1
|
Ye Q, He XO, D’Urzo A. A Review on the Safety and Efficacy of Inhaled Corticosteroids in the Management of Asthma. Pulm Ther 2017. [DOI: 10.1007/s41030-017-0043-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
|
2
|
Assessing the risks and benefits of step-down asthma care: a case-based approach. Curr Allergy Asthma Rep 2015; 15:503. [PMID: 25687171 DOI: 10.1007/s11882-014-0503-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Guidelines have called for pharmacologic stepped care to improve asthma treatment. Therapeutic options which have been approved provide physicians and their patients alternatives for stepping up asthma treatment to achieve control. However, few studies have been performed to identify and characterize procedures for optimal stepping-down treatment in patients with asthma. The resulting uncertainty as well as a lack of prioritization for asthma reassessment once control has been maintained has led to a lack of well-defined procedures for stepping down asthma treatment. However, recent studies provide guidance regarding the risks of stepping down asthma medications. This review uses case-based examples to demonstrate how health care providers may engage patients in discussions regarding guideline recommendations to promote individualized asthma care.
Collapse
|
3
|
Rank MA, Peters SP. The risks, benefits, and uncertainties of stepping down asthma medications. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:503-9; quiz 510. [PMID: 25213042 DOI: 10.1016/j.jaip.2014.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/20/2014] [Accepted: 03/21/2014] [Indexed: 11/29/2022]
Abstract
Stepwise adjustments have been suggested as a framework to manage chronic asthma over time. In this framework, individuals with good asthma control and a low risk for future asthma exacerbations may be considered for a reduction or "step down" of their chronic asthma medications. In this article, we discuss how patients may benefit or be harmed by stepping down asthma medications. Based on the literature presented in this article, we recommend that clinicians discuss the option of stepping down with patients when symptoms are stable, lung function is near normal, and biomarkers (if measured) are near normal. Other factors that should be considered in the decision to step down include the length of asthma stability, age of the patient, time of year, and patient preferences. Reducing the dose of inhaled corticosteroid by 25% to 50% appears to be the safest method of stepping down. A clear plan of care and follow-up is needed when stepping down asthma medications because many patients are likely to have recurrent exacerbations.
Collapse
Affiliation(s)
- Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz.
| | - Stephen P Peters
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
4
|
Abstract
Inhaled corticosteroids (ICSs) are recommended for treatment of persistent asthma. Several ICSs are available and delivered by a variety of devices. After the banning of chlorofluorocarbon (CFC), a formulation of hydrofluoroalkane (HFA)-flunisolide marketed with an in-built spacer has been developed, complying with the request of efficacy and safety for children and adults. It delivers an aerosol with mass median aerodynamic diameter smaller than that of the CFC-formulation (1.2 vs 3.8 m). The extrafine aerosol and the add-on spacer are peculiarities of HFA-flunisolide with respect to the traditional ICSs, assuring larger lung deposition, lower oro-pharyngeal dose and targeting small airways. HFA-flunisolide with the spacer is effective at one-third the dose of CFC-flunisolide delivered without spacer. HFA-flunisolide may be considered an effective alternative to currently available ICSs for asthma management of adult and pediatric patients 6 years of age and older.
Collapse
Affiliation(s)
- Andrea S Melani
- Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte, Azienda Ospedaliera Universitaria Senese, Viale Bracci, 53100 Siena, Italy
| |
Collapse
|
5
|
Hagan JB, Samant SA, Volcheck GW, Li JT, Hagan CR, Erwin PJ, Rank MA. The risk of asthma exacerbation after reducing inhaled corticosteroids: a systematic review and meta-analysis of randomized controlled trials. Allergy 2014; 69:510-6. [PMID: 24571355 DOI: 10.1111/all.12368] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Asthma guidelines suggest reducing controller medications when asthma is stable. METHODS The purpose of the study is to estimate the risk of asthma exacerbation in stable asthmatics who reduce inhaled corticosteroids (ICS) compared to those who maintain a stable ICS dose. We identified articles from a systematic review of English and non-English articles using MEDLINE, EMBASE, Web of Science, and CENTRAL (inception to May 25, 2013). We included randomized controlled trials (RCTs) with a stable asthma run-in period of 4 weeks or more, an intervention to reduce ICS, and a follow-up period of at least 3 months. RESULTS The search strategy identified 2253 potential articles, of which 206 were reviewed at the full-text level and 6 met criteria for inclusion. The relative risk of an asthma exacerbation in individuals who reduced ICS compared to those who maintained the same ICS dose was 1.25 (95% CI 0.96, 1.62; P = 0.10; I(2) = 0%) in studies with a mean follow-up of 22 weeks. Individuals who reduced ICS had a decreased% predicted FEV1 of 0.87% (95% CI -1.58%,3.33%; P = 0.49, I(2) = 58%) and a decreased mean morning peak expiratory flow of 9.57 l/min (95% CI 1.25, 17.90; P = 0.02; I(2) = 74%) compared to those individuals who maintained a stable ICS dose. CONCLUSIONS Asthma exacerbations were statistically no more likely among individuals who reduced ICS compared to those who maintained their ICS dose, supporting current guidelines which recommend decreasing ICS by 50% after a period of asthma stability.
Collapse
Affiliation(s)
- J. B. Hagan
- Division of Allergic Diseases; Mayo Clinic; Rochester MN USA
| | - S. A. Samant
- Division of Allergic Diseases; Mayo Clinic; Rochester MN USA
| | - G. W. Volcheck
- Division of Allergic Diseases; Mayo Clinic; Rochester MN USA
| | - J. T. Li
- Division of Allergic Diseases; Mayo Clinic; Rochester MN USA
| | | | | | - M. A. Rank
- Division of Allergy, Asthma, and Clinical Immunology; Mayo Clinic; Scottsdale AZ USA
| |
Collapse
|
6
|
Burioka N, Fukuoka Y, Koyanagi S, Miyata M, Takata M, Chikumi H, Takane H, Watanabe M, Endo M, Sako T, Suyama H, Ohdo S, Shimizu E. Asthma: Chronopharmacotherapy and the molecular clock. Adv Drug Deliv Rev 2010; 62:946-55. [PMID: 20359514 DOI: 10.1016/j.addr.2010.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Revised: 03/17/2010] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
Abstract
Bronchial asthma is characterized by chronic airways inflammation and reversible airflow limitation. In patients with asthma, symptoms generally worsen during the early hours of the morning, and pulmonary function often deteriorates at the same time, suggesting a role for chronopharmacotherapy. Several drugs for asthma have been developed based on chronopharmacology. Most medications employed for the chronotherapy of asthma are administered once at night with the goal of preventing chronic airway inflammation or development of airflow limitation. In addition to bronchodilators, the inhaled glucocorticosteroid ciclesonide is now available with once-daily dosing, which also improves patients' compliance. Numerous investigations have demonstrated the usefulness of chronotherapy for asthma, especially for patients with nocturnal asthma. This review focuses on chronotherapy of asthma, and also provides a molecular biological explanation for the influence of asthma medications on the clock genes.
Collapse
|
7
|
Wu K, Goyal N, Stark JG, Hochhaus G. Evaluation of the administration time effect on the cumulative cortisol suppression and cumulative lymphocytes suppression for once-daily inhaled corticosteroids: a population modeling/simulation approach. J Clin Pharmacol 2008; 48:1069-80. [PMID: 18728243 DOI: 10.1177/0091270008320607] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inhaled glucocorticoids continue to be first-line therapy in asthma. To improve improving patient compliance, newer inhaled glucocorticoids have been developed for once-a-day treatment. This study was interested in identifying the optimal time of dosing using 2 surrogate markers of glucocorticoid action. A previously published study on the pharmacokinetics and pharmacodynamics (cortisol and blood lymphocyte suppression) of the inhaled glucocorticoids budesonide and fluticasone propionate was reanalyzed using a population pharmacokinetic approach. A stochastic numerical simulation using NONMEM assessed the effects of time of dosing on cortisol (side effect parameter) and blood lymphocytes (side effect and effect parameter). The effects on cortisol were more pronounced when the glucocorticoids were given in the morning, whereas the effects on lymphocytes (an effect controlled by endogenous and exogenous glucocorticoids) were maximized when dosing occurred in the late afternoon or evening. Twice-daily dosing of the same dose resulted in smaller differences between maximum and minimal effects. These were of no clinical relevance. Simulations for once-daily dosing support clinical studies that reported a higher antiasthmatic effect and lower cortisol suppression when once-daily dosing occurs in the evening.
Collapse
Affiliation(s)
- Kai Wu
- Novartis, Cambridge, Massachusetts, USA
| | | | | | | |
Collapse
|
8
|
Smolensky MH, Lemmer B, Reinberg AE. Chronobiology and chronotherapy of allergic rhinitis and bronchial asthma. Adv Drug Deliv Rev 2007; 59:852-82. [PMID: 17900748 DOI: 10.1016/j.addr.2007.08.016] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 08/02/2007] [Indexed: 11/28/2022]
Abstract
Study of the chronobiology of allergic rhinitis (AR) and bronchial asthma (BA) and the chronopharmacology and chronotherapy of the medications used in their treatment began five decades ago. AR is an inflammatory disease of the upper airway tissue with hypersensitivity to specific environmental antigens, resulting in further local inflammation, vasomotor changes, and mucus hypersecretion. Symptoms include sneezing, nasal congestion, and runny and itchy nose. Approximately 25% of children and 40% of adults in USA are affected by AR during one or more seasons of the year. The manifestation and severity of AR symptoms exhibit prominent 24-h variation; in most persons they are worse overnight or early in the morning and often comprise nighttime sleep, resulting in poor daytime quality of life, compromised school and work performance, and irritability and moodiness. BA is also an inflammatory medical condition of the lower airways characterized by hypersensitivity to specific environmental antigens, resulting in greater local inflammation as well as bronchoconstriction, vasomotor change, and mucus hypersecretion. In USA an estimated 6.5 million children and 15.7 million adults have BA. The onset and worsening of BA are signaled by chest wheeze and/or croupy cough and difficult and labored breathing. Like AR, BA is primarily a nighttime medical condition. AR is treated with H1-antagonist, decongestant, and anti-inflammatory (glucocorticoid and leukotriene receptor antagonist and modifier) medications. Only H1-antagonist AR medications have been studied for their chronopharmacology and potential chronotherapy. BA is treated with some of the same medications and also theophylline and beta2-agonists. The chronopharmacology and chronotherapy of many classes of BA medications have been explored. This article reviews the rather extensive knowledge of the chronobiology of AR and BA and the chronopharmacology and chronotherapy of the various medications used in their treatment.
Collapse
Affiliation(s)
- Michael H Smolensky
- School of Public Health, RAS-Rm. W606, University of Texas Health Science Center at Houston, 1200 Herman Pressler, Houston, Texas 77030, USA.
| | | | | |
Collapse
|
9
|
Shigyo M, Inoue H, Honda Y, Takata S, Iwanaga T, Koto H, Takahashi N, Ichiki H, Aizawa H. Once-daily administration of fluticasone propionate does not worsen controlled airway hyperresponsiveness in patients with asthma. Respiration 2006; 72:480-5. [PMID: 16210886 DOI: 10.1159/000087671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2004] [Accepted: 10/20/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Inhaled steroids are currently the most important drugs for asthma patients, but compliance tends to be low. Compliance could be improved by reducing the number of daily administrations. OBJECTIVES In the present study, we compared once- and twice-daily administration of fluticasone propionate (FP) to determine the differences in efficacy. METHODS Subjects were 40 patients diagnosed with bronchial asthma with stable symptoms and pulmonary functions who were on twice-daily FP administration of 100 microg. There were 14 men and 26 women ranging from 29 to 72 years of age. After a 4-week observation period, subjects were randomized into two administration groups by the envelope method and followed for 8 weeks: group A, once-daily administration (200 microg of FP at night), and group B, twice-daily administration (100 microg of FP in the morning and at night). Clinical symptoms, pulmonary functions and airway responsiveness were compared between these two groups. RESULTS No significant deterioration in clinical symptoms, pulmonary functions and airway responsiveness were observed in group A compared with group B. CONCLUSIONS These results demonstrate that once-daily FP administration is as effective as twice-daily administration, and that it may improve the compliance for inhaled steroids.
Collapse
Affiliation(s)
- M Shigyo
- Clinical Research Institute, National Fukuoka-Higashi Hospital, Fukuoka, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Weiss M, Vered I, Foldes AJ, Cohen YC, Shamir-Elron Y, Ish-Shalom S. Treatment preference and tolerability with alendronate once weekly over a 3-month period: an Israeli multi-center study. Aging Clin Exp Res 2005; 17:143-9. [PMID: 15977463 DOI: 10.1007/bf03324587] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS Osteoporosis is a chronic condition requiring long-term treatment, for which compliance is not easy to achieve. 70 mg of alendronate once weekly (alendronate OW) provides equivalent efficacy to treatment with 10 mg of alendronate once a day (alendronate OD); however, there are relatively few data regarding patient and physician preferences for once-weekly vs daily dosing. The aim of this study was to measure compliance, convenience, tolerance and relative preference of alendronate OW treatment among post-menopausal women with osteoporosis and physician satisfaction, compared with previous treatment with alendronate OD. METHODS This open-label, prospective multi-center trial was conducted at 14 hospitals and 150 primary-care community clinics in Israel. Post-menopausal osteoporotic women (n = 3710), who had been treated for at least 1 month with alendronate OD during the preceding year, were treated with alendronate OW for 12 weeks. Convenience, satisfaction, tolerance and relative preference of alendronate OW during the trial, compared with past experience with alendronate OD, were recorded. RESULTS Overall, 96% of the patients preferred the alendronate OW regimen to the 10-mg daily dosage. Nearly all (98%) the patients who completed 12 weeks of treatment, including 77% of patients who had previously discontinued daily treatment due to intolerance, were willing to continue the alendronate OW regimen. Patient-reported compliance with dosing instructions was over 98%. Alendronate OW was well tolerated; only 2.8% of patients discontinued, due to adverse events. Physicians were highly satisfied with the once-weekly dosing regimen, and recommended continued treatment with alendronate OW for 99% of the patients. CONCLUSIONS The majority of post-menopausal women with osteoporosis, including those who were previously intolerant to alendronate OD, preferred alendronate OW to the once-daily dosing regimen. It is important to consider patient preference when selecting the appropriate treatment for osteoporosis.
Collapse
Affiliation(s)
- Mordechai Weiss
- Endocrine Institute, Assaf Harofeh Medical Center, Zerifin, Israel
| | | | | | | | | | | |
Collapse
|
11
|
Selroos O, Edsbäcker S, Hultquist C. Once-daily inhaled budesonide for the treatment of asthma: clinical evidence and pharmacokinetic explanation. J Asthma 2005; 41:771-90. [PMID: 15641626 DOI: 10.1081/jas-200038344] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Budesonide, a widely used inhaled corticosteroid (ICS) with a favorable therapeutic ratio, is available via a dry powder inhaler (Pulmicort Turbuhaler) and as a suspension for nebulization (Pulmicort Respules). METHODS MEDLINE and an AstraZeneca database were searched to identify relevant controlled clinical trials published between 1986 and 2002 using the key words budesonide OR inhaled corticosteroid, AND once daily. RESULTS Thirty-four controlled clinical studies involving once-daily administration of budesonide to asthmatic patients were identified. Excluding long-term studies, this review presents data from 23 controlled studies for 4466 adults or adolescents and 1532 children with asthma and demonstrates efficacy of budesonide in both corticosteroid-naïve patients and patients previously treated with ICS. Once-daily administration of budesonide achieves clinical efficacy comparable with that of twice-daily regimens in patients with mild-to-moderate asthma and is equally effective when given in the morning or evening. Once-daily administration simplifies treatment regimens and may improve patient compliance. The tolerability profiles of budesonide once-daily via Turbuhaler or as budesonide inhalation suspension are good and comparable with those for twice-daily dosing. CONCLUSIONS Once-daily budesonide is effective and well tolerated as initial treatment for adults and children with mild asthma and as maintenance therapy in patients with more severe asthma once asthma control has been achieved.
Collapse
|
12
|
Shafazand S, Colice G. Flunisolide HFA for the treatment of asthma: an old friend reformulated. Expert Opin Pharmacother 2004; 5:1163-73. [PMID: 15155115 DOI: 10.1517/14656566.5.5.1163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The environmental mandate to eliminate the production of ozone-depleting products including chlorofluorocarbon (CFC) propellants has encouraged much needed research into improving modes of delivery of inhaled corticosteroids and enhancing drug deposition. Consequently, flunisolide CFC, an inhaled corticosteroid with a proven track record in the treatment of asthma, has been reformulated using a hydrofluoroalkane (HFA) as a propellant and is now awaiting FDA approval. Flunisolide HFA is a solution aerosol, unlike flunisolide CFC which is a suspension aerosol. As a solution aerosol, flunisolide HFA has a smaller mean particle size than flunisolide CFC. In addition, the built-in spacer included in the flunisolide HFA inhaler acts to reduce ex-actuator particle size; the smaller particle size of flunisolide HFA results in an improved deposition profile. Flunisolide HFA has substantially more lung deposition and much less oropharyngeal deposition than flunisolide CFC. Limited information is currently available on the clinical performance of flunisolide HFA. A single dose-response study has been performed in adults and in children comparing multiple doses of flunisolide HFA and flunisolide CFC. These studies indicate that flunisolide HFA is effective in controlling asthma. No unusual safety concerns have been noted, although further studies are needed to determine the long-term systemic effects of flunisolide HFA.
Collapse
Affiliation(s)
- Shirin Shafazand
- The George Washington University, Washington Hospital Center, Washington, DC 20010, USA.
| | | |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Inhaled corticosteroids (ICS) are the mainstay of asthma therapy. Although compliance to this type of medication is often suboptimal and once-daily dosing can help to improve adherence to the treatment, the clinical implications of such a mode of administration should be determined. RECENT FINDINGS This review summarizes the recent studies on comparative efficacy of once-versus twice-daily administration of ICS, in light of previous reports. SUMMARY Although twice-daily administration of ICS is often better to optimize asthma parameters, in many patients, asthma can be sufficiently controlled by a once-daily regimen of most ICS. An increased frequency of dosing seems preferable if asthma becomes uncontrolled or is severe, although this requires further study. A therapeutic trial should, however, be done to ensure that asthma control is adequate. Comparative long-term effects of such a strategy on inflammatory and remodeling parameters remain to be determined, as does the proportion of patients who can adequately control their asthma with once-daily administration of the various ICS available.
Collapse
Affiliation(s)
- Louis-Philippe Boulet
- Institut de cardiologie et de pneumologie de l'Université Laval, Hôpital Laval, Quebec City, QC, Canada.
| |
Collapse
|
14
|
Angus RM. Inhaled corticosteroids (budesonide): the cornerstone of asthma therapy--what are the options? Pulm Pharmacol Ther 2003; 15:479-84. [PMID: 12493333 DOI: 10.1006/pupt.2002.0397] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The clinical value of corticosteroids in treating asthma has long been recognised. Major advances in the use of these drugs came with the introduction of inhaled corticosteroids (ICS) and the recognition that even mild asthma has an inflammatory component. ICS are now considered as first-line therapy in all asthma treatment guidelines. Over the past decade there has been clarification of the dose-response relationship with ICS and confirmation of the general long-term efficacy and safety of these drugs in both adults and children. Recent work has focused on simplifying dosing regimens and investigating flexibility of dosing. Moreover, ICS can be used in combination with other agents such as long-acting inhaled beta(2)-agonists to provide effective asthma control in patients with persistent asthma not adequately controlled on ICS alone. Thus, ICS remain the cornerstone of modern asthma therapy.
Collapse
Affiliation(s)
- R M Angus
- University Hospital Aintree, Lower Lane, Liverpool L9 6AL, UK.
| |
Collapse
|
15
|
Abstract
Determining which drug is suitable for, and which patient can benefit from, a once-daily dose of prophylactic treatment is important for practitioners who want to improve therapeutic compliance in children with asthma. According to the literature, once-daily delivery of cromolyn sodium, nedocromil or beclomethasone dipropionate must be avoided. On the other hand, switching from a twice-daily to a once-daily regimen is efficient and safe only in children with well-controlled asthma using nebulized or dry-powder budesonide, dry-powder fluticasone propionate, flunisolide, or sustained-release theophylline. Such information is not available for long-acting beta2-agonists, except for oral bambuterol. Initiating a once-daily treatment in previously untreated children can only be based on low doses of inhaled budesonide or on an oral drug, montelukast. Further studies in children with severe asthma or treated with metered-dose inhalers and spacer devices are required before recommending a once-daily drug delivery in such situations.
Collapse
|
16
|
Kuntz KM, Kitch BT, Fuhlbrigge AL, Paltiel AD, Weiss ST. A novel approach to defining the relationship between lung function and symptom status in asthma. J Clin Epidemiol 2002; 55:11-8. [PMID: 11781117 DOI: 10.1016/s0895-4356(01)00412-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We present a novel approach to estimating functional relationships between forced expiratory volume in 1 second (FEV(1)) and asthma-related symptoms on a population-wide basis. We used asthma-related clinical trials that reported estimates of mean lung function (measured as FEV(1) percent predicted) and symptoms (symptom score or percentage of symptom days or nighttime awakenings). Using average baseline values from each study in weighted linear regression analyses, we found a negative association between lung function and symptom score (P < 0.001) and the percentage of nighttime awakenings (P = 0.18), but no association between lung function and symptom days. We also found consistent relationships between the mean changes in lung function and symptoms at follow-up within the studies. Functional relationships between FEV(1) percent predicted and asthma-related symptoms can be useful for inferring the effect on the symptoms of a population associated with overall improvements in lung function.
Collapse
Affiliation(s)
- Karen M Kuntz
- Department of Health Policy and Management, Harvard School of Public Health, 718 Huntington Ave., Boston, MA, USA.
| | | | | | | | | |
Collapse
|
17
|
Postma DS, Sevette C, Martinat Y, Schlösser N, Aumann J, Kafé H. Treatment of asthma by the inhaled corticosteroid ciclesonide given either in the morning or evening. Eur Respir J 2001; 17:1083-8. [PMID: 11491148 DOI: 10.1183/09031936.01.00099701] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The study addressed the question whether the novel inhaled prodrug corticosteroid ciclesonide is equally effective when inhaled in the morning compared to the evening. For this purpose a double-blind, randomized, parallel group study was initiated in which 209 asthmatic patients (forced expiratory volume in one second = 50-90% predicted) inhaled either 200 microg ciclesonide in the morning or in the evening, for 8 weeks. Efficacy was assessed by means of spirometry as well as daily recordings of morning and evening peak expiratory flow (PEF), symptoms and use of rescue medication. The 24-h urinary cortisol excretion was measured to evaluate any effect on hypothalamic-pituitary-adrenol axis. Ciclesonide significantly improved asthma control. Morning and evening administration was shown to be equally effective for the different spirometry variables, evening PEF, symptoms, use of rescue medication and number of asthma exacerbations. Regarding morning PEF, the improvements after evening dosing were more prominent and equivalence of morning and evening administration could not be demonstrated. No relevant influence on cortisol excretion was found. Overall, the study indicates that ciclesonide can be given either in the morning or in the evening to meet the patients' preference and individual medical needs, although evening administration may lead to a more pronounced improvement in morning peak expiratory flow.
Collapse
Affiliation(s)
- D S Postma
- Dept of Pulmonology, University Hospital, Groningen, The Netherlands
| | | | | | | | | | | |
Collapse
|
18
|
Nelson HS. Corticosteroid dosing and asthma control. Ann Allergy Asthma Immunol 2001; 86:599-602. [PMID: 11428731 DOI: 10.1016/s1081-1206(10)62285-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
19
|
LaForce CF, Pearlman DS, Ruff ME, Silvers WS, Weinstein SW, Clements DS, Brown A, Duke S, Harding SM, House KW. Efficacy and safety of dry powder fluticasone propionate in children with persistent asthma. Ann Allergy Asthma Immunol 2000; 85:407-15. [PMID: 11101186 DOI: 10.1016/s1081-1206(10)62556-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Flovent Diskus is a powder formulation of the inhaled corticosteroid fluticasone propionate (FP) delivered via a breath-actuated, multidose inhaler. OBJECTIVE To determine the efficacy and safety of dry powder FP administered once or twice daily (200 microg per day) to children with persistent asthma. METHODS Twelve-week, randomized, double-blind, placebo-controlled, multicenter trial with a 52-week, open-label extension. Children aged 4 to 11 were required to have pulmonary function 50% to 85% of predicted values. The population was stratified for baseline therapy (inhaled corticosteroid/cromolyn or bronchodilators only). After a 2-week placebo run-in, 242 patients received dry powder FP 200 microg each morning, dry powder FP 100 microg BID, or placebo for 12 weeks; 192 were rerandomized to the QD or BID regimen for an additional 52 weeks of open-label treatment. Primary endpoints were mean changes in FEV1 and morning PEF recorded at clinic visits. RESULTS Both dry powder FP regimens significantly improved FEV1, evening PEF, and asthma symptoms at the double-blind phase endpoint (P < or = .017 compared with placebo). The BID regimen also significantly improved morning PEF and nighttime awakenings due to asthma (P < or = .005). Among patients previously treated with inhaled corticosteroids/cromolyn, improvements observed with the QD and BID regimens were similar. Patients switched from BID to open-label QD treatment showed additional improvements at week 52 generally comparable to patients who received the BID regimen during both phases. Fluticasone propionate was well tolerated for up to 64 weeks with few reports of drug-related adverse events or morning plasma cortisol abnormalities. CONCLUSIONS Once daily dosing of dry powder FP 200 microg is an effective and convenient alternative for children whose asthma is controlled with a more frequent dosing regimen of inhaled corticosteroids.
Collapse
Affiliation(s)
- C F LaForce
- North Carolina Clinical Research, Raleigh 27607, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
ZuWallack R, Adelglass J, Clifford DP, Duke SP, Wire PD, Faris M, Harding SM. Long-term efficacy and safety of fluticasone propionate powder administered once or twice daily via inhaler to patients with moderate asthma. Chest 2000; 118:303-12. [PMID: 10936117 DOI: 10.1378/chest.118.2.303] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of fluticasone propionate administered as a once-daily or twice-daily regimen over a period of 1 year to patients with moderate asthma. DESIGN Double-blind, randomized, parallel group, and placebo-controlled phase (12 weeks) and an open-label phase (54 weeks). SETTING Multicenter study in an outpatient setting. PARTICIPANTS Patients (n = 253; age, > or = 12 years) with a mean FEV(1) of 67% predicted normal were stratified according to baseline therapy of maintenance inhaled corticosteroids vs beta(2)-agonists alone. MEASUREMENTS AND INTERVENTIONS Fluticasone propionate (250 microg bid or 500 microg qd) or placebo (bid) was administered via the Diskus multidose powder inhaler (Glaxo Wellcome; Research Triangle Park, NC) for 12 weeks. During open-label treatment, patients were re-randomized to once-daily or twice-daily fluticasone propionate. RESULTS Compared to placebo, fluticasone propionate administered qd or bid significantly improved FEV(1) (p < 0.001), morning (p < 0.001) and evening peak expiratory flow (PEF; p < 0.001), asthma symptom scores (p < or = 0.001), and albuterol use (p </= 0.001), and decreased nighttime awakenings. By the end of 12 weeks, withdrawal due to lack of efficacy was significantly higher in the placebo group than in the once-daily (p = 0.001) or twice-daily (p < 0.001) groups. When comparing the two active dosing regimens, significant differences in favor of twice-daily dosing were noted in FEV(1), albuterol use, and withdrawal due to lack of efficacy. During 54 weeks of open-label treatment, FEV(1) and PEF continued to improve with both regimens, and improvements seen in the first 12 weeks were maintained in patients who switched from twice-daily to once-daily dosing. Fluticasone propionate treatment over a 54-week period was well tolerated, with few drug-related adverse events, which were primarily topical effects of inhaled corticosteroids. CONCLUSIONS Fluticasone propionate powder improved lung function when administered either qd or bid over a 1-year period to patients with moderate asthma, with twice-daily dosing demonstrating significantly greater improvement in some efficacy parameters than once-daily dosing over the first 12 weeks of treatment. Fluticasone propionate treatment was not associated with significant systemic effects.
Collapse
Affiliation(s)
- R ZuWallack
- Saint Francis Hospital & Medical Center, Hartford, CT 06105, USA
| | | | | | | | | | | | | |
Collapse
|
21
|
Campbell LM. Once-daily inhaled corticosteroids in mild to moderate asthma: improving acceptance of treatment. Drugs 2000; 58 Suppl 4:25-33; discussion 52. [PMID: 10711856 DOI: 10.2165/00003495-199958004-00004] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Despite the established efficacy of inhaled corticosteroids in improving lung function in asthma, there has not been a corresponding improvement in morbidity and mortality associated with the disease, which, in part, may result from non-compliance with the prescribed regimen. The reasons for this are many and varied, but an important measure in improving the level of compliance in asthma patients is simplification of the treatment regimen, which may be achieved by reducing the dose frequency and improving the ease of administration. In clinical trials designed to determine whether a reduction in dose frequency to once daily is associated with similar efficacy to that with more frequent administration, a number of studies have shown that once-daily administration of inhaled corticosteroids in both adults and children is as effective in controlling asthma as twice-daily administration of the same dosage, both when given as initial therapy in corticosteroid-naïve patients and in patients already receiving an inhaled corticosteroid. The drug for which most evidence to support a dosage change from twice-daily to once-daily therapy currently exists is budesonide, though limited evidence with other inhaled corticosteroids such as beclomethasone dipropionate, fluticasone propionate and flunisolide also supports once-daily use. Despite the larger single dosage with once-daily budesonide therapy, there has been no evidence in clinical trials of a greater incidence of local adverse effects such as hoarseness, throat irritation or oropharyngeal candidosis, and no evidence of adrenal suppression or growth retardation. Since compliance is an important factor that can affect the success or failure of asthma therapy, a reduction in the frequency of administration to once daily offers the potential advantage of improved compliance with treatment and hence better control of asthma. In the short term clinical trials conducted to date, patient preferences have favoured the once-daily regimen over twice-daily administration. When combined with other (e.g. educational) measures to improve patient compliance, a switch from twice-daily (or more frequent) administration to once-daily inhaled corticosteroid therapy seems likely to be beneficial in improving the long term outcome of treatment.
Collapse
Affiliation(s)
- L M Campbell
- Southbank Surgery, Kirkintilloch, Glasgow, Scotland
| |
Collapse
|
22
|
Möller C. Once-daily inhaled corticosteroids in children with asthma: dry powder inhalers. Drugs 2000; 58 Suppl 4:35-41; discussion 52-3. [PMID: 10711857 DOI: 10.2165/00003495-199958004-00005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The cornerstone of pharmacological management of asthma in childhood is inhaled corticosteroids. These drugs are intended for long term treatment and, consequently, compliance is a major issue. Once-daily administration of maintenance medication would simplify treatment and it is likely that it would lead to better compliance. Moreover, the excellent safety profile of inhaled corticosteroid treatment tailored to disease severity may, theoretically, be further improved with once-daily administration. Studies comparing inhaled corticosteroids given once or twice daily to patients with asthma indicate that unstable asthma is best treated with at least 2 daily doses. On the other hand, it has been demonstrated that, if the asthma is stabilised, most children can be treated with inhaled corticosteroids once daily without loss of efficacy. Thus, the data suggest that newly diagnosed asthma, or asthma after deterioration, should first be reliably controlled with inhaled corticosteroids divided into at least 2 daily doses. Once-daily maintenance treatment should then be tried with the aim of improving compliance and quality of life. A dry powder inhalation device is probably the best choice for children from the age of 5 years.
Collapse
Affiliation(s)
- C Möller
- Department of Pediatrics, Umeå University, Sweden.
| |
Collapse
|
23
|
Bielory L, Picone F, Rabinowitz P, Rossoff L, Winder J, Incaudo G, Wu J, Newman K. Multicentre, Randomised, Parallel-Group Study of the Efficacy and Tolerability of Flunisolide Administered Once Daily via AeroChamber?? in the Treatment of Mild to Moderate Asthma. Clin Drug Investig 2000. [DOI: 10.2165/00044011-200019020-00002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
24
|
Leflein J. Once-daily use of inhaled corticosteroids: A new regimen in the treatment of persistent asthma. Allergol Int 2000. [DOI: 10.1046/j.1440-1592.2000.00153.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
25
|
Abstract
Asthma is an inflammatory condition of the airways. First-line therapy involves the use of inhaled corticosteroids as anti-inflammatory agents to control the underlying process. Bronchodilators are used for symptom relief. Short-acting beta-agonists provide rapid relief of bronchoconstriction, whereas long-acting beta-agonists control the symptoms and reduce the frequency of exacerbations when combined with inhaled corticosteroids. Anticholinergic bronchodilators have a minor role in acute exacerbations and in patients troubled by adverse effects from beta-agonists. Theophylline has a bronchodilator action in asthma, but its role as an anti-inflammatory agent needs to be examined further. Because of their toxicity, corticosteroid-sparing agents have a limited role, being restricted to patients with severe uncontrolled asthma. New selective phosphodiesterase IV inhibitors show both anti-inflammatory and bronchodilator characteristics with fewer adverse effects. Other new approaches to the control of inflammation come from the antileukotriene drugs, which improve pulmonary function in patients with chronic asthma. The antileukotrienes have shown promising results, especially in the treatment of asthma caused by aspirin (acetylsalicylic acid), exercise and cold air. Other new therapies being studied include anti-immunoglobulin E, antitryptase and anti-CD4 agents. These newer possibilities suggest that the range of available treatment options will expand significantly over the next decade.
Collapse
Affiliation(s)
- A Tavakkoli
- Respiratory Medicine, Guy's Hospital, London, England
| | | |
Collapse
|
26
|
Giorgi PL, Oggiano N, Kantar A, Coppa GV, Ricciotti R, Arena F, Bernardi F, Colombo ML, Fano M, D'arcais AF, Guarnaccia S, La Rosa M, Marcucci F, Panasci G, Sensi L, Spinello M, Biraghi M. Bone metabolism in children with asthma treated with nebulized flunisolide: a multicenter italian study. Curr Ther Res Clin Exp 1998. [DOI: 10.1016/s0011-393x(98)85055-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
|
27
|
|