Efficacy and safety of budesonide inhalation suspension (Pulmicort Respules) in young children with inhaled steroid-dependent, persistent asthma

The safety of long-term use of inhaled corticosteroids in patients with asthma: A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was performed to determine the safety of long-term use of ICS in patients with asthma.

METHODS

A systematic search was made of PubMed, Embase, Web of Science, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of asthma with ICS, compared with non-ICS treatment (placebo or other active drugs), were reviewed.

RESULTS

Eighty-six RCTs (enrolling 51,538 participants) met the inclusion criteria. Oral or oropharyngeal candidiasis (RR 2.58, 95% CI 2.00 to 3.33), and dysphonia/hoarseness (RR 1.56, 95% CI 1.31 to 1.85) were less frequent in the control group. There was no statistically significant difference in the risk of upper respiratory tract infection, lower respiratory tract infection, influenza, decline in bone mineral density, and fractures between the two groups.

CONCLUSION

In addition to the mild local adverse events, the long-term use of ICS was safe in patients with asthma.

The possibility of short-term hypothalamic-pituitary-adrenal axis suppression with high-volume, high-dose nasal mometasone irrigation in postsurgical patients with chronic rhinosinusitis

BACKGROUND

Medically refractory chronic rhinosinusitis (CRS) is often treated with functional endoscopic sinus surgery (FESS) and high-volume steroid nasal irrigation. While budesonide is the most common steroid irrigation for this indication, mometasone has a superior pharmacokinetic profile, which may allow dose escalation. The safety and efficacy of mometasone at higher concentrations than previously used in treating CRS have not been explored.

METHODS

Patients were recruited from a tertiary level clinic between June 2018 and December 2019. Inclusion criteria included adults (>18 years); CRS diagnosis; previous FESS; pre-treatment morning cortisol within normal range; minimum of twice daily high-volume sinonasal mometasone irrigations (total dose of 4 mg) for 12 weeks; and post-treatment morning cortisol measured within 2 weeks following the study period. Patients with potential for endogenous or exogenous disruption of the HPA axis were excluded.

RESULTS

14 patients were enrolled in this prospective cohort study. In all but one patient, pre- and post-treatment morning cortisol levels were not significantly different and were within normal limits (6.7-25.4 μg/dL). Following an uninterrupted 12-week treatment course, no evidence of HPA axis suppression was found (P = 0.915). The single patient who was found to have a low (1.3 μg/dL) post-treatment morning serum cortisol level reportedly received an intraarticular steroid shot several days prior to the blood draw. She remained asymptomatic and her rechecked serum cortisol was within normal limits at 12.3 μg/dL.

CONCLUSIONS

High-volume 2 mg twice daily sinonasal mometasone irrigations did not cause HPA axis suppression in a representative sample of patients with refractory CRS post-FESS with normal baseline cortisol levels.

Cost-effectiveness analysis of double low-dose budesonide and low-dose budesonide plus montelukast among pediatric patients with persistent asthma receiving Step 3 treatment in China

AIMS

For children aged 1-5 years with persistent asthma, double low-dose inhaled corticosteroids (ICS) are recommended as the preferred Step 3 treatment and low-dose ICS plus leukotriene receptor antagonists (LTRA) as an alternative. Budesonide inhalation suspension (0.5 mg daily) and montelukast (4.0 mg daily) are commonly used low-dose ICS and LTRA, respectively, among children in China. This study compared the cost-effectiveness of double low-dose budesonide vs. low-dose budesonide plus montelukast from a Chinese healthcare payer's perspective.

METHODS

A Markov model was constructed with four health states (i.e. no exacerbation, mild exacerbation, moderate-to-severe exacerbation, and death). Transition probabilities were estimated based on exacerbation rates, case-fatality of hospitalized patients due to exacerbation, and natural mortality. Treatment adherence was considered and assumed to impact both drug costs and exacerbation rates. Costs (in 2019 Chinese Yuan [¥]) included drug costs and exacerbation management costs. Cost inputs and utilities for each health state were obtained from a public database and the literature. In-depth interviews were conducted with a health economics expert to validate the model, and a clinical expert to verify inputs and assumptions related to clinical practice. Costs and quality-adjusted life-years (QALYs) were estimated over a year. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Compared with low-dose budesonide plus montelukast, double low-dose budesonide was associated with lower costs (¥1,534 vs. ¥2,327), fewer exacerbation events (0.43 vs. 1.67) and slightly better QALYs (0.98 vs. 0.97). Sensitivity analyses supported the robustness of the results and the generalizability of findings across geographic regions in China.

CONCLUSION

The cost-effectiveness analysis suggests that double low-dose budesonide is a dominant Step 3 treatment strategy compared with low-dose budesonide plus montelukast for patients aged 1-5 years with persistent asthma in China.

Role of Inhaled Corticosteroids for Asthma Exacerbation in Children: An Updated Meta-Analysis

Background:

Several studies showed that inhaled corticosteroids (ICS) may be a potential treatment in acute asthma exacerbation in children. This study was an update meta-analysis on the roles of ICS in the management of acute asthma exacerbation in children presenting to the hospital.

Materials and Methods:

Published articles with key words of ICS for asthma exacerbation, asthma attacks, and acute asthma in children aged under 18 years in the hospital setting with outcome of hospital admission between 2009 and 2018 were enrolled. The databases used in this study were Medline, Scopus, and Web of Science. Odds ratio of comparison between ICS and other treatments on hospital admissions was calculated.

Results:

There were 311 eligible studies met the searching criteria; seven eligible studies for the analysis; comprised of three meta-analysis and four added studies. The ICS had a significant reduction in hospital admission compared with placebo in overall with odds ratio of 0.63 (95% confidence interval [CI]: 0.41–0.96) and in moderate-to-severe group with odds ratio of 0.17 (95% CI: 0.05–0.51). Comparing with systemic corticosteroid (SC), ICS had significantly lower hospital admissions overall and in mild-to-moderate group with odds ratios of 0.63 and 0.26, respectively. The combination of ICS and SC had odds ratio of 0.75 (95% CI: 0.57–0.99) over SC in moderate-to-severe asthma exacerbation.

Conclusions:

ICS significantly reduced hospital admission in asthma exacerbation in children. It may be used alone for mild-to-moderate asthma exacerbation and combination with SC for moderate-to-severe asthma exacerbation.

Benefit:Risk Profile of Budesonide in Obstructive Airways Disease

Airway inflammation is a major contributing factor in both asthma and chronic obstructive pulmonary disease (COPD) and represents an important target for treatment. Inhaled corticosteroids (ICS) as monotherapy or in combination therapy with long-acting β₂-agonists or long-acting muscarinic antagonists are used extensively in the treatment of asthma and COPD. The development of ICS for their anti-inflammatory properties progressed through efforts to increase topical potency and minimise systemic potency and through advances in inhaled delivery technology. Budesonide is a potent, non-halogenated ICS that was developed in the early 1970s and is now one of the most widely used lung medicines worldwide. Inhaled budesonide's physiochemical and pharmacokinetic/pharmacodynamic properties allow it to reach a rapid and high airway efficacy due to its more balanced relationship between water solubility and lipophilicity. When absorbed from the airways and lung tissue, its moderate lipophilicity shortens systemic exposure, and its unique property of intracellular esterification acts like a sustained release mechanism within airway tissues, contributing to its airway selectivity and a low risk of adverse events. There is a large volume of clinical evidence supporting the efficacy and safety of budesonide, both alone and in combination with the fast- and long-acting β₂-agonist formoterol, as maintenance therapy in patients with asthma and with COPD. The combination of budesonide/formoterol can also be used as an as-needed reliever with anti-inflammatory properties, with or without regular maintenance for asthma, a novel approach that is already approved by some country-specific regulatory authorities and currently recommended in the Global Initiative for Asthma (GINA) guidelines. Budesonide remains one of the most well-established and versatile of the inhaled anti-inflammatory drugs. This narrative review provides a clinical reappraisal of the benefit:risk profile of budesonide in the management of asthma and COPD.

Efficacy and safety of inhalation budesonide in the treatment of pediatric asthma in the emergency department: a systematic review and meta-analysis

BACKGROUND

This study was aimed to evaluate the beneficial role of inhalation budesonide(BUD) in improving the pulmonary functions, and reducing the hospital admission rate, worsening of asthma and commonly encountered adverse events in pediatric asthma.

METHODS

The electronic search was performed using PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases to identify the randomized control trials(RCTs).

RESULTS

21 RCTs involving 12,787 subjects were included. The meta-analysis revealed that the BUD has reduced the hospitalization rate (Mantel-Haenszel (M-H), random effects odd ratio (RE-OR) of 0.34, p = 0.003, I² = 75%), and worsening of asthma (M-H, RE-OR 0.38, p = 0.001, I² = 73%); significantly improved the pulmonary functions such as FEV1 (Inverse variance (IV): 1.05, p < 0.0001, I² = 94%), PEFR (IV: 1.40, p < 0.0001, I² = 87%), morning PEF (IV: 1.04, p < 0.0001, I² = 91%), and evening PEF (IV: 1.29, p < 0.0001, I² = 92%) compared to control. Further, the incidences of adverse events like Pharyngitis (M-H, RE-OR 0.88, at 95% CI, p = 0.69, I² = 0%), Sinusitis (M-H, RE-OR 0.78, p = 0.79, I² = 0%), Respiratory infections (M-H, RE-OR 0.96, p = 0.46, I² = 0%), Otitis media (M-H, RE-OR 0.82, p = 0.32, I² = 12%) and Fever (M-H, RE-OR 0.78, p = 0.64, I² = 0%) were almost same between BUD and control.

CONCLUSION

The outcomes of the meta-analysis suggest that high-dose inhalation BUD could benefit the pediatric patients in minimizing the worsening of asthma and hospitalization rate, along with improving the pulmonary functions, with negligible adverse drug reactions.

Nebulized Inhaled Corticosteroids in Asthma Treatment in Children 5 Years or Younger: A Systematic Review and Global Expert Analysis

Although nebulized corticosteroids (NebCSs) are a key treatment option for young children with asthma or viral-induced wheezing (VIW), there are no uniform recommendations on their best use. This systematic review aimed to clarify the role of NebCSs in children 5 years or younger for the management of acute asthma exacerbations, asthma maintenance therapy, and the treatment of VIW. Electronic databases were used to identify relevant English language articles with no date restrictions. Studies reporting efficacy data in children 5 years or younger, with a double-blind, placebo- or open-controlled, randomized design, and inclusion of 40 or more participants (no lower patient limit for VIW) were included. Ten articles on asthma exacerbation, 9 on asthma maintenance, and 7 on VIW were identified. Results showed NebCSs to be at least as efficacious as oral corticosteroids in the emergency room for the management of mild to moderate asthma exacerbations. In asthma maintenance, nebulized budesonide, the agent of focus in all trials analyzed, significantly reduced the risk of further asthma exacerbations compared with placebo, cromolyn sodium, and montelukast. Intermittent NebCS treatment of VIW was as effective as continuous daily treatment. In summary, NebCSs are effective and well tolerated in patients 5 years or younger for the management of acute and chronic asthma.

Management of Asthma in the Preschool Child

The management of asthma in the preschool population is challenging because disease phenotypes are heterogeneous and evolving. Available therapies aimed at preventing persistent symptoms and recurrent exacerbations include inhaled corticosteroids and leukotriene receptor antagonists; episodic use of inhaled corticosteroids and azithromycin may result in a decrease in exacerbations among children with intermittent disease. This article reviews an approach using patient characteristics for selecting initial treatment approaches based on disease phenotype, such as symptom patterns or evidence of atopic markers. Evidence for and against the use of oral corticosteroids during acute episodes and barriers to adherence and effective treatment are discussed.

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

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

Pivotal efficacy trials of inhaled corticosteroids in asthma

BACKGROUND

Inhaled corticosteroids (ICSs) are the mainstay of daily controller treatment for persistent and uncontrolled asthma. However, many clinicians are wary of ICSs because of safety concerns. Clinicians need to know the underlying efficacy data that support the use of ICSs to weigh efficacy against safety.

OBJECTIVE

To discuss efficacy data from pivotal trials to aid clinicians in their decisions to use ICSs.

METHODS

Key efficacy studies were selected to augment discussion.

RESULTS

Clinical studies have revealed that ICSs are effective in reducing the risk of exacerbations in both children and adults. ICSs also reduce the risk of hospitalization and asthma-related death, improve asthma symptoms, and improve quality of life. In addition, ICSs improve lung function and airway responsiveness and reduce airway inflammation and remodeling. In young children, ICSs improve daytime and nighttime symptoms, improve lung function, reduce the risk of exacerbations, and reduce the need for rescue medications. To date, evidence is conflicting about whether intermittent ICS treatment is as effective as daily ICS treatment. The possibility of lower efficacy of intermittent therapy needs to be weighed against a reduced risk of slowed growth in children.

CONCLUSION

ICSs effectively reduce the risk of exacerbations, hospitalizations, and asthma-related death and improve asthma symptoms, quality of life, lung function, and airway responsiveness. ICSs also reduce airway inflammation and remodeling. Intermittent therapy may not be as effective as daily therapy, and clinicians should weigh reduced efficacy against reduced risk of adverse effects, particularly slowed growth in children.

Real-life effectiveness and safety of the inhalation suspension budesonide comparator vs the originator product for the treatment of patients with asthma: a historical cohort study using a US health claims database

Objective

The objective of this study was to determine whether the effectiveness of budesonide comparator is non-inferior to budesonide reference in the prevention of asthma exacerbations. Asthma-related hospitalizations and safety were also examined.

Methods

This study used a matched, historic cohort design. Data were drawn from the Clinformatics™ Data Mart US claims database and included a 1-year baseline, starting 1 year before the index prescription date, and a 1-year outcome period. Patients received budesonide comparator or reference treatment. The primary outcome was the rate of asthma exacerbations. Non-inferiority for budesonide comparator vs budesonide reference was established if the 95% confidence interval (CI) upper limit of mean difference in proportions between treatments was <15%. Secondary outcomes examined rate of asthma-related hospitalizations and adverse events (AEs).

Results

The budesonide comparator and reference-matched cohorts each included 3109 patients. The adjusted upper 95% CI for the difference in proportions of patients experiencing asthma exacerbations was 0.035 (3.5%), demonstrating non-inferiority. Cohorts did not significantly differ in the rate of asthma exacerbations (adjusted rate ratio [RR]=1.04, 95% CI: 0.95–1.14) or rate of asthma-related hospitalizations (adjusted RR=1.10, 95% CI: 0.99–1.24) after adjusting for baseline confounders. No asthma exacerbations occurred during the outcome period in 72.9% of budesonide comparator patients and 71.8% of budesonide reference patients. No asthma-related hospitalizations occurred in 77.9% of patients in the budesonide comparator cohort and 79.0% of patients in the budesonide reference cohort. The most frequent AEs were throat irritation (≤0.4% of patients) and hoarseness/dysphonia (0.02% of patients). AEs did not significantly differ between treatment cohorts.

Conclusion

In this real-life study, non-inferiority of the budesonide comparator vs reference was met for the primary end point of asthma exacerbation rates. Asthma-related hospitalization and AE rates did not differ between the two treatment cohorts. The budesonide comparator is an effective and safe treatment alternative for asthma exacerbations.

Inhaled Corticosteroids and Respiratory Infections in Children With Asthma: A Meta-analysis

CONTEXT

Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in adult patients with chronic obstructive pulmonary disease.

OBJECTIVE

To assess the association between ICS use and risk of pneumonia and other respiratory infections in children with asthma.

DATA SOURCES

We searched PubMed from inception until May 2015. We also searched clinicaltrials.gov and databases of pharmaceutical manufacturers.

STUDY SELECTION

We selected randomized trials that compared ICS with placebo for at least 4 weeks in children with asthma.

DATA EXTRACTION

We included 39 trials, of which 31 trials with 11 615 patients contributed data to meta-analyses.

RESULTS

The incidence of pneumonia was 0.58% (44/7465) in the ICS group and 1.51% (63/4150) in the placebo group. The meta-analysis of 9 trials that revealed at least 1 event of pneumonia revealed a reduced risk of pneumonia in patients taking ICS (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.44 to 0.94). Using risk difference as effect measure, the meta-analysis including all 31 trials revealed no significant difference in the risk of pneumonia between the ICS and placebo groups (risk difference: -0.1%; 95% CI: -0.3% to 0.2%). No significant association was found between ICS and risk of pharyngitis (RR: 1.01; 95% CI: 0.87 to 1.18), otitis media (RR: 1.07; 95% CI: 0.83 to 1.37), and sinusitis (RR: 0.89; 95% CI: 0.76 to 1.05).

LIMITATIONS

Lack of clearly defined criteria for respiratory infections and possible publication bias.

CONCLUSIONS

Regular use of ICS may not increase the risk of pneumonia or other respiratory infections in children with asthma.

Early treatment in preschool children: an evidence-based approach

PURPOSE OF REVIEW

Wheezing is a common symptom in early childhood but only some of these children will experience continued wheezing symptoms in later childhood making the diagnosis and treatment of these children challenging. This review covers recent findings regarding the epidemiology, diagnosis, evaluation, and treatment of preschool-aged children with asthma.

RECENT FINDINGS

Key characteristics that distinguish the childhood asthma-predictive phenotype include male sex, history of wheezing with lower respiratory tract infections, history of parental asthma, history of atopic dermatitis, eosinophilia, early sensitization to food or aeroallergens, or lower lung function in early life. The preschool-aged asthma population tends to be characterized as exacerbation prone with relatively limited impairment. The diagnosis of asthma in preschool-aged children is often based on symptom patterns, presence of risk factors, and therapeutic responses. Asthma management includes intermittent and daily inhaled corticosteroids, daily leukotriene-receptor antagonists, and, in rare cases, combination therapies.

SUMMARY

The diagnosis of asthma in preschool-aged children is based on symptom patterns and the presence of risk factors, and the goals of asthma management are achieved through a partnership between the family and the healthcare team using regular assessment of symptom control and response to daily controller therapy.

Ethnic differences in adverse drug reactions to asthma medications: a systematic review

BACKGROUND

Information on ethnic diversity of adverse drug reactions (ADRs) to asthma medications is rare despite evidence suggesting higher risk for African Americans when using β2-adrenergic receptor agonists. The objectives are to investigate how ethnic background was involved in ADR assessment and to examine the relationship between ethnic background and ADRs to asthma medications.

METHODS

MEDLINE was searched until March 2014. All types of studies reporting ADRs to asthma medications involving more than one ethnic group were included. Extracted information includes study designs, ethnic backgrounds, intervention, and types and severities of ADRs.

RESULTS

Among the selected 15 randomised clinical trials, six pooled analyses of randomized clinical trials, and five prospective observational studies, only six studies compared ADRs across different ethnic groups. The majority of the comparisons were either statistically insignificant or inconclusive.

CONCLUSIONS

Ethnicity was largely overlooked. Most studies neglected to report ADRs by ethnicity. Lack of consistency in defining ethnicities complicated further pooled analyses. Despite the higher prevalence of asthma among specific ethnic minority groups, few studies disaggregated information by ethnic background, and reports of ADRs to asthma medications in different ethnic groups were rare. We suggest that the inclusion of ADR analysis by different ethnic backgrounds is desirable.

Budesonide inhalation suspension versus methylprednisolone for treatment of moderate bronchial asthma attacks

Background

Owing to their side effects, administration of steroids for bronchial asthma attacks should be minimized. We investigated whether budesonide inhalation suspension (BIS) could replace intravenous steroid administration for the treatment of moderate bronchial asthma attacks.

Subjects and Methods

The subjects were children aged 5 years and younger hospitalized for moderate bronchial asthma attacks. Patients were randomly assigned to one of two groups: 20 patients received methylprednisolone (mPSL) and 20 were treated with BIS. The mPSL group began treatment with inhalation of procaterol hydrochloride (0.3 mL) and disodium cromoglycate (2 mL) three times a day and systemic administration of mPSL (1 mg/kg) three times a day. The BIS group began treatment with inhalation of procaterol hydrochloride (0.3 mL) and BIS (0.5 mg) three times a day. The frequency of inhalations and steroid administration was adjusted according to the severity of symptoms. The cortisol level at discharge was measured.

Results

There were no significant differences between the two groups in terms of the severity of attacks and duration of management, or in terms of therapeutic efficacy, duration of wheezing, or period of hospitalization. The frequency of inhalations on days 3 to 6 of hospitalization was lower in the BIS group than in the mPSL group, and the cortisol level at discharge was significantly higher in the BIS group (13.9 ± 6.1 μg/dL) than in the mPSL group (8.0 ± 2.1 μg/dL) (p = 0.008).

Conclusion

In patients with recurrent wheezing or bronchial asthma of <5 years, the efficacy of BIS is equivalent or better than mPSL for moderate bronchial asthma attacks, and in contrast to steroid treatment, BIS treatment do not suppress adrenocortical function.

Aerosol characteristics of admixture of budesonide inhalation suspension with a beta2-agonist, procaterol

BACKGROUND

Nebulized drugs for asthma treatment are often mixed together in order to simplify inhalation regimens, although not recommended. We therefore evaluated aerosol characteristics and physicochemical stability of the admixture of an inhaled corticosteroid suspension with a beta2-agonist solution.

METHODS

An 8-stage cascade impactor was used to measure the particle size distribution of admixture of Pulmicort® Respules® (budesonide, 0.5mg/2mL) with Meptin® Inhalation Solution Unit (procaterol hydrochloride, 30μg/0.3mL) from a jet nebulizer, PARI LC Plus®. Concentration of each drug was assayed with high-pressure liquid chromatography. Physicochemical compatibility was also assessed up to 24 hours after mixing.

RESULTS

With regard to budesonide, impactor parameters such as mass median aerodynamic diameter (MMAD) and respirable mass (RM) were comparable between admixtures and single-drug preparations (2.92 ± 0.03 vs 2.99 ± 0.14μm, 146.8 ± 2.9 vs 147.6 ± 8.2μg, respectively). On the other hand, delivery rates of procaterol increased when admixed with budesonide suspension, resulting in significantly higher RM (15.1 ± 0.8 vs 10.2 ± 0.5μg, p < 0.01). Variations from initial concentration in the percentages of drug remaining at any time point were less than 10%, and there were no appreciable changes in pH of the admixtures for up to 24 hours.

CONCLUSIONS

There is a possibility that admixture might influence of aerodynamic characteristics of procaterol, but not budesonide. In vivo data will be needed for the clinical implications of our findings.

Efficacy and safety of fluticasone/formoterol combination therapy in patients with moderate-to-severe asthma

BACKGROUND

The inhaled corticosteroid, fluticasone propionate, and the long-acting β(2)-adrenergic agonist, formoterol fumarate, are both highly effective treatments for bronchial asthma. This study (NCT00393952/EudraCT number: 2006-005989-39) compared the efficacy and safety of fluticasone/formoterol combination therapy (flutiform(®); 250/10 μg) administered twice daily (b.i.d.) via a single aerosol inhaler, with the individual components (fluticasone 250 μg b.i.d.; formoterol 10 μg b.i.d.), in adult and adolescent patients with moderate-to-severe asthma.

METHODS

This was a 12-week, double-blind, randomised, parallel-group, multicentre, placebocontrolled phase 3 study. The co-primary efficacy endpoints were: i) the mean change in the forced expiratory volume in the first second (FEV(1)) from morning pre-dose at baseline to pre-dose at week 12 (fluticasone/formoterol 250/10 μg vs. formoterol), ii) the mean change in FEV(1) from morning pre-dose at baseline to 2 h post-dose at week 12 (fluticasone/formoterol 250/10 μg vs. fluticasone), and iii) the number of patients who discontinued prematurely due to lack of treatment efficacy (fluticasone/formoterol 250/10 μg vs. placebo). The secondary endpoints included measures of lung function, disease control, and asthma symptoms. Safety was assessed based on adverse events, vital signs, and clinical laboratory evaluations.

RESULTS

Overall, 395 (70.9%) patients completed the study. Fluticasone/formoterol 250/10 μg b.i.d. was superior to the individual components and placebo for all three co-primary endpoints and demonstrated numerically greater improvements for multiple secondary efficacy analyses. Fluticasone/formoterol combination therapy had a good safety profile over the 12 weeks.

CONCLUSION

Fluticasone/formoterol combination therapy will provide clinicians with an efficacious alternative treatment option for patients with moderate-to-severe asthma.

Budesonide inhalation suspension versus montelukast in children aged 2 to 4 years with mild persistent asthma

BACKGROUND

Budesonide inhalation suspension (BIS) and montelukast provide acceptable asthma control, whereas overall measures favored BIS in children aged 2 to 8 years with mild persistent asthma.

OBJECTIVE

We compared BIS and montelukast over a 1-year period in children aged 2 to 4 years with asthma.

METHODS

Data were derived from a 52-week, open-label, randomized, active-controlled, multicenter study (NCT00641472). Children with mild asthma received either BIS 0.5 mg or montelukast 4 to 5 mg once daily. Patients were stepped up to twice-daily BIS or oral corticosteroids for mild or severe asthma worsening, respectively. Primary efficacy assessment was time to first additional asthma medication for exacerbation over 52 weeks.

RESULTS

Two hundred two patients, age 2 to 4 years, received BIS (n = 105) or montelukast (n = 97). No difference was observed between the BIS and montelukast groups in median time to first additional asthma medication over 52 weeks (183 vs 86 days). Statistically significant differences were observed in favor of BIS over montelukast in the percentage of patients requiring oral steroids at 52 weeks (21.9% vs 37.1%; P = .022), the rate (number/patient/year) of additional courses of medication (1.35 vs 2.30; P = .003), the rate of additional oral steroid therapy (0.44 vs 0.88; P = .008), and caregivers' ability to manage the patient's symptoms (P = .026). Both treatments were well tolerated.

CONCLUSION

BIS and montelukast provided acceptable asthma control in children aged 2 to 4 years with mild persistent asthma with no significant difference between treatments in the primary end point; however, several secondary outcomes showed statistically significant differences (and many had numerical differences) in favor of BIS over montelukast.

A systematic review with attempted network meta-analysis of asthma therapy recommended for five to eighteen year olds in GINA steps three and four

Background

The recommendations for the treatment of moderate persistent asthma in the Global Initiative for Asthma (GINA) guidelines for paediatric asthma are mainly based on scientific evidence extrapolated from studies in adults or on consensus. Furthermore, clinical decision-making would benefit from formal ranking of treatments in terms of effectiveness.

Our objective is to assess all randomized trial-based evidence specifically pertaining to 5-18 year olds with moderate persistent asthma. Rank the different drug treatments of GINA guideline steps 3&4 in terms of effectiveness.

Methods

Systematic review with network meta-analysis. After a comprehensive search in Central, Medline, Embase, CINAHL and the WHO search portal two reviewers selected RCTs performed in 4,129 children from 5-18 year old, with moderate persistent asthma comparing any GINA step 3&4 medication options. Further quality was assessed according the Cochrane Collaboration’s tool and data-extracted included papers and built a network of the trials. Attempt at ranking treatments with formal statistical methods employing direct and indirect (e.g. through placebo) connections between all treatments.

Results

8,175 references were screened; 23 randomized trials (RCT), comparing head-to-head (n=17) or against placebo (n=10), met the inclusion criteria. Except for theophylline as add-on therapy in step 4, a closed network allowed all comparisons to be made, either directly or indirectly. Huge variation in, and incomplete reporting of, outcome measurements across RCTs precluded assessment of relative efficacies.

Conclusion

Evidence-based ranking of effectiveness of drug treatments in GINA steps 3&4 is not possible yet. Existing initiatives for harmonization of outcome measurements in asthma trials need urgent implementation.

Daily or intermittent budesonide in preschool children with recurrent wheezing

BACKGROUND

Daily inhaled glucocorticoids are recommended for young children at risk for asthma exacerbations, as indicated by a positive value on the modified asthma predictive index (API) and an exacerbation in the preceding year, but concern remains about daily adherence and effects on growth. We compared daily therapy with intermittent therapy.

METHODS

We studied 278 children between the ages of 12 and 53 months who had positive values on the modified API, recurrent wheezing episodes, and at least one exacerbation in the previous year but a low degree of impairment. Children were randomly assigned to receive a budesonide inhalation suspension for 1 year as either an intermittent high-dose regimen (1 mg twice daily for 7 days, starting early during a predefined respiratory tract illness) or a daily low-dose regimen (0.5 mg nightly) with corresponding placebos. The primary outcome was the frequency of exacerbations requiring oral glucocorticoid therapy.

RESULTS

The daily regimen of budesonide did not differ significantly from the intermittent regimen with respect to the frequency of exacerbations, with a rate per patient-year for the daily regimen of 0.97 (95% confidence interval [CI], 0.76 to 1.22) versus a rate of 0.95 (95% CI, 0.75 to 1.20) for the intermittent regimen (relative rate in the intermittent-regimen group, 0.99; 95% CI, 0.71 to 1.35; P=0.60). There were also no significant between-group differences in several other measures of asthma severity, including the time to the first exacerbation, or adverse events. The mean exposure to budesonide was 104 mg less with the intermittent regimen than with the daily regimen.

CONCLUSIONS

A daily low-dose regimen of budesonide was not superior to an intermittent high-dose regimen in reducing asthma exacerbations. Daily administration led to greater exposure to the drug at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; MIST ClinicalTrials.gov number, NCT00675584.).

Dose response of inhaled corticosteroids in children with persistent asthma: a systematic review

OBJECTIVE

To assess the dose-response relationship (benefits and harms) of inhaled corticosteroids (ICSs) in children with persistent asthma.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared ≥2 doses of ICSs in children aged 3 to 18 years with persistent asthma. Medline was searched for articles published between 1950 and August 2009. Main outcomes of our analyses included morning and evening peak expiratory flow, forced expiratory volume in 1 second, asthma symptom score, β(2)-agonist use, withdrawal because of lack of efficacy, and adverse events. Meta-analyses were performed to compare moderate (300-400 μg/day) with low (≤200 μg/day beclomethasone-equivalent) doses of ICSs.

RESULTS

Fourteen RCTs (5768 asthmatic children) that evaluated 5 ICSs were included. The pooled standardized mean difference from 6 trials revealed a small but statistically significant increase of moderate over low doses in improving forced expiratory volume in 1 second (standardized mean difference: 0.11 [95% confidence interval: 0.01-0.21]) among children with mild-to-moderate asthma. There was no significant difference between 2 doses in terms of other efficacy outcomes. Local adverse events were uncommon, and there was no evidence of dose-response relationship at low-to-moderate doses.

CONCLUSIONS

Compared with low doses, moderate doses of ICSs may not provide clinically relevant therapeutic advantage in children with mild-to-moderate persistent asthma. Additional RCTs are needed to clarify the dose-response relationship of ICSs in persistent childhood asthma.

Five-day course of budesonide inhalation suspension is as effective as oral prednisolone in the treatment of mild to severe acute asthma exacerbations in adults

BACKGROUND

Limited evidence is available on the use of budesonide inhalation suspension (BIS) for the treatment of mild to severe acute asthma exacerbations (AAE) in adults in an inpatient setting. This study was conducted to evaluate the efficacy of a five-day course of BIS compared with oral prednisolone (OP) in the management of adults with AAE.

METHODS

A retrospective study examined the response of 28 patients hospitalized with mild to severe acute asthma exacerbation from January 2003 to December 2003. These patients, who were steroid free ≥ 1 yr, were administered a five-day course of BIS (2 × 2 mg bid) or OP (2 × 15 mg bid). PEF, FEV(1) and asthma symptom scores were recorded daily.

RESULTS

The BIS (n = 13) and OP (n = 15) treatment groups were comparable at baseline for demographic characteristics and prebronchodilator (fenoterol) FEV(1) of 52.4% predicted normal value and 54.6% predicted normal value, respectively. Mean change of morning PEF was 152 L/min during BIS treatment and 130 L/min for OP treatment; the mean changes of morning forced expiratory volumes in 1 s (FEV(1)) were 1.0 and 0.7 L, respectively. The mean change in daytime symptom scores were -1.6 and -1.3 in the BIS and the OP groups, respectively. Improvements in PEF, FEV(1) and daytime symptom scores were significantly different between baseline and after treatment in each treatment group (p < 0.05). However, improvements in both BIS and OP groups were similar.

CONCLUSION

Budesonide inhalation suspension may be an alternative treatment of acute asthma exacerbation in adults who are at risk for systemic corticosteroids.

The transient value of classifying preschool wheeze into episodic viral wheeze and multiple trigger wheeze

BACKGROUND

A recently proposed method for classifying preschool wheeze is to describe it as either episodic (viral) wheeze or multiple trigger wheeze. In research studies, phenotype is generally determined by retrospective questionnaire.

AIM

To determine whether recently proposed phenotypes of preschool wheeze are stable over time.

METHODS

In all, 132 two to six-year-old children with doctor diagnosed asthma on maintenance inhaled corticosteroids were classified as having episodic (viral) wheeze or multiple trigger wheeze at a screening visit and then followed up at three-monthly intervals for a year. At each follow-up visit, standardized questionnaires were used to determine whether the subjects wheezed only with, or also in the absence of colds. Stability of the phenotypes was assessed at the end of the study.

RESULTS

Phenotype as determined by retrospective parental report at the start of the study was not predictive of phenotype during the study year. Phenotypic classification remained the same in 45.9% of children and altered in 54.1% of children.

CONCLUSION

When children with preschool wheeze are classified into episodic (viral) wheeze or multiple trigger wheeze based on retrospective questionnaire, the classification is likely to change significantly within a 1-year period.

Aerosol delivery of nebulised budesonide in young children with asthma

BACKGROUND

Lung deposition of inhaled steroids, likely to be of benefit in the anti-inflammatory treatment of asthma in young children, is low. This is explained by age specific anatomical and physiological characteristics as well as poor cooperation with aerosol therapy. However, total lung deposition and the ratio of lung deposition to oropharyngeal deposition are key determinants of clinical efficacy and of systemic side effects of aerosolized drugs.

OBJECTIVES

The aim of this study was to determine lung deposition and ratio of lung deposition to oropharyngeal deposition using a modified vibrating membrane nebuliser to deliver budesonide with a small particle size, taking into account the needs of young children.

PATIENTS AND METHODS

Ten asthmatic children (5 males), mean age 20.3 months (range 6-41 months) inhaled radiolabelled budesonide (MMD 2.6microm) through a modified vibrating membrane nebuliser (modified PARI e-Flow). Lung deposition expressed as a percentage of the emitted dose was measured using scintigraphy and the ratio of lung deposition to oropharyngeal deposition was calculated.

RESULTS

Mean lung deposition (SD) expressed as percentage of emitted dose and mean lung to oropharyngeal deposition ratio (SD) in quietly breathing children (n=5) and in children crying during inhalation were 48.6% (10.5) versus 20.0% (10.9), and 1.0 (0.3) versus 0.3 (0.2), respectively.

CONCLUSIONS

We have shown that by using an improved age-adjusted complementary combination of delivery device and drug formulation to deliver small particles, lung deposition and ratio of lung deposition to oropharyngeal deposition in young asthmatic children is highly improved. But the main factor limiting aerosol delivery in this age group remains cooperation.

The effect of nasally administered budesonide respules on adrenal cortex function in patients with chronic rhinosinusitis

OBJECTIVES

To evaluate whether nasal administration of budesonide in adults with chronic rhinosinusitis for 30 days suppresses adrenal function and to assess its clinical efficacy.

DESIGN

An open-label prospective study.

SETTING

Academic medical center.

PATIENTS

We assessed adrenal function in 9 patients using the cosyntropin test before and after budesonide therapy.

INTERVENTION

Budesonide respule therapy.

MAIN OUTCOME MEASURE

Scores from the Sino-Nasal Outcome Test-20 (SNOT-20), a tool for assessing rhinosinusitis health and quality of life, were used to assess efficacy of budesonide treatment.

RESULTS

All of our patients showed adequate adrenal response to cosyntropin stimulation before and after the budesonide trial. The mean difference in SNOT-20 scores was -1 (95% confidence interval, -1.77 to -0.23; P = .02), indicating clinically significant improvement after therapy.

CONCLUSION

Our findings suggest that using budesonide nasal wash may be clinically effective in decreasing the symptoms of chronic rhinosinusitis and does so without suppression of the hypothalamic-pituitary-adrenal axis in patients with chronic rhinosinusitis.

Efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing and asthma: a systematic review with meta-analysis

OBJECTIVE

To compare the efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing or asthma.

METHODS

Randomized, prospective, controlled trials published January 1996 to March 2008 with a minimum of 4 weeks of inhaled corticosteroids versus placebo were retrieved through Medline, Embase, and Central databases. The primary outcome was wheezing/asthma exacerbations; secondary outcomes were withdrawal caused by wheezing/asthma exacerbations, changes in symptoms score, pulmonary function (peak expiratory flow and forced expiratory volume in 1 second), or albuterol use.

RESULTS

Of eighty-nine studies identified, 29 (N = 3592 subjects) met the criteria for inclusion. Patients who received inhaled corticosteroids had significantly less wheezing/asthma exacerbations than those on placebo (18.0% vs 32.1%); posthoc subgroup analysis suggests that this effect was higher in those with a diagnosis of asthma than wheeze but was independent of age (infants versus preschoolers), atopic condition, type of inhaled corticosteroid (budesonide metered-dose inhaler versus fluticasone metered-dose inhaler), mode of delivery (metered-dose inhaler versus nebulizer), and study quality (Jadad score: <4 vs >/=4) and duration (<12 vs >/=12 weeks). In addition, children treated with inhaled corticosteroids had significantly fewer withdrawals caused by wheezing/asthma exacerbations, less albuterol use, and more clinical and functional improvement than those on placebo.

CONCLUSIONS

Infants and preschoolers with recurrent wheezing or asthma had less wheezing/asthma exacerbations and improve their symptoms and lung function during treatment with inhaled corticosteroids.

Ciclesonide: a safe and effective inhaled corticosteroid for the treatment of asthma

Ciclesonide is a novel inhaled corticosteroid used in the continuous treatment of mild-to-severe asthma. Its formulation and mechanism of action yield a low oral and systemic bioavailability, and high pulmonary deposition. In multiple clinical trials, ciclesonide is at least as effective as either fluticasone propionate or budesonide at symptom control, while in many cases having improved safety outcomes and tolerability. The improved safety and comparable efficacy profiles of ciclesonide demonstrated in current studies could potentially yield a treatment option that may lead to improved adherence and outcome.

Inhaled corticosteroids and asthma control in children: assessing impairment and risk

OBJECTIVE

To review the use of inhaled corticosteroids on asthma control in children by using the new therapeutic paradigm outlined in the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.

METHODS

A systematic review of the literature was performed by using the Medline and Embase databases (January 1996 to October 2007).

RESULTS

A total of 18 placebo-controlled, clinical trials in >8000 children (aged 0-17 years) with asthma met the criteria for evaluating monotherapy with inhaled corticosteroids: 13 double-blind studies of inhaled corticosteroids versus placebo and 5 controlled studies that compared inhaled corticosteroids to a nonsteroid antiinflammatory agent. The findings can be summarized as follows: (1) Compared with placebo, inhaled corticosteroid treatment was associated with reductions in both the impairment and risk domains. (2) Improvements in impairment and risk observed with inhaled corticosteroids were generally greater than those observed with nonsteroid antiinflammatory comparator medications. (3) Inhaled corticosteroids were well tolerated. (4) Small reductions in growth rates were evident when compared with placebo and/or comparator nonsteroid antiinflammatory medication use in the long-term (>1-year) studies, but when measured, the reductions diminished with time.

CONCLUSIONS

Treatment with inhaled corticosteroids improves the asthma-control domains of impairment and risk in children. Differences in study protocols make detailed comparisons difficult. Specific needs for additional trials include (1) more studies using appropriate indicators for impairment (eg, rescue-medication use; symptoms scores; asthma/episode-free days) and risk (eg, forced expiratory volume in 1 second in children who can perform spirometry; exacerbations requiring oral corticosteroids; urgent care usage) and (2) more studies evaluating adolescents; the majority of the data reported were for children up to the age of 12 years, and data for adolescents are often lost (either grouped with adults [eg, studies in patients > or =12 years old] or not included [eg, studies of school-aged children < or =12 years old]). Attention should be given to standardizing variables that will permit comparison of outcomes between trials.

[Nebulized corticosteroids and pediatricians: results of the NUAGES survey]

INTRODUCTION

The aim of the study was to analyze the data of the NUAGES survey (a survey on the practice of nebulization in France), concerning the prescriptions of nebulized steroids from 514 pediatricians.

MATERIAL AND METHODS

The reason why nebulization was chosen as a delivery route, the diseases motivating the prescription, the age of the patients, the kind of drug used, and the prescription and device modalities were studied.

RESULTS

Efficacy in treating various respiratory diseases was the main reason cited for using nebulization, in particular severe persistent asthma (76%). Pediatricians prescribed nebulization mainly to infants (60%). The most frequently used drug was budesonide suspension (89%), but the intravenous route for steroids (18%) and drug admixtures (62%) were also proposed by nebulization. A specific prescription for the nebulizer was given in 75% of the cases, with the type of interface to use specified in 66%.

DISCUSSION

Pediatricians consider that nebulization is well adapted to young children. Although the proper steroid is usually chosen, unfortunately, it is often prescribed with other drugs, with 1 prescription out of 4 not following the recommendations. Prescription of the device is not optimal and may compromise the efficacy of the treatment.

CONCLUSION

Nebulization is a potential mode of delivery for steroids that is difficult to prescribe and warrants improved pediatrician training.

Comparative study of budesonide inhalation suspension and montelukast in young children with mild persistent asthma

BACKGROUND

Budesonide inhalation suspension and the leukotriene receptor antagonist montelukast have demonstrated efficacy in children with mild persistent asthma, but comparative long-term studies in young children are needed.

OBJECTIVE

To compare the long-term efficacy and safety of budesonide inhalation suspension and montelukast.

METHODS

After a run-in period, children 2 to 8 years old with mild asthma or recurrent wheezing were randomized to once-daily budesonide inhalation suspension 0.5 mg or once-daily oral montelukast 4 or 5 mg for 52 weeks. Subjects were stepped up to twice-daily budesonide inhalation suspension or oral corticosteroids for mild or severe asthma worsening, respectively. The primary outcome was time to first additional medication for asthma worsening at 52 weeks. Secondary variables included times to the first additional asthma medication measured at 12 and 26 weeks; times to the first asthma exacerbation (mild and severe) measured at 12, 26, and 52 weeks; exacerbation rates (mild and severe) over a period of 52 weeks; diary variables (eg, peak expiratory flow [PEF]); patient-reported outcomes; and Global Physician and Caregiver Assessments.

RESULTS

No significant between-group differences were observed for time to first additional asthma medication at 52 weeks; however, time to first additional asthma medication was longer (unadjusted P = .050) at 12 weeks and exacerbation rates were lower over a period of 52 weeks (unadjusted P = .034) for budesonide versus montelukast. Time to first severe exacerbation (requiring oral corticosteroids) was similar in both groups, but the percentage of subjects requiring oral corticosteroids over a period of 52 weeks was lower with budesonide (25.5% vs 32.0%). Peak flow and Caregiver and Physician Global Assessments favored budesonide.

CONCLUSION

Both treatments provided acceptable asthma control; however, overall measures favored budesonide inhalation suspension over montelukast.

CLINICAL IMPLICATIONS

These findings are consistent with studies in older children demonstrating better outcomes with inhaled corticosteroids versus montelukast.

A 12-week, multicenter, randomized, partially blinded, active-controlled, parallel-group study of budesonide inhalation suspension in adolescents and adults with moderate to severe persistent asthma previously receiving inhaled corticosteroids with a metered-dose or dry powder inhaler

BACKGROUND

Nebulized budesonide inhalation suspension (BIS) is approved in the United States for children with asthma aged 1 to 8 years.

OBJECTIVE

The primary objective of this study was to compare the efficacy of BIS 0.5 mg QD and 2.0 mg BID in terms of the mean change from baseline to end of treatment in predose forced expiratory volume in 1 second (FEV1).

METHODS

In this 12-week, partially blinded, randomized study, subjects aged >or=12 years with moderate to severe persistent asthma previously receiving inhaled corticosteroids (ICSs) by dry powder inhaler (DPI) or metered-dose inhaler (MDI) continued therapy during a 2- to 3-week run-in period and then switched to BIS 0.5 mg QD, 1.0 mg QD, 1.0 mg BID, or 2.0 mg BID, or budesonide DPI 400 microg BID (active reference arm). Besides FEV1 (the primary variable), other outcome variables included changes in forced vital capacity (FVC) from baseline to weeks 4, 8, and 12 and to the average over the treatment period; as well as changes from baseline to the end of treatment in diary-collected daytime and nighttime asthma symptom scores, rescue medication use, nighttime awakenings due to asthma, morning and evening peak expiratory flow (PEF), percentages of symptom-free and medication-free periods, and the incidence of predefined asthma events. Adverse events were recorded by subjects. Steady-state pharmacokinetics of budesonide were assessed in all treatment arms. Efficacy analyses included data in a modified intent-to-treat approach. Differences in the change from baseline to end of treatment in FEV1 were assessed using analysis of covariance (ANCOVA). For secondary variables, changes from baseline to each visit or to the treatmentperiod average were compared among groups using an ANCOVA model. P <or= 0.05 was considered statistically significant.

RESULTS

The randomized population consisted of 758 subjects: 57 (7.5%) aged 12 to <17 years, 667 (88.0%) aged 17 to <65 years, and 34 (4.5%) aged >or=65 years. There was no significant difference in mean change in predose FEV1 between BIS 0.5 mg QD and BIS 2.0 mg BID (0.02 vs 0.01 L). On average, mean values for the BIS dosage groups did not indicate any deterioration from baseline to the treatment period for variables associated with asthma control such as FEV1, FVC, daytime and nighttime asthma symptom scores, rescue medication use, nighttime awakenings, morning and evening PEF, percentages of symptom-free and rescue medication-free periods, and predefined asthma events. The BIS 1.0-mg BID treatment appeared to be closest to budesonide DPI in plasma budesonide concentrations and improvement in predose FEV1 (0.08 vs 0.12 L). All treatments were well tolerated.

CONCLUSIONS

In this study, no difference in efficacy between BIS 2.0 mg BID and 0.5 mg QD was found in adolescents and adults with persistent asthma when transitioned from ICSs delivered with a DPI or MDI. Subjects taking all BIS dosages experienced similar responses for variables associated with asthma control.

Successful treatment of previously uncontrolled adult asthma with budesonide inhalation suspension: five-year case histories

OBJECTIVE

To determine whether nebulized budesonide inhalation suspension (BIS) is effective in treating adults with asthma that has been uncontrolled by inhaled therapies.

CASE SUMMARIES

Three adults with severe persistent asthma were switched to BIS after poor outcomes with other controller medications, including inhaled corticosteroids (ICSs). BIS dosages were initiated with 1 mg twice daily. Based on physician discretion as symptoms improved, dosages were decreased to 0.5 mg twice daily (2 pts.) or once daily (1 pt.). Patients were instructed to self-manage their asthma, increasing their dosages during periods of asthma worsening. Peak expiratory flow (PEF) was assessed before and after the initiation of BIS. The number of healthcare visits and oral corticosteroid courses recorded in patient medical records during the 3 years before and 5 years after initiation of BIS therapy were compared. In all 3 cases, BIS improved asthma control. BIS consistently increased PEF and reduced the number of urgent care visits and oral corticosteroid courses. All patients reported satisfaction with BIS therapy.

DISCUSSION

Despite proven effectiveness of ICSs for persistent asthma, some patients fail to respond optimally to treatment administered via an inhaler. These 3 case reports suggest that BIS is effective in treating adults with severe persistent asthma who fail to respond optimally to treatment with other ICS preparations. Failure to use inhalers properly, previous poor adherence in 1 case, or patient preference for the nebulizer might explain why nebulized BIS was more effective than other inhaler therapies.

CONCLUSIONS

Switching adults with uncontrolled asthma to BIS therapy may be a valuable treatment option for those who are unable to achieve optimal asthma control, despite asthma education and training on inhaler technique.

Association between common asthma therapies and recurrent asthma exacerbations in children enrolled in a state Medicaid plan

PURPOSE

To evaluate the effectiveness of budesonide inhalation suspension relative to other common asthma therapies in a high-risk population, a study was conducted to compare the risk of having a repeat asthma-related hospitalization or emergency department (ED) visit in a Medicaid population of children; the relationship between asthma medication adherence level and repeat asthma hospitalizations or ED visits was also evaluated.

METHODS

Children eight years of age or younger, with a hospitalization or ED visit for asthma between January 1999 and June 2001 (index event), were identified in a Florida Medicaid database. Claims data for each child were examined 12 months before and after the index event. Cox proportional hazards regression was used to model the risk of subsequent asthma exacerbation according to the asthma medication received during the first 30 days after the index event. Logistic regression was used to model the relationship between medication adherence as measured by the medication possession ratio (MPR) and the likelihood of a subsequent asthma exacerbation.

RESULTS

There were 10,976 children in the study. Patients who had a claim for budesonide inhalation suspension had a lower risk of a subsequent hospitalization or ED visit (hazard ratio, 0.55; 95% confidence interval, 0.41-0.76; p < 0.001) than patients who did not have budesonide inhalation suspension claims. Other controller medications were not associated with a reduction in the risk of subsequent asthma exacerbations. Adherence to medication was poor (a median MPR of 0.08 for budesonide inhalation suspension and a median MPR of 0.16 for any asthma controller medication). The odds of a repeat hospitalization or ED visit were significantly lower for children who were adherent to their asthma controller medication.

CONCLUSION

Children with asthma and insured by Medicaid were at a high risk of repeat exacerbations leading to increased hospitalizations and ED visits. Treatment with budesonide inhalation suspension in the first 30 days after a hospitalization or ED visit for asthma was associated with a significant reduction in the risk of repeat asthma-related hospitalizations or ED visits during the following year. Children who were adherent to their asthma controller medication had significantly lower odds of having a subsequent asthma exacerbation.

Antibody response after varicella vaccination in children treated with budesonide inhalation suspension or non-steroidal conventional asthma therapy

We evaluated if budesonide inhalation suspension (BIS) reduces the immunogenicity of the varicella vaccine in paediatric patients with asthma. This open-label, parallel-group, cohort study included varicella-naïve (disease and vaccine) children aged 12 months to 8 years with asthma requiring therapy. Patients who received > or = 4 weeks of asthma treatment with BIS 0.25-1 mg daily or non-steroidal conventional asthma therapy (NSCAT) daily or as needed and met eligibility requirements received the varicella vaccine (Varivax) and continued the same asthma treatment for > or = 8 weeks postvaccination. Varicella-zoster virus (VZV) antibody levels were assessed before and 6 weeks after vaccination using a glycoprotein enzyme-linked immunosorbent assay (gpELISA). Adverse events (AEs) were assessed throughout the study. Antibody levels were analysed in 243 of 274 patients who were vaccinated and received treatment. After immunisation, the percentage of patients in each group achieving a 'protective' level of VZV antibody (> or = 5 gpELISA units/ml) was similar: 85% (129/151) in the BIS group and 90% (83/92) in the NSCAT group (relative risk = 0.95; 95% confidence interval 0.86-1.04). Eight patients in each group reported AEs related to varicella vaccination (primarily pyrexia, agitation and injection-site reactions). There were no cases of severe varicella in either group; one case of mild varicella-like rash was reported in a 12-month-old child in the NSCAT group 11 days after vaccination. VZV antibody responses and tolerability to the live varicella vaccine in paediatric asthma patients treated with BIS vs. NSCAT were comparable, demonstrating that young children with asthma receiving nebulised BIS can be immunised effectively with Varivax.

Paediatric pulmonary drug delivery: considerations in asthma treatment

Aerosol therapy, the preferred route of administration for glucocorticosteroids and short-acting beta(2)-adrenergic agonists in the treatment of paediatric asthma, may be given via nebulisers, metered-dose inhalers and dry powder inhalers. For glucocorticosteroids, therapy with aerosolised medication results in higher concentrations of drug at the target organ with minimal systemic side effects compared with oral treatments. The dose of drug that reaches the airways in children with asthma is dependent on both the delivery device and patient-related factors. Factors that affect aerosol drug delivery are reviewed briefly. Advantages and disadvantages of each device and device-specific factors that influence patient preferences are examined. Although age-based device recommendations have been made, the optimal choice for drug delivery is the one that the patient or caregiver prefers to use, can use correctly and is most likely to use consistently.

Holding chambers versus nebulisers for inhaled steroids in chronic asthma

BACKGROUND

Inhaled corticosteroids are available in the form of a suspension for nebulisation, although the role of this mode of therapy in the treatment of chronic asthma is still unclear.

OBJECTIVES

To assess the efficacy and safety of inhaled corticosteroids delivered via nebuliser versus holding chamber for the treatment of chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trial Register (1999) and reference lists of articles. We contacted the authors of studies and pharmaceutical companies for additional studies and hand-searched the British Journal of Clinical Research, European Journal of Clinical Research and major respiratory society meeting abstracts (1997-1999). Date of last search August 2005.

SELECTION CRITERIA

Randomised controlled trials comparing nebuliser to holding chamber in the delivery of inhaled corticosteroids for the treatment of chronic asthma. All age groups of patients were considered. Two reviewers assessed articles for inclusion; two reviewers independently assessed included studies for methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data; authors were contacted to clarify missing information. Quantitative analyses were undertaken using Review Manager 4.1 with MetaView 3.1.

MAIN RESULTS

Two studies were selected for inclusion (63 subjects), both concerned adults. An additional small study including 14 children was identified for the 2005 update. Methodological quality was variable. Due to design differences it was not appropriate to pool the studies. The single high quality study compared budesonide 2000-8000 mcg delivered via Pari Inhalier Boy jet nebuliser with inspiration-only inhalation to budesonide 1600 mcg via large volume spacer. The nebuliser delivery led to higher morning peak expiratory flow values (25 L/min p<0.01), higher evening values (30L/min, p<0.01), lower rescue beta2 agonist use and symptom scores compared to the holding chamber delivery.

AUTHORS' CONCLUSIONS

Budesonide in high dose delivered by the particular nebuliser used in the only double-blinded study that could be included in this review was more effective than budesonide 1600 mcg via a large volume spacer. However, it is not clear whether this was an effect of nominal dose delivered or delivery system. Cost, compliance and patient preference are important determinants of clinical effectiveness that still require further assessment. Future studies are needed to evaluate the relative effectiveness of inhaled corticosteroids delivered by different combinations of nebuliser/compressor compared to holding chamber. Moreover, further studies assessing these delivery methods are needed in infants and pre-school children, as these are groups that are likely to be considered for treatment with nebulised corticosteroids.

Budesonide inhalation suspension for the treatment of asthma in infants and children

On the basis of the well recognised role of inflammation in the pathogenesis of asthma, anti-inflammatory therapy, in the form of inhaled corticosteroids, has become the mainstay of treatment in patients with persistent asthma. Budesonide inhalation suspension (BIS) is a nonhalogenated corticosteroid with a high ratio of local anti-inflammatory activity to systemic activity. Furthermore, BIS is approved in >70 countries for the maintenance treatment of bronchial asthma in both paediatric and adult patients (approval is limited to paediatric patients in the US and France).Randomised, double-blind, placebo-controlled trials conducted in >1000 children have demonstrated the efficacy of BIS in children with persistent asthma of varying degrees of severity. In children frequently hospitalised with uncontrolled asthma, initiation of BIS therapy can reduce the need for emergency intervention. Moreover, limited data suggest that BIS is effective for the treatment of acute exacerbations of asthma in children and may reduce the need for short courses of oral corticosteroids.BIS is well tolerated in children, with an adverse event profile similar to that of placebo, and no clinically relevant changes in adrenal function have been demonstrated during the course of short- and long-term (1-year) studies. Small but statistically significant reductions in growth velocity have been demonstrated with BIS over 1 year of treatment. However, available evidence suggests that growth effects are transient in children receiving budesonide and that these children eventually achieve full adult height.

Advances in the management of pediatric asthma: a review of recent FDA drug approvals and label updates

Children have the highest prevalence of asthma of any age group. In the United States during 2001, there were 12.6 million physician and hospital outpatient visits for asthma treatment, of which almost 5 million involved children 18 years and younger. Therapeutic advances in pediatric asthma could improve patient outcomes and potentially reduce the burden on health care systems. Efforts to obtain efficacy and safety data in pediatric populations and develop pediatric formulations of asthma treatments have been encouraged by the FDA and clinicians. This article reviews the newest additions to asthma therapies approved for use in children, including an inhaled corticosteroid, some long-acting beta2-agonists, some leukotriene-receptor blockers, and a single-isomer, short-acting beta2-agonist.

Corticóide inalatório: efeitos no crescimento e na supressão adrenal

Este artigo é uma revisão da literatura médica sobre os corticosteróides inalatórios e seus efeitos no crescimento e na supressão adrenal em crianças e adolescentes. Utilizaram-se o Medline e artigos publicados em jornais científicos nacionais e internacionais, principalmente nos últimos cinco anos, para a revisão da literatura. Há controvérsias acerca dos efeitos colaterais dos corticóides inalatórios. Nos 21 estudos sobre crescimento e uso de corticóides inalatórios, notou-se que houve diferença significativa no primeiro ano (retardo de 1 a 1,5 cm) quando se utilizou principalmente beclometasona e budesonida inalatórias, mas não se verificou diferença na altura final adulta quando estudos de mais longa duração foram conduzidos, fazendo-se relação com a altura dos pais. Entretanto, em dez artigos sobre uso de corticóide inalatório e supressão adrenal, foram relatadas hipoglicemia, parada de ganho de peso e altura, e alterações nos exames de cortisol sérico matinal e urinário de 24 h, principalmente com uso de doses altas de corticóide inalatório. Corticóides inalatórios podem diminuir o crescimento no primeiro ano de uso, mas não a altura final adulta. São necessárias mais pesquisas com longo tempo de acompanhamento de crianças em uso de corticóide inalatório para se avaliar o impacto sobre o crescimento final. Monitorar a altura é uma medida para se avaliar eficácia e segurança no uso de corticóide inalatório em crianças. Exames que avaliam o eixo hipotalâmico pituitário adrenal e a insuficiência adrenal devem ser correlacionados com sintomas clínicos ou efeitos colaterais.

Safety features of budesonide inhalation suspension in the long-term treatment of asthma in young children

Early inhaled corticosteroid treatment improves symptom control and pulmonary function in children with asthma; however, long-term safety data are limited in infants and young children. This study assessed the long-term safety of budesonide inhalation suspension (BIS) in young children with persistent asthma. To continue to provide BIS to children who needed it-prior to US Food and Drug Administration approval-children 8 years of age or younger with mild, moderate, or severe persistent asthma who previously completed a 52-week open-label study of BIS were enrolled in an additional multicenter, open-label study that was to be concluded upon BIS approval. Patients already receiving BIS continued their current regimens. Patients younger than 4 years and those 4 years of age or older not receiving BIS at baseline started with total daily doses of 0.5 and 1.0 mg, respectively. BIS doses were adjusted throughout the study based on individual response. Adverse events and changes in laboratory parameters, vital signs, and physical examination findings were assessed. Of 198 enrolled patients, 152 (76.8%), 68 (34.3%), and 31 (15.7%) completed 1, 2, and 3 years of BIS treatment (mean daily dose 0.62+/-0.32 mg), respectively. One hundred sixty-six (83.8%) patients experienced an adverse event, of which 8.6% were considered by the investigator to be drug related. Adverse events were those typically occurring in a pediatric asthma population, with respiratory infection (49.0%) and sinusitis (25.3%) occurring at the greatest incidence. Only 2 patients withdrew due to adverse events. Mean changes in laboratory test results and physical examination findings were not clinically important throughout the study. Long-term BIS treatment is well tolerated in young children with persistent asthma, with a safety profile similar to that of short-term administration.

Factors guiding the choice of delivery device for inhaled corticosteroids in the long-term management of stable asthma and COPD: focus on budesonide

Inhaled corticosteroids (ICSs) have become the mainstay of chronic controller therapy to treat airways inflammation in asthma and to reduce exacerbations in chronic obstructive pulmonary disease. An array of ICSs are now available that are aerosolized by a range of delivery systems. Such devices include pressurized (or propellant) metered-dose inhalers (pMDIs), pMDIs plus valved holding chambers or spacers, breath-actuated inhalers, and nebulizers. More recently, dry-powder inhalers (DPIs) were developed to help overcome problems of hand-breath coordination associated with pMDIs. The clinical benefit of ICSs therapy is determined by a complex interplay between the nature and severity of the disease, the type of drug and its formulation, and characteristics of the delivery device together with the patient's ability to use the device correctly. The ICSs budesonide is available by pMDI, DPI, and nebulizer-allowing the physician to select the best device for each individual patient. Indeed, the availability of budesonide in three different delivery systems allows versatility for the prescribing physician and provides continuity of drug therapy for younger patients who may remain on the same ICSs as they mature.

[Adverse events of inhaled steroids in childhood]

The adverse events of the inhaled steroids on growth and bone mineralization concern the pediatricians. From the available current data, we exposed the following conclusions: 1) Inhaled steroids must be preferred to oral steroids; 2) Short, middle and long-term adverse effects of inhaled steroids have to be differentiated. Only the long-term effects reflect possible sequela; 3) The adverse effects are specific from the considered inhaled steroids, the most recent available drugs having less adverse effects on bone and growth; 4) Recent data did not show consequences on the adult height and bone mineralization; 5) Recommendations in the use of inhaled steroids must be known by the practitioners in order to limit the adverse events of these drugs. Growth need to be surveyed in children with inhaled steroids and more studies are still necessary. In addition, we enhanced that local adverse effects should be sought by the physicians. Cough after inhalation was frequent and might be a negative factor of compliance.

Safety of budesonide inhalation suspension in infants aged six to twelve months with mild to moderate persistent asthma or recurrent wheeze

OBJECTIVE

To compare the safety of budesonide inhalation suspension (BIS) with placebo in infants 6 to 12 months of age with mild to moderate persistent asthma or recurrent wheeze.

STUDY DESIGN

In this multicenter, randomized, double-blinded, parallel-group, placebo-controlled study, 141 patients received 0.5 mg BIS (n = 48), 1.0 mg BIS (n = 44), or placebo (n = 49) once daily for 12 weeks. The primary variable was adrenal function, based on cosyntropin-stimulated plasma cortisol levels. Spontaneous adverse events and clinical laboratory findings also were monitored.

RESULTS

Overall, the types and frequencies of adverse events reported during the study were comparable across treatment groups. The response to cosyntropin stimulation was similar across treatment groups, with no significant difference between BIS treatment and placebo.

CONCLUSIONS

The safety profile of BIS was similar to that of placebo, with no suppressive effect on adrenal function in patients 6 to 12 months of age with mild to moderate persistent asthma or recurrent wheeze.

Optimizing inhaled corticosteroid therapy in children with chronic asthma

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