 92350 Le Plessis-Robinson, France; Assistance publique-Hôpitaux de Paris, hôpital universitaire de Bicêtre, DHU Thorax Innovation, centre de référence de l'hypertension pulmonaire sévère, service de pneumologie, 78, avenue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France.
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Jain N, Satish K, Abhyankar N, Velayudhan N, Gurunathan J. Repeated exacerbation of asthma: An intrinsic phenotype of uncontrolled asthma. Lung India 2019; 36:131-138. [PMID: 30829247 PMCID: PMC6410599 DOI: 10.4103/lungindia.lungindia_434_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Asthma is a chronic disease of the airways affecting a large number of people across the globe. Uncontrolled asthma poses an emotional as well as the physical burden on patients and results in a great economic burden. “Exacerbation-prone phenotype” asthmatics are a cluster of patients who may suffer from more frequent and severe exacerbations than other asthmatics. Factors such as inadequate symptom control, improper adherence to medications, and incorrect use of inhalers are responsible for frequent asthma exacerbations. Caring for the patient with “exacerbation-prone asthma” needs participation from both the doctor as well as the patient. Self-management, improving knowledge about the disease, control of comorbidities, and a stepwise approach with the use of a single inhaler maintenance and reliever therapy in patients with severe asthma could help in delivering better care for the “exacerbation-prone phenotype” of asthmatics.
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Affiliation(s)
- Neeraj Jain
- Department of Pulmonary Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - K Satish
- Department of Pulmonary Medicine, Fortis Hospital, Cunningham Road, Bengaluru, Karnataka, India
| | - Nitin Abhyankar
- Department of Pulmonary Medicine, Poona Hospital and Research Centre, Pune, Maharashtra, India
| | - Nila Velayudhan
- Respiratory Medical Affairs, AstraZeneca Pharma India Limited, Bengaluru, Karnataka, India
| | - Jayakumar Gurunathan
- Respiratory Medical Affairs, AstraZeneca Pharma India Limited, Bengaluru, Karnataka, India
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Rodriguez-Martinez CE, Sossa-Briceño MP, Castro-Rodriguez JA. Cost Effectiveness of Pharmacological Treatments for Asthma: A Systematic Review. PHARMACOECONOMICS 2018; 36:1165-1200. [PMID: 29869050 DOI: 10.1007/s40273-018-0668-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE The objective of this article was to summarize the findings of all the available studies on alternative pharmacological treatments for asthma and assess their methodological quality, as well as to identify the main drivers of the cost effectiveness of pharmacological treatments for the disease. METHODS A systematic review of the literature in seven electronic databases was conducted in order to identify all the available health economic evidence on alternative pharmacological treatments for asthma published up to April 2017. The reporting quality of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. RESULTS A total of 72 studies were included in the review, classified as follows: medications for acute asthma treatment (n = 5, 6.9%); inhaled corticosteroids (ICS) administered alone or in conjunction with long-acting β-agonists (LABA) or tiotropium for chronic asthma treatment (n = 38, 52.8%); direct comparisons between different combinations of ICS, ICS/LABA, leukotriene receptor antagonists (LTRA), and sodium cromoglycate for chronic asthma treatment (n = 14, 19.4%); and omalizumab for chronic asthma treatment (n = 15, 20.8%). ICS were reported to be cost effective when compared with LTRA for the management of persistent asthma. In patients with inadequately controlled asthma taking ICS, the addition of long-acting β-agonist (LABA) preparations has been demonstrated to be cost effective, especially when combinations of ICS/LABA containing formoterol are used for both maintenance and reliever therapy. In patients with uncontrolled severe persistent allergic asthma, omalizumab therapy could be cost effective in a carefully selected subgroup of patients with the more severe forms of the disease. The quality of reporting in the studies, according to the CHEERS checklist, was very uneven. The main cost-effectiveness drivers identified were the cost or rate of asthma exacerbations, the cost or rate of the use of asthma medications, the asthma mortality risk, and the rate of utilization of health services for asthma. CONCLUSIONS The present findings are in line with the pharmacological recommendations for stepwise management of asthma given in the most recent evidence-based clinical practice guidelines for the disease. The identified reporting quality of the available health economic evidence is useful for identifying aspects where there is room for improvement in future asthma cost-effectiveness studies.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Carrera 45 No. 26-85, Bogota, Colombia.
- Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Av. Cra 9 No. 131A-02, Bogota, Colombia.
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Carrera 45 No. 26-85, Bogota, Colombia
| | - Jose A Castro-Rodriguez
- Division of Pediatrics, School of Medicine, Pontificia Universidad Catolica de Chile, Av Libertador Bernardo O'Higgins 340, Santiago, Región Metropolitana, Chile
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Xia Y, Xia L, Shen H. SMART in the Management of Patients With Persistent Asthma. JAMA 2018; 320:933-934. [PMID: 30193266 DOI: 10.1001/jama.2018.8573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Yang Xia
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lexin Xia
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Huahao Shen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Affiliation(s)
- Diana M Sobieraj
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
| | - William L Baker
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
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Sobieraj DM, Weeda ER, Nguyen E, Coleman CI, White CM, Lazarus SC, Blake KV, Lang JE, Baker WL. Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma: A Systematic Review and Meta-analysis. JAMA 2018; 319:1485-1496. [PMID: 29554195 PMCID: PMC5876810 DOI: 10.1001/jama.2018.2769] [Citation(s) in RCA: 197] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Combined use of inhaled corticosteroids and long-acting β-agonists (LABAs) as the controller and the quick relief therapy termed single maintenance and reliever therapy (SMART) is a potential therapeutic regimen for the management of persistent asthma. OBJECTIVE To conduct a systematic review and meta-analysis of the effects of SMART in patients with persistent asthma. DATA SOURCES AND STUDY SELECTION The databases of MEDLINE via OVID, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were searched from database inception through August 2016 and updated through November 28, 2017. Two reviewers selected randomized clinical trials or observational studies evaluating SMART vs inhaled corticosteroids with or without a LABA used as the controller therapy and short-acting β-agonists as the relief therapy for patients aged 5 years or older with persistent asthma and reporting on an outcome of interest. DATA EXTRACTION AND SYNTHESIS Meta-analyses were conducted using a random-effects model to calculate risk ratios (RRs), risk differences (RDs), and mean differences with corresponding 95% CIs. Citation screening, data abstraction, risk assessment, and strength of evidence grading were completed by 2 independent reviewers. MAIN OUTCOMES AND MEASURES Asthma exacerbations. RESULTS The analyses included 16 randomized clinical trials (N = 22 748 patients), 15 of which evaluated SMART as a combination therapy with budesonide and formoterol in a dry-powder inhaler. Among patients aged 12 years or older (n = 22 524; mean age, 42 years; 14 634 [65%] were female), SMART was associated with a reduced risk of asthma exacerbations compared with the same dose of inhaled corticosteroids and LABA as the controller therapy (RR, 0.68 [95% CI, 0.58 to 0.80]; RD, -6.4% [95% CI, -10.2% to -2.6%]) and a higher dose of inhaled corticosteroids and LABA as the controller therapy (RR, 0.77 [95% CI, 0.60 to 0.98]; RD, -2.8% [95% CI, -5.2% to -0.3%]). Similar results were seen when SMART was compared with inhaled corticosteroids alone as the controller therapy. Among patients aged 4 to 11 years (n = 341; median age, 8 [range, 4-11] years; 69 [31%] were female), SMART was associated with a reduced risk of asthma exacerbations compared with a higher dose of inhaled corticosteroids as the controller therapy (RR, 0.55 [95% CI, 0.32 to 0.94]; RD, -12.0% [95% CI, -22.5% to -1.5%]) or the same dose of inhaled corticosteroids and LABA as the controller therapy (RR, 0.38 [95% CI, 0.23 to 0.63]; RD, -23.2% [95% CI, -33.6% to -12.1%]). CONCLUSIONS AND RELEVANCE In this meta-analysis of patients with persistent asthma, the use of single maintenance and reliever therapy compared with inhaled corticosteroids as the controller therapy (with or without a long-acting β-agonist) and short-acting β-agonists as the relief therapy was associated with a lower risk of asthma exacerbations. Evidence for patients aged 4 to 11 years was limited.
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Affiliation(s)
- Diana M. Sobieraj
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
| | - Erin R. Weeda
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
| | - Elaine Nguyen
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
| | - Craig I. Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
| | - C. Michael White
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
| | - Stephen C. Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco
| | - Kathryn V. Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children’s Specialty Care, Jacksonville, Florida
| | - Jason E. Lang
- Division of Allergy, Immunology, and Pulmonary Medicine, Duke University School of Medicine, Duke Children’s Hospital and Health Center, Durham, North Carolina
| | - William L. Baker
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs
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19
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Wolthers OD. Budesonide + formoterol fumarate dihydrate for the treatment of asthma. Expert Opin Pharmacother 2016; 17:1023-30. [PMID: 27070946 DOI: 10.1517/14656566.2016.1165207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION One of the most widely used fixed combinations in asthma management is dry powder budesonide+formoterol fumarate dihydrate which is commercially available as Symbicort Turbuhaler(®) (and generic products), Easyhaler Bufomix(®) and DuoRespSpiromax(®) inhaler. The aim of this paper was to review the fixed dry powder combination of inhaled budesonide+formoterol fumarate dihydrate for asthma treatment in adolescents and adults. AREAS COVERED A literature search using relevant search terms, reference lists for reviews and meta-analyses was performed. EXPERT OPINION In symptomatic adolescent and adult patients with asthma maintenance and reliever therapy with a single-inhaler fixed combination of dry powder budesonide+formoterol fumarate dihydrate is an evidenced option. The combination treatment is convenient to patients. It reduces the number of exacerbations requiring treatment with oral corticosteroids. In some patients the strategy may also reduce the total intake of inhaled corticosteroids over time. Whether important outcome measures of asthma treatment, such as hospital admission and emergency room visit rates, may be reduced is less well documented since the published studies may have been influenced by publication bias. Non-pharmaceutical company-sponsored research evaluating such measures is needed. There is no evidence for the use of single inhaler fixed combinations of inhaled corticosteroids+long-acting β(2)-agonists in children (<12 years of age), and budesonide+formoterol fumarate dihydrate should not be prescribed to the age group.
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Affiliation(s)
- Ole D Wolthers
- a Asthma and Allergy Clinic , Children´s Clinic Randers , Randers , Denmark
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20
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Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, Prasad KT, Yenge LB, Singh N, Behera D, Jindal SK, Gupta D, Balamugesh T, Bhalla A, Chaudhry D, Chhabra SK, Chokhani R, Chopra V, Dadhwal DS, D’Souza G, Garg M, Gaur SN, Gopal B, Ghoshal AG, Guleria R, Gupta KB, Haldar I, Jain S, Jain NK, Jain VK, Janmeja AK, Kant S, Kashyap S, Khilnani GC, Kishan J, Kumar R, Koul PA, Mahashur A, Mandal AK, Malhotra S, Mohammed S, Mohapatra PR, Patel D, Prasad R, Ray P, Samaria JK, Singh PS, Sawhney H, Shafiq N, Sharma N, Sidhu UPS, Singla R, Suri JC, Talwar D, Varma S. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015; 32:S3-S42. [PMID: 25948889 PMCID: PMC4405919 DOI: 10.4103/0970-2113.154517] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Venkata N Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Lakshmikant B Yenge
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surinder K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Thanagakunam Balamugesh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashish Bhalla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dhruva Chaudhry
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sunil K Chhabra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ramesh Chokhani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vishal Chopra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Devendra S Dadhwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - George D’Souza
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Mandeep Garg
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Shailendra N Gaur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Bharat Gopal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Aloke G Ghoshal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Randeep Guleria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Krishna B Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Indranil Haldar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sanjay Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nirmal K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vikram K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok K Janmeja
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surya Kant
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surender Kashyap
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Gopi C Khilnani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai Kishan
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Raj Kumar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Parvaiz A Koul
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok Mahashur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Amit K Mandal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Samir Malhotra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sabir Mohammed
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dharmesh Patel
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rajendra Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Pallab Ray
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai K Samaria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Potsangbam Sarat Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Honey Sawhney
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nusrat Shafiq
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Sharma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Updesh Pal S Sidhu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rupak Singla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jagdish C Suri
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Deepak Talwar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Subhash Varma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
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Loymans RJB, Gemperli A, Cohen J, Rubinstein SM, Sterk PJ, Reddel HK, Jüni P, ter Riet G. Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: network meta-analysis. BMJ 2014; 348:g3009. [PMID: 24919052 PMCID: PMC4019015 DOI: 10.1136/bmj.g3009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the comparative effectiveness and safety of current maintenance strategies in preventing exacerbations of asthma. DESIGN Systematic review and network meta-analysis using Bayesian statistics. DATA SOURCES Cochrane systematic reviews on chronic asthma, complemented by an updated search when appropriate. ELIGIBILITY CRITERIA TRIALS OF Adults with asthma randomised to maintenance treatments of at least 24 weeks duration and that reported on asthma exacerbations in full text. Low dose inhaled corticosteroid treatment was the comparator strategy. The primary effectiveness outcome was the rate of severe exacerbations. The secondary outcome was the composite of moderate or severe exacerbations. The rate of withdrawal was analysed as a safety outcome. RESULTS 64 trials with 59,622 patient years of follow-up comparing 15 strategies and placebo were included. For prevention of severe exacerbations, combined inhaled corticosteroids and long acting β agonists as maintenance and reliever treatment and combined inhaled corticosteroids and long acting β agonists in a fixed daily dose performed equally well and were ranked first for effectiveness. The rate ratios compared with low dose inhaled corticosteroids were 0.44 (95% credible interval 0.29 to 0.66) and 0.51 (0.35 to 0.77), respectively. Other combined strategies were not superior to inhaled corticosteroids and all single drug treatments were inferior to single low dose inhaled corticosteroids. Safety was best for conventional best (guideline based) practice and combined maintenance and reliever therapy. CONCLUSIONS Strategies with combined inhaled corticosteroids and long acting β agonists are most effective and safe in preventing severe exacerbations of asthma, although some heterogeneity was observed in this network meta-analysis of full text reports.
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Affiliation(s)
- Rik J B Loymans
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
| | - Armin Gemperli
- Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Berne, Switzerland Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland Swiss Paraplegic Research, Nottwil, Switzerland
| | - Judith Cohen
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
| | - Sidney M Rubinstein
- Department of Health Sciences, Section Health Economics and Health Technology Assessment, VU University Amsterdam, Amsterdam, Netherlands
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Peter Jüni
- Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Berne, Switzerland
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
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Kew KM, Karner C, Mindus SM, Ferrara G. Combination formoterol and budesonide as maintenance and reliever therapy versus combination inhaler maintenance for chronic asthma in adults and children. Cochrane Database Syst Rev 2013; 2013:CD009019. [PMID: 24343671 PMCID: PMC8949777 DOI: 10.1002/14651858.cd009019.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Asthma is characterised by chronic inflammation of the airways and recurrent exacerbations with wheezing, chest tightness and cough. Treatment with inhaled steroids and bronchodilators often results in good control of symptoms, prevention of further morbidity and mortality and improved quality of life. Several steroids and beta2-agonists (long- and short-acting) as well as combinations of these treatments are available in a single inhaler to be used once or twice a day, with a separate inhaler for relief of symptoms when needed (for patients in Step three or higher, according to Global Initiative for Asthma (GINA) guidelines). Budesonide/formoterol is also licenced for use as maintenance and reliever therapy from a single inhaler (SiT; sometimes referred to as SMART therapy). SiT can be prescribed at a lower dose than other combination therapy because of the additional steroid doses being received as reliever therapy. It has been suggested that using SiT improves compliance and hence reduces symptoms and exacerbations, but it is unclear whether it increases side effects associated with the use of inhaled steroids. OBJECTIVES To assess the efficacy and safety of budesonide/formoterol in a single inhaler (SiT) to be used for both maintenance and reliever therapy in asthma in comparison with maintenance treatment provided through combination inhalers with a higher maintenance steroid dose (either fluticasone/salmeterol or budesonide/formoterol), along with additional fast-acting beta2-agonists for relief of symptoms. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials, online trial registries and drug company websites. The most recent search was conducted in November 2013. SELECTION CRITERIA We included parallel-group, randomised controlled trials of at least 12 weeks' duration. Studies were included if they compared single-inhaler therapy with budesonide/formoterol (SiT) versus combination inhalers at a higher maintenance dose of steroids than was given in the SiT arm (either salmeterol/fluticasone or budesonide/formoterol). DATA COLLECTION AND ANALYSIS We used standard methods expected by The Cochrane Collaboration. Primary outcomes were exacerbations requiring hospitalisation, exacerbations requiring oral corticosteroids and serious adverse events (including mortality). MAIN RESULTS Four studies randomly assigning 9130 people with asthma were included; two were six-month double-blind studies, and two were 12-month open-label studies. No trials included children younger than age 12. Trials included more women than men, with mean age ranging from 38 to 45, and mean baseline steroid dose (inhaled beclomethasone (BDP) equivalent) from 636 to 888 μg. Mean baseline forced expiratory volume in one second (FEV1) percentage predicted was between 70% and 73% in three of the trials, and 96% in another. All studies were funded by AstraZeneca and were generally free from methodological biases, although the two open-label studies were rated as having high risk for blinding, and some evidence of selective outcome reporting was found. These possible sources of bias did not lead us to downgrade the quality of the evidence. The quantity of inhaled steroids, including puffs taken for relief from symptoms, was consistently lower for SiT than for the comparison groups.Separate data for exacerbations leading to hospitalisations, to emergency room (ER) visits or to a course of oral steroids could not be obtained. Compared with higher fixed-dose combination inhalers, fewer people using SiT had exacerbations requiring hospitalisation or a visit to the ER (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.57 to 0.90; I(2) = 0%, P = 0.66), and fewer had exacerbations requiring a course of oral corticosteroids (OR 0.75, 95% CI 0.65 to 0.87; I(2) = 0%, P = 0.82). This translates to one less person admitted to hospital or visiting the ER (95% CI 0 to 2 fewer) and two fewer people needing oral steroids (95% CI 1 to 3 fewer) compared with fixed-dose combination treatment with a short-acting beta-agonist (SABA) reliever (per 100 treated over eight months). No statistical heterogeneity was observed in either outcome, and the evidence was rated of high quality. Although issues with blinding were evident in two of the studies, and one study recruited a less severe population, sensitivity analyses did not change the main results, so quality was not downgraded.We could not rule out the possibility that SiT increased rates of serious adverse events (OR 0.92, 95% CI 0.74 to 1.13; I(2) = 0%, P = 0.98; moderate-quality evidence, downgraded owing to imprecision).We were unable to say whether SiT improved results for several secondary outcomes (morning and evening peak expiratory flow (PEF), rescue medication use, symptoms scales), and in cases where results were significant, the effect sizes were not considered clinically meaningful (predose FEV1, nocturnal awakenings and quality of life). AUTHORS' CONCLUSIONS SiT reduces the number of people having asthma exacerbations requiring oral steroids and the number requiring hospitalisation or an ER visit compared with fixed-dose combination inhalers. Evidence for serious adverse events was unclear. The mean daily dose of inhaled corticosteroids (ICS) in SiT, including the total dose administered with reliever use, was always lower than that of the other combination groups. This suggests that the flexibility in steroid administration that is possible with SiT might be more effective than a standard fixed-dose combination by increasing the dose only when needed and keeping it low during stable stages of the disease. Data for hospitalisations alone could not be obtained, and no studies have yet addressed this question in children younger than age 12.
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Affiliation(s)
- Kayleigh M Kew
- St George's, University of LondonPopulation Health Sciences and EducationCranmer TerraceLondonUKSW17 0RE
| | | | - Stephanie M Mindus
- Karolinska University Hospital SolnaDepartment of Respiratory Medicine and AllergyStockholmSwedenSE‐171 76
| | - Giovanni Ferrara
- Karolinska University Hospital SolnaDepartment of Respiratory Medicine and AllergyStockholmSwedenSE‐171 76
- Karolinska InstitutetRespiratory Medicine Unit, Department of MedicineStockholmSweden
- University of PerugiaSection of Respiratory Diseases, Department of Internal MedicinePerugiaItaly
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Cisneros C, Quiralte J, Capel M, Casado MÁ, Mellstrom C. Análisis coste-efectividad de budesonida/formoterol en el tratamiento de mantenimiento y a demanda (Symbicort SMART®) frente a salmeterol/fluticasona más terbutalina, en el tratamiento del asma persistente en España. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/bf03321485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chauhan BF, Chartrand C, Ducharme FM. Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults. Cochrane Database Syst Rev 2013:CD009611. [PMID: 23450606 DOI: 10.1002/14651858.cd009611.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Daily inhaled corticosteroids (ICS) are the recommended mainstay of treatment in children and adults with persistent asthma. However, often, ICS are used intermittently by patients or recommended by physicians to be used only at the onset of exacerbations. OBJECTIVES The aim of this review was to compare the efficacy and safety of intermittent versus daily ICS in the management of children and adults with persistent asthma and preschool-aged children suspected of persistent asthma. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov web site up to October 2012. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared intermittent ICS versus daily ICS in children and adults with persistent asthma. No co-interventions were permitted other than rescue relievers and oral corticosteroids used during exacerbations. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, methodological quality and extracted data. The primary efficacy outcome was the number of patients with one or more exacerbations requiring oral corticosteroids and the primary safety outcome was the number of patients with serious adverse health events. Secondary outcomes included exacerbations, lung function tests, asthma control, adverse effects, withdrawal rates and inflammatory markers. Equivalence was assumed if the risk ratio (RR) estimate and its 95% confidence interval (CI) were between 0.9 and 1.1. Quality of the evidence was assessed using GRADE. MAIN RESULTS Six trials (including one trial testing two relevant protocols) met the inclusion criteria for a total of seven group comparisons. The four paediatric trials (two involving preschool children and two school-aged children) and two adult parallel-group trials, lasting 12 to 52 weeks, were of high methodological quality. A total of 1211 patients with confirmed, or suspected, persistent asthma contributed to the meta-analyses. There was no statistically significant group difference in the risk of patients experiencing one or more exacerbations requiring oral corticosteroids (1204 patients; RR 1.07; 95% CI 0.87 to 1.32; the large confidence interval translates into a risk of exacerbations in the intermittent ICS group varying between 17% and 25%, assuming a 19% risk with daily ICS). Age, severity of airway obstruction, step-up protocol used during exacerbations and trial duration did not significantly influence the primary efficacy outcome. No group difference was observed in the risk of patients with serious adverse health events (1055 patients; RR 0.82; 95% CI 0.33 to 2.03). Compared to the daily ICS group, the intermittent ICS group displayed a smaller improvement in change from baseline peak expiratory flow rate (PEFR) by 2.56% (95% CI -4.49% to -0.63%), fewer symptom-free days (standardised mean difference (SMD) -0.15 (95% CI -0.28 to -0.03), fewer asthma control days -9% (95% CI -14% to -4%), more use of rescue β2-agonists by 0.12 puffs/day (95% CI 0 to 0.23) and a greater increase from baseline in exhaled nitric oxide of 16.80 parts per billion (95% CI 11.95 to 21.64). There was no significant group difference in forced expiratory volume in one second (FEV1), quality of life, airway hyper-reactivity, adverse effects, hospitalisations, emergency department visits or withdrawals. In paediatric trials, intermittent ICS (budesonide and beclomethasone) were associated with greater growth by 0.41 cm change from baseline (532 children; 95% CI 0.13 to 0.69) compared to daily treatment. AUTHORS' CONCLUSIONS In children and adults with persistent asthma and in preschool children suspected of persistent asthma, there was low quality evidence that intermittent and daily ICS strategies were similarly effective in the use of rescue oral corticosteroids and the rate of severe adverse health events. The strength of the evidence means that we cannot currently assume equivalence between the two options.. Daily ICS was superior to intermittent ICS in several indicators of lung function, airway inflammation, asthma control and reliever use. Both treatments appeared safe, but a modest growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. Clinicians should carefully weigh the potential benefits and harm of each treatment option, taking into account the unknown long-term (> one year) impact of intermittent therapy on lung growth and lung function decline.
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Affiliation(s)
- Bhupendrasinh F Chauhan
- Clinical Research Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, Canada.
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Chauhan BF, Chartrand C, Ducharme FM. Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults. Cochrane Database Syst Rev 2012; 12:CD009611. [PMID: 23235678 DOI: 10.1002/14651858.cd009611.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Daily inhaled corticosteroids (ICS) are the recommended mainstay of treatment in children and adults with persistent asthma. Yet often, ICS are used intermittently by patients or recommended by physicians to be used only at the onset of exacerbations. OBJECTIVES The aim of this review was to compare the efficacy and safety of intermittent versus daily ICS in the management of children and adults with persistent asthma and preschool-aged children suspected of persistent asthma. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov website up to December 2011. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared intermittent ICS versus daily ICS in children and adults with persistent asthma. No co-interventions were permitted other than rescue relievers and oral corticosteroids used during exacerbations. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, methodological quality and extracted data. The primary efficacy outcome was the number of patients with one or more exacerbations requiring oral corticosteroids and the primary safety outcome was the number of patients with serious adverse health events. Secondary outcomes included exacerbations, lung function tests, asthma control, adverse effects, withdrawal rates and inflammatory markers. Equivalence was assumed if the risk ratio (RR) estimate and its 95% confidence interval (CI) were between 0.9 and 1.1. MAIN RESULTS Six trials (including one trial testing two relevant protocols) met the inclusion criteria for a total of seven group comparisons. The four paediatric trials (two involving preschool children and two school-aged children) and two adult parallel-group trials, lasting 12 to 52 weeks, were of high methodological quality. A total of 1211 patients with confirmed, or suspected, persistent asthma contributed to the meta-analyses. There was no statistically significant group difference in the risk of patients experiencing one or more exacerbations requiring oral corticosteroids (1204 patients; RR 1.07; 95% CI 0.87 to 1.32). The patients' age, severity of airway obstruction, step-up protocol used during exacerbations and trial duration did not significantly influence the primary efficacy outcome. No group difference was observed in the risk of patients with serious adverse health events (1055 patients; RR 0.82; 95% CI 0.33 to 2.03). Compared to the daily ICS group, the intermittent ICS group displayed a smaller improvement in change from baseline peak expiratory flow rate (PEFR) by 2.56% (95% CI -4.49% to -0.63%), fewer symptom-free days (standardised mean difference (SMD) -0.15 (95% CI -0.28 to -0.03), fewer asthma control days -9% (95% CI -14% to -4%), more use of rescue β(2)-agonists by 0.12 puffs/day (95% CI 0 to 0.23) and a greater increase from baseline in exhaled nitric oxide of 16.80 parts per billion (95% CI 11.95 to 21.64). There was no significant group difference in forced expiratory volume in one second (FEV(1)), quality of life, airway hyper-reactivity, adverse effects, hospitalisations, emergency department visits or withdrawals. In paediatric trials, intermittent ICS (budesonide and beclomethasone) were associated with greater growth by 0.41 cm change from baseline (532 children; 95% CI 0.13 to 0.69) compared to daily treatment. AUTHORS' CONCLUSIONS In children and adults with persistent asthma and in preschool children suspected of persistent asthma, intermittent and daily ICS strategies did not significantly differ in the use of rescue oral corticosteroids and the rate of severe adverse health events, neither did they reach equivalence. Daily ICS was superior to intermittent ICS in several indicators of lung function, airway inflammation, asthma control and reliever use. Both treatments appeared safe, but a modest growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. The clinician should carefully weigh the potential benefits and harm of each treatment option, taking into account the unknown long-term (> one year) impact of intermittent therapy on lung growth and lung function decline.
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Affiliation(s)
- Bhupendrasinh F Chauhan
- Clinical Research Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, Canada.
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Lougheed MD, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, FitzGerald M, Leigh R, Watson W, Boulet LP. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012; 19:127-64. [PMID: 22536582 PMCID: PMC3373283 DOI: 10.1155/2012/635624] [Citation(s) in RCA: 207] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and⁄or gaps in the previous guidelines. METHODS Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS⁄long-acting beta(2)-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations. RESULTS The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified. CONCLUSIONS The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee's new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.
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Towards the Grade of Recommendations, Assessment, Development and Evaluation system: methods and results of budesonide/formoterol maintenance and reliever therapy research. Curr Opin Allergy Clin Immunol 2011; 11:361-74. [PMID: 21659859 DOI: 10.1097/aci.0b013e3283489c0e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Guidelines for clinical practice are expected to gather evidence-based recommendations to support optimal medical behaviours. The aim of the current review is to explore how currently available research regarding the strategy of using budesonide/formoterol (BUD/FORM) as maintenance and reliever therapy (Symbicort SMART) covers the items considered by the Grade of Recommendations, Assessment, Development and Evaluation (GRADE) system, through a comparative analysis of methodological approaches, clinical outcomes, patient-reported outcomes and costs, in order to highlight uncovered areas. RECENT FINDINGS Thirteen trials providing data on 21 095 analysed patients were available. No serious limits in methodological study features were found. Evaluation of the clinical outcome was consistent with the efficacy of BUD/FORM maintenance and reliever therapy. As the time to first exacerbation was the primary outcome in most of the studies, conclusive indications cannot be drawn regarding other clinical outcomes or patient-reported outcomes, which were investigated as secondary outcomes. A comprehensive systematic review exploring all critical and important outcomes is desirable, but further research concerning the safety issues of Long Acting β2 Agonists (LABA) and patients' reported outcomes about the SMART in respect to alternative strategies is likely to affect a clear recommendation in the near future. SUMMARY The efficacy of BUD/FORM maintenance and reliever therapy in extending the time to first exacerbation appears consistent between studies. Further studies exploring all patients' important outcomes are needed. Clinical and economic assessments are worthy of being investigated to verify the directness of the evidence in respect to real life patients and different geographical realities.
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An economic evaluation of budesonide/formoterol for maintenance and reliever treatment in asthma in general practice. Adv Ther 2009; 26:872-85. [PMID: 19768640 DOI: 10.1007/s12325-009-0063-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In budesonide/formoterol (Symbicort(R) Turbuhaler(R), AstraZeneca, Lund, Sweden) maintenance and reliever therapy (SMART), patients with asthma take a daily maintenance dose of budesonide/formoterol, with the option of taking additional doses for symptom relief instead of a short-acting beta(2)-agonist (SABA). This study assesses the cost-effectiveness of SMART compared with usual care in patients with mild-to-moderate persistent asthma treated by general practitioners in the Netherlands from a societal perspective. METHODS The study was linked to a randomized, active-controlled, open-label, multicenter, 12-month clinical trial, with a prospective collection of resource use. One hundred and two patients > or =18 years with mild-to-moderate persistent asthma and daily inhaled corticosteroids (ICS) prior to the trial were included. SMART was given as two inhalations of budesonide/formoterol (100/6 microg) once daily, plus additional doses as needed. The control group was treated according to guidelines, which prescribe medium daily doses of ICS plus an SABA if needed. A long-acting beta(2)-agonist (LABA) is added if necessary. Effectiveness was measured as the proportion of asthma-control days, Asthma Control Questionnaire (ACQ) scores, the net proportion of patients with relevant ACQ improvement, and the proportion of well-controlled patients. Costs included asthma medication, physician contacts, and absence from work. RESULTS Mean total costs for SMART were <euro>134.81 lower (95% CI: -<euro>439.48; <euro>44.85). Production losses were <euro>94.10 (95% CI: -<euro>300.60; <euro>0.29) lower for SMART (<euro>10.77 vs. <euro>104.87). No significant differences in health outcomes were seen, with 3.81 fewer asthma-control days per patient-year for SMART (95% CI: -36.8; 30.8), a 0.049 better ACQ score (95% CI: -0.21; 0.29), a 5.8% larger net proportion of improved patients (95% CI: t15.6%; 27.3%), and a 2.1% (95% CI: -25.5; 20.8%) smaller increase in the proportion of well-controlled patients. CONCLUSIONS Treating primary care patients with mild-to-moderate persistent asthma with SMART instead of ICS plus bronchodilators does not affect health outcomes and does not increase costs; therefore, is likely to be an alternative for guideline-directed treatment, from a health and economic perspective.
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Cates CJ, Lasserson TJ. Combination formoterol and inhaled steroid versus beta2-agonist as relief medication for chronic asthma in adults and children. Cochrane Database Syst Rev 2009; 2009:CD007085. [PMID: 19160317 PMCID: PMC4023854 DOI: 10.1002/14651858.cd007085.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Formoterol has a fast onset of action and can therefore be used to relieve symptoms of asthma. A combination inhaler can deliver formoterol with different doses of inhaled corticosteroid; when used as a reliever both drugs will be delivered more frequently when asthma symptoms increase. This has the potential to treat both bronchoconstriction and inflammation in the early stages of exacerbations. OBJECTIVES To assess the efficacy and safety of combined inhalers containing both formoterol and an inhaled corticosteroid when used for reliever therapy in adults and children with chronic asthma. SEARCH STRATEGY We last searched the Cochrane Airways Group trials register in April 2008. SELECTION CRITERIA Randomised trials in adults and children with chronic asthma, where a combination inhaler containing formoterol and inhaled corticosteroid is compared with fast-acting beta2-agonist alone for the relief of asthma symptoms. This should be the only planned difference between the trial arms. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the characteristics and results of each study. Authors or manufacturers were asked to supply unpublished data in relation to primary outcomes. MAIN RESULTS Three trials involving 5905 participants were included. In patients with mild asthma who do not need maintenance treatment, no clinically important advantages of budesonide/formoterol as reliever were found in comparison to formoterol as reliever.Two studies enrolled patients with more severe asthma who were not controlled on high doses of inhaled corticosteroids (around 700 mcg/day in adults), and had suffered a clinically important asthma exacerbation in the past year. Hospitalisations related to asthma in the two studies comparing budesonide/formoterol for maintenance and relief with the same dose of budesonide/formoterol for maintenance with terbutaline for relief yielded an odds ratio of 0.68 (95% CI 0.40 to 1.16), which was not a statistically significant reduction. One adult study found a reduction in exacerbations requiring oral corticosteroids compared to terbutaline, odds ratio 0.56 (95% CI 0.42 to 0.74) and the study in children found less serious adverse events with budesonide/formoterol used for maintenance and relief. There was no significant difference in annual growth in children using budesonide/formoterol reliever in comparison to terbutaline. AUTHORS' CONCLUSIONS In mild asthma it is not yet known whether patients who use a budesonide/formoterol inhaler for relief of asthma symptoms derive any clinically important benefits. In more severe asthma, one study that enrolled patients who were not controlled on quite high doses of inhaled corticosteroids, and had suffered an exacerbation in the previous year, demonstrated a reduction in the risk of exacerbations that require oral corticosteroids with budesonide/formoterol for maintenance and relief in comparison with budesonide/formoterol for maintenance and terbutaline or formoterol for relief. The incidence of serious adverse events in children was also less using budesonide/formoterol for maintenance and relief in one study, which similarly enrolled children who were not controlled on medium to high doses of inhaled corticosteroids, and compared to terbutaline relief with an explorative maintenance dose of budesonide/formoterol that is not approved for treatment.
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Affiliation(s)
- Christopher J Cates
- Community Health Sciences, St George's, University of London, Cranmer Terrace, London, UK, SW17 0RE.
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