Current issues for establishing inhaled corticosteroids as the antiinflammatory agents of choice in asthma

Oleic acid attenuates asthma pathogenesis via Th1/Th2 immune cell modulation, TLR3/4-NF-κB-related inflammation suppression, and intrinsic apoptotic pathway induction

WHO reported that asthma was responsible for 455,000 deaths in 2019 and asthma patients was evaluated 262 million in May 2023. The incidence is expected to increase as the average life expectancy increases, highlighting asthma as a significant health challenge in an aging society. The etiology of asthma is linked to an imbalance of Th1 and Th2 cells, respiratory inflammation, and pulmonary cell proliferation. The purpose of this study is to investigate the anti-asthmatic effect and potential mechanism of oleic acid. The anti-inflammatory effect of oleic acid was evaluated in an LPS-induced RAW 264.7 cell model, and immune modulation and the anti-apoptotic effect were measured in an ovalbumin-induced BALB/c mouse model. A variety of analytical procedures, such as MTT, qPCR, ELISA, Western blotting, immunofluorescence, gene transfection, immunohistochemistry, and several staining methods (Diff Quik, H&E, PAS), were used to evaluate the effectiveness and mechanisms of these methods. The results from in vitro experiments showed that oleic acid could reduce the levels of inflammatory cytokines (TNF-α, IL-6, and IL-1β), and molecular docking studies suggested that oleic acid could interact with TLR3 and TLR4 proteins to form ligand-protein complexes, showing good binding affinity. Additionally, oleic acid attenuated the expression of MAPK pathway components (JNK, p38 MAPK) and NF-κB pathway constituents (IκB, NF-κB, COX-2, PGE2). In vivo results indicated that oleic acid reduced the levels of inflammatory cells (WBCs and eosinophils) and IgE activity, reduced the expression of the Th2 cell transcription factor GATA-3, and decreased the levels of Th2/Th17-related cytokines (IL-4, TNF-α, and IL-6). Oleic acid also alleviated OVA-induced pathological changes in the lung, such as epithelial cell proliferation, inflammatory cell infiltration, and mucus hypersecretion. OVA restored apoptosis in lung epithelial cells by modulating the expression of Bcl-2 and Bax. In summary, oleic acid has potential as a novel candidate for asthma treatment through its ability to regulate immune cells, exert anti-inflammatory effects, and promote apoptosis, thereby ameliorating asthma manifestations.

The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today

The Global Initiative for Asthma (GINA) recommends that short-acting β2-agonist (SABA) monotherapy should no longer be prescribed, and that as-needed combination inhaled corticosteroids (ICS)-formoterol is the preferred reliever therapy in adults and adolescents with mild asthma. These recommendations are based on the risks of SABA monotherapy, the evidence that ICS-formoterol reliever therapy markedly decreases the occurrence of severe asthma exacerbations compared with SABA reliever therapy alone, and because ICS-formoterol reliever therapy has a favorable risk/benefit profile compared with maintenance ICS plus SABA reliever therapy. Data supporting the use of combination ICS-albuterol reliever therapy in mild asthma are more limited, but there are studies that inform its use in this population. In this review, we compare, using a pros and cons format, the (1) long-term safety and efficacy of ICS-formoterol reliever therapy versus SABA reliever therapy alone, (2) long-term safety and efficacy of ICS-albuterol reliever therapy versus SABA reliever therapy alone, (3) immediate bronchodilator effects of ICS-formoterol versus SABA alone, and (4) clinical and regulatory factors that may inform reliever therapy prescription decisions. By presenting the evidence of these reliever inhaler options, we hope to inform the reader while also calling for necessary future effectiveness and implementation research.

Macmoondongtang modulates Th1-/Th2-related cytokines and alleviates asthma in a murine model

Objective

Macmoondongtang has been used as a traditional medicine to treat pulmonary disease in Korea. However, the mechanism underlying its therapeutic effect has yet to be reported. In the present study, the role of macmoondongtang as a respiratory medicine, especially as an anti-asthmatic agent, has been attributed to the down-regulation of interleukin (IL)-4 and tumor necrosis factor (TNF)-α.

Materials & methods

BALB/c mice were divided into five groups: control, asthma-induced control, dexamethasone treatment, treatment with 150 mg/kg macmoondongtang, and treatment with 1500 mg/kg macmoondongtang. To evaluate the anti-asthmatic effect of macmoondongtang, we investigated its suppressive or inhibitory effects against typical asthmatic changes such as differential cell count in bronchioalveolar fluid (BALF), serum IgE levels, lung morphology, expression of Th1/Th2 cell transcription factors such as T-bet and GATA-3, and Th1-/Th2-/Th17-related cytokines such as interferon (IFN)-γ, IL-12p40, IL-4, -5, -13, TNF-α, and IL-6. The active ingredients in macmoondongtang were further analyzed.

Results

Macmoondongtang treatment down-regulated serum IgE level, a very important marker of hyper-responsiveness. It reversed typical morphological changes such as mucous hypersecretion, lung epithelial cell hyperplasia, and inflammatory cell infiltration near bronchioalveolar space and veins. Macmoondongtang significantly decreased neutrophil count in BALF, as well as reduced T-bet, IFN-γ, and TNF-α expression in the lung. It also showed a dose-dependent control of inflammatory cells in BALF, controlled the expression of IL-12, IL-4, and IL-5 genes in the lung, and the protein expression of IL12p40, GATA-3, IL-4, IL-5, and IL-13. The component analysis revealed glycyrrhizin and liquiritin as the active ingredients.

Conclusions

Macmoondongtang treatment alleviates asthma symptoms and modulate the Th1-/Th2- related cytokines. Glycyrrhizin and liquiritin could be the major the active therapeutic components.

Bitter Taste Receptors: an Answer to Comprehensive Asthma Control?

PURPOSE OF REVIEW

Asthma is marked by peculiar pathological features involving airway contraction, an impinging inflammation in the lungs, and an inexorably progressive remodeling of pulmonary architecture. Current medications for management of asthma exacerbations fail to optimally mitigate these pathologies, which is partly due to the intrinsic heterogeneity in the development and progression of asthma within different populations. In recent years, the discovery of the ectopic expression of TAS2Rs in extraoral tissues and different cell types, combined with significant strides in gaining mechanistic understanding into receptor signaling and function, has revealed the potential to target TAS2Rs for asthma relief.

RECENT FINDINGS

TAS2R activation leads to relaxation of airway smooth muscle cells and bronchodilation. In addition, findings from preclinical studies in murine model of asthma suggest that TAS2R agonists inhibit allergen-induced airway inflammation, remodeling, and hyperresponsiveness. In this review, we expand on the opportunity presented by TAS2Rs in the development of a comprehensive asthma treatment that overcomes the limitations set forth by current asthma therapeutics.

[Persistent asthma: Chronic therapy quantitative compliance in daily practice]

INTRODUCTION

The aim of the study was to assess, compliance with maintenance treatment in patients with persistent asthma in clinical practice.

METHODS

This observational, cross-sectional, prospective, multicenter study was conducted in metropolitan France on patients with persistent asthma under the care of a representative sample of general practitioners and pneumologists. Compliance was determined via access to the Health Insurance database allowing comparison between the actual consumption of medications and the corresponding theoretical consumption related to prescription. Additional compliance data were obtained using the validated Morisky questionnaire.

RESULTS

Eighty one physicians included 488 patients, mean age of 51 years, 55% women. The statement of consumption (SC) was available for 35% of patients however the Morisky questionnaire (present for 85% of patients) showed a similar compliance between patients with or without SC. The good compliance rate (compliance ≥80%) was observed in 51% based on the SC and in 38% based on the Morisky questionnaire. Among possible predictive factors, only obesity was associated with a bad compliance (19% vs 7%, P<0.05). Patients with poor compliances displayed more severe symptoms and a higher rate of non-control (21.7% vs 5.7%, P<0.01).

CONCLUSIONS

The statement of consumption is a useful tool to provide quantitative measurement of compliance in daily practice.

Mycoleptodonoides aitchisonii suppresses asthma via Th2 and Th1 cell regulation in an ovalbumin‑induced asthma mouse model

Asthma is a chronic respiratory disease related to hyper‑responsiveness. The majority of patients suffer mild symptoms, however, some cases, especially in the young and the elderly, can lead to death by apnea. Mycoleptodonoides atichisonii (M. atichisonii) is an edible mushroom that has previously been reported to possess several bioactive properties, such as the synthesis of nerve growth factors, anti‑obesity effects and the ability to prevent cell death. In the current study, the authors evaluated the anti‑asthmatic effects of M. atichisonii using an ovalbumin‑induced asthma mouse model. M. atichisonii dose‑dependently suppressed the levels of white blood cells, eosinophils and immunoglobulin (Ig)E in BALB/c mice, resulting from ovalbumin‑induced asthma. M. atichisonii recovered the typical asthmatic morphological changes in lungs, such as mucous hyper‑secretion, epithelial layer hyperplasia, eosinophil infiltration and various cell surface molecules, such as CD3, CD4, CD8, CD19 and major histocompatibility complex class II. With the exception of CD19+ cells and IL‑12p40, M. atichisonii affected almost all factors related to asthma induction including the T helper (Th)1/Th2 transcription factors, T‑bet and GATA‑3, Th1‑related cytokines, Th2‑related cytokines and proinflammatory cytokines. In addition, M. atichisonii significantly inhibited the expression of IL‑5, IL‑13 and IL‑6. The authors concluded that M. atichisonii may be a promising drug candidate against asthma.

Opuntia humifusa modulates morphological changes characteristic of asthma via IL-4 and IL-13 in an asthma murine model

Asthma is a chronic pulmonary disease that affects an estimated 235 million people worldwide, but asthma drugs have many adverse effects. Opuntia humifusa (eastern prickly pear) has been used as a food and traditional medicine worldwide; however, its anti-asthmatic effects have not been reported. We evaluated O. humifusa as a potential therapeutic or preventive component of anti-asthmatic drugs. We divided ovalbumin-sensitized mice into the following groups: normal control, asthma-induced control, dexamethasone-treated group (positive control), 50 mg/kg O. humifusa-treated group, 100 mg/kg O. humifusa-treated group, and 500 mg/kg O. humifusa-treated group. Levels of Th1/Th2/Th17-related cytokines were evaluated using RT-PCR, ELISA, and immunohistochemistry. O. humifusa dose-dependently suppressed the morphological changes typically observed in asthma, such as goblet cell hyperplasia, inflammatory cell infiltration, mucous hypersecretion, and relative basement membrane thickening in the respiratory system. These results may be attributable to regulation of Th1-/Th2-/Th17-related factors, especially interleukin (IL)-4 and IL-13. We conclude that O. humifusa is a potential anti-asthmatic functional food.

Abbreviations: O. humifusa: Opuntia humifusa; Th: helper T; RT-PCR: real-time polymerase chain reaction; ELISA: enzyme-linked immunosorbent assay; IL: interleukin; WHO: World Health Organization; IFN-γ: interferon gamma; TNF-α: tumor necrosis factor-alpha; IgE: immunoglobulin E; CD: cluster of differentiation; OVA: ovalbumin; DEX: dexamethasone; BALF: bronchoalveolar fluid; H&E: hematoxylin and eosin; PAS: periodic acid-schiff; PBS: phosphate-buffered saline; BM: basement membrane; cDNA: complementary deoxyribonucleic acid; RNA: ribo nucleic acid; RIPA: radioimmunoprecipitation assay; IHC: immunohistochemistry; HPLC: high-performance liquid chromatography; SD: standard deviation; WBC: white blood cells; APCs: antigen-presenting cells

Vilanterol and fluticasone furoate for asthma

BACKGROUND

Vilanterol (VI) is a long-acting beta2-agonist (LABA) that binds to the beta2-adrenoceptor on the airway smooth muscle, producing bronchodilation. LABA therapy, which is well established in adults as part of the British Thoracic Society (BTS) Guidelines for the Management of Asthma, leads to improvement in symptoms and lung function and reduction in exacerbations. At present, the commonly used LABAs licensed for use in asthma management (formoterol and salmeterol) require twice-daily administration, whereas VI is a once-daily therapy.Fluticasone furoate (FF) is an inhaled corticosteroid (ICS), and ICS therapy is recommended by the BTS asthma guidelines. ICSs, the mainstay of asthma treatment, lead to a reduction in both airway inflammation and airway hyper-responsiveness. Regular use leads to improvement in symptoms and lung function. ICSs are currently recommended as 'preventer' therapy for patients who use a 'reliever' medication (e.g. short-acting beta2 agonist (SABA), salbutamol) three or more times per week. Most of the commonly used ICS treatments are twice-daily medications, although two once-daily products are currently licensed (ciclesonide and mometasone).At the present time, only one once-daily ICS/LABA combination (FF/VI) is available, and several other combination inhalers are recommended for twice-daily administration.

OBJECTIVES

To compare effects of VI and FF in combination versus placebo, or versus other ICSs and/or LABAs, on acute exacerbations and on health-related quality of life (HRQoL) in adults and children with chronic asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Register of trials, clinical trial registries, manufacturers' websites and reference lists of included studies up to June 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults and children with a diagnosis of asthma. Included studies compared VI and FF combined versus placebo, or versus other ICSs and/or LABAs. Our primary outcomes were health-related quality of life, severe asthma exacerbation, as defined by hospital admissions or treatment with a course of oral corticosteroids, and serious adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and analysed outcomes using a fixed-effect model. We used standard Cochrane methods.

MAIN RESULTS

We identified 14 studies that met our inclusion criteria, with a total of 6641 randomised participants, of whom 5638 completed the study. All studies lasted between two and 78 weeks and showed good methodological quality overall.We included 10 comparisons in this review, seven for which the dose of VI and FF was 100/25 mcg (VI/FF 100/25 mcg vs placebo; VI/FF 100/25 mcg vs same dose of FF; VI/FF 100/25 mcg vs same dose of VI; VI/FF 100/25 mcg vs fluticasone propionate (FP) 500 mcg twice-daily; VI/FF 100/25 mcg vs fluticasone propionate/salmeterol (FP/SAL) 250/50 mcg twice-daily; VI/FF 100/25 mcg vs FP/SAL 250/25 mcg twice-daily; FF/VI 100/25 vs FP/SAL500/50) and three for which the dose of VI and FF was 200/25 mcg (VI/FF 200/25 mcg vs placebo; VI/FF 200/25 mcg vs FP 500 mcg; VI/FF 200/25 mcg vs same dose of FF).We found very few opportunities to combine results from the 14 included studies in meta-analyses. We tabulated the data for our pre-specified primary outcomes. In particular, we found insufficient information to assess whether once-daily VI/FF was better or worse than twice-daily FP/SAL in terms of efficacy or safety.Only one of the 14 studies looked at health-related quality of life when comparing VI and FF 100/25 mcg versus placebo and identified a significant advantage of VI/FF 100/25 mcg (mean difference (MD) 0.30, 95% confidence interval (CI) 0.14 to 0.46; 329 participants); we recognised this as moderate-quality evidence. Only two studies compared VI/FF 100/25 mcg versus placebo with respect to exacerbations; both studies reported no exacerbations in either treatment arm. Five studies (VI/FF 100/25 mcg vs placebo) sought information on serious adverse events; all five studies reported no serious adverse events in the VI/FF 100/25 mcg or placebo arms. We found no comparison relevant to our primary outcomes for VI/FF at a higher dose (200/25 mcg) versus placebo.The small number of studies contributing to each comparison precludes the opportunity to draw robust conclusions for clinical practice. These studies were not of sufficient duration to allow conclusions about long-term side effects.

AUTHORS' CONCLUSIONS

Some evidence suggests clear advantages for VI/FF, in combination, compared with placebo, particularly for forced expiratory volume in one second (FEV1) and peak expiratory flow; however, the variety of questions addressed in the included studies did not allow review authors to draw firm conclusions. Information was insufficient for assessment of whether once-daily VI/FF was better or worse than twice-daily FP/SAL in terms of efficacy or safety. It is clear that more research is required to reduce the uncertainties that surround interpretation of these studies. It will be necessary for these findings to be replicated in other work before more robust conclusions are revealed. Only five of the 13 included studies provided data on health-related quality of life, and only six recorded asthma exacerbations. Only one study focused on paediatric patients, so no conclusions can be drawn for the paediatric population. More research is needed, particularly in the primary outcome areas selected for this review, so that we can draw firmer conclusions in the next update of this review.

Erythronium japonicum attenuates histopathological lung abnormalities in a mouse model of ovalbumin-induced asthma

Asthma is a chronic lung condition that can induce mucus hypersecretion and pulmonary obstruction and may even cause death, particularly in children and older individuals. Erythronium japonicum (E. japonicum) is a traditional herb used in Korea and East Asian countries that has been found to exert free radical scavenging activity and anti-proliferative effects in human colorectal carcinoma cells. In the present study, we evaluated the anti-asthmatic effects of an extract of E. japonicum in a mouse model of ovalbumin (OVA)-induced asthma. Female BALB/c mice were sensitized with an intraperitoneal injection of OVA and aluminum hydroxide hydrate on days 1 and 8 and then received the following treatments on days 21 to 25: i) control (no treatment), ii) sterilized tap water (given orally), iii) 1 mg/kg/day dexamethasone (administered orally), iv) 60 mg/kg/day E. japonicum extract, and v) 600 mg/kg/day E. japonicum extract. On the same days, all the mice except those in the control group were challenged 1 h later with nebulized 5% OVA for 30 min. We found that treatment with E. japonicum extract suppressed the OVA-induced increase in the number of white blood cells and decreased the IgE level in the bronchoalveolar lavage fluid samples obtained from the mice. Histopathological analysis of the lung tissues revealed that E. japonicum attenuated the asthma-related morphological changes in the mouse lung tissue, including the increased secretion of mucus in the bronchioles, eosinophil infiltration around the bronchioles and vessels, and goblet cell and epithelial cell hyperplasia. Immunohistochemical analysis revealed that treatment with E. japonicum extract suppressed the OVA-induced proliferation of T helper cells (CD4⁺) and B cells (CD19⁺) in the mouse lung tissue. Furthermore, treatment with E. japonicum extract modulated the expression of both T helper 2 cell-related factors [GATA binding protein 3 (GATA-3), tumor necrosis factor-α (TNF-α), interleukin (IL)-4, IL-5, IL-6 and IL-13], as well as that of T helper 1 cell-related factors [(interferon-γ (IFN-γ), IL-12p35 and IL-12p40]. These findings suggest that E. japonicum may potentially be used as an anti-asthmatic treatment.

Bacillus subtilis KCTC 11782BP-produced alginate oligosaccharide effectively suppresses asthma via T-helper cell type 2-related cytokines

According to the World Health Organization in 2013, 235 million people are afflicted with asthma. Asthma is a severe pulmonary disease that can be caused by the imbalance of T-helper (Th) type 1 (Th1) and type 2 (Th2) cells, and it is potentially fatal. In this study, we evaluated the anti-asthmatic effect of alginate oligosaccharide (AO), which was prepared from seaweed and converted by Bacillus subtilis KCTC 11782BP, in the mouse model of ovalbumin (OVA)-induced asthma. BALB/c mice were divided into the vehicle control (sensitized but not challenged), asthma induction, positive control (1 mg/kg dexamethasone), 50 mg/kg/day AO-treated, 200 mg/kg/day AO-treated, and 400 mg/kg/day AO-treated groups. The numbers or levels of inflammatory cells, eosinophils, and immunoglobulin (Ig) E were measured in bronchoalveolar lavage fluid (BALF), and asthma-related morphological and cytokine changes were analyzed in lung tissues. Our results show that AO dramatically reduced inflammatory cell numbers, eosinophil count, and IgE levels in BALF, and it dose-dependently inhibited asthmatic histopathological changes in the lung. In addition, AO dose-dependently suppressed the expression of CD3+ T-cell co-receptors, CD4+ Th cells, CD8+ cytotoxic T-cell-related factors, macrophages, and MHCII class. AO dose-dependently decreased the expression levels of Th1/2 cells-regulatory transcription factors such as GATA-3 which modulates Th2 cell proliferation and T-bet which does Th1 cell proliferation. The mRNA levels of all Th1/2-related cytokines, except IL-12α, were dose-dependently suppressed by AO treatment. In particular, the mRNA levels of IL-5, IL-6, and IL-13 were significantly inhibited by AO treatment. Our findings suggest that AO has the potential to be an anti-asthmatic drug candidate, due to its modulation of Th1/Th2 cytokines, which contribute to the pathogenesis of asthma.

1'-Acetoxychavicol acetate isolated from Alpinia galanga ameliorates ovalbumin-induced asthma in mice

The World Health Organization reports that 235 million people are currently affected by asthma. This disease is associated with an imbalance of Th1 and Th2 cells, which results in the upregulation of cytokines that promote chronic inflammation of the respiratory system. The inflammatory response causes airway obstruction and can ultimately result in death. In this study we evaluated the effect of 1'-acetoxychavicol acetate (ACA) isolated from Alpinia galanga rhizomes in a mouse model of ovalbumin (OVA)-induced asthma. To generate the mouse model, BALB/c mice were sensitized by intraperitoneal injection of OVA and then challenged with OVA inhalation for 5 days. Mice in the vehicle control group were sensitized with OVA but not challenged with OVA. Treatment groups received dexamethasone, 25 mg/kg/day ACA, or 50 mg/kg/day ACA for 5 days. Asthma-related inflammation was assessed by bronchoalveolar lavage fluid cell counts and histopathological and immunohistochemical analysis of lung tissues. Our results showed that ACA reduced the infiltration of white blood cells (especially eosinophils) and the level of IgE in the lungs of mice challenged with OVA and suppressed histopathological changes such as airway remodeling, goblet-cell hyperplasia, eosinophil infiltration, and glycoprotein secretion. In addition, ACA inhibited expression of the Th2 cytokines interleukin (IL)-4 and IL-13, and Th1 cytokines IL-12α and interferon-γ. Because asthmatic reactions are mediated by diverse immune and inflammatory pathways, ACA shows promise as an antiasthmatic drug candidate.

Optimal management of severe/refractory asthma

Asthma is a chronic inflammatory disease of the airways, affecting approximately 300 million people worldwide. Asthma results in airway hyperresponsiveness, leading to paroxysmal symptoms of wheeze, cough, shortness of breath, and chest tightness. When these symptoms remain uncontrolled, despite treatment with high doses of inhaled and ingested corticosteroids, asthmatic patients are predisposed to greater morbidity and require more health care support. Treating patients with severe asthma can be difficult and often poses a challenge to physicians when providing ongoing management. This clinical review aims to discuss the definition, prevalence and evaluation of severe asthmatics, and provides a review of the existing pharmacologic and non-pharmacologic treatment options.

Best Treatment Guidelines For Bronchial Asthma

Asthma is a common disease worldwide with significant ethnic and regional variations. An increasing morbidity and mortality, as well as health care burden from asthma have been recognized lately. Several evidence based guidelines have been developed with an aim to standardize and improve the quality of management. These guidelines seek to translate the advances in the understanding of pathogenesis of asthma and in the development of new agents and strategies into practical application at all levels of healthcare. These advocate an assessment of the patients to classify the severity of diseases followed by a step-wise approach to treatment. With the current management we hope to achieve minimum or nil day time and night time symptoms, prevent acute exacerbations and attain normal or near normal lung function, thus improving the overall quality of life.

Montelukast added to fluticasone propionate does not alter inflammation or outcomes

BACKGROUND

Airway inflammation is a key pathological feature of asthma which underlies its clinical presentation.

OBJECTIVES

To examine whether adding a leukotriene modifier to an inhaled corticosteroid produces further clinical and/or anti-inflammatory benefits in patients symptomatic on short-acting beta(2)-agonists.

METHODS

Patients uncontrolled on short-acting beta(2)-agonists were treated for 12 weeks with either fluticasone propionate (100mcg BD) or fluticasone propionate (100mcg BD) and montelukast (10mg QD) in a randomized, double-blind, parallel group study. Bronchoscopy with endobronchial biopsy and bronchoalveolar lavage (BAL) was performed before and after treatment to compare effects on airway inflammation.

RESULTS

Of 103 subjects enrolled, 89 subjects completed treatment and 82 subjects had matched pair biopsy samples. Submucosal eosinophil counts, the primary endpoint, and asthma control improved to similar extents after both treatments (p<or=0.008). Both treatments significantly reduced submucosal mast cell, CD3+, CD4+, CD8+ and CD25+ cell counts. Submucosal mast cell reduction was greater in the fluticasone propionate plus montelukast group. There were no differences between treatments in BAL markers of inflammation or thickness of sub-epithelial collagen.

CONCLUSIONS

Low-dose fluticasone propionate significantly improves clinical disease control and reduces airway inflammation in asthma patients uncontrolled with short-acting beta(2)-agonists without further improvement when montelukast is added to low-dose fluticasone propionate.

Pneumonia in elderly patients with chronic obstructive pulmonary disease

This article reviews the association between pneumonia and chronic obstructive pulmonary disease (COPD) and the possible role of inhaled corticosteroids in increasing the risk of pneumonia in patients with COPD. An increased risk of pneumonia with inhaled corticosteroids was first reported from the Toward Revolution in COPD Health (TORCH) study, a large randomized clinical trial comparing fluticasone, salmeterol, or a combination of the two medications with placebo. We carried out a large observational study using a health care administrative database of information on hospitalizations and medication use among patients older than 65 years of age in Quebec. We found an excess of pneumonia requiring hospitalization and an excess of pneumonia hospitalizations leading to death in relation to current use of inhaled corticosteroids, especially at high doses. Here, we explore the potential mechanisms of this association and try to weigh the benefits and risks of therapy with inhaled corticosteroids in patients with COPD.

Chronic inflammation and asthma

Allergic asthma is a complex and chronic inflammatory disorder which is associated with airway hyper-responsiveness and tissue remodelling of the airway structure. Although originally thought to be a Th2-driven inflammatory response to inhaled innocuous allergen, the immune response in asthma is now considered highly heterogeneous. There are now various in vivo systems which have been designed to examine the pathways leading to the development of this chronic immune response and reflect, in part this heterogeneity. Furthermore, the emergence of endogenous immunoregulatory pathways and active pro-resolving mediators hold great potential for future therapeutic intervention. In this review, the key cellular and molecular mediators relating to chronic allergic airway disease are discussed, as well as emerging players in the regulation of chronic allergic inflammation.

Similar efficacy of ciclesonide once daily versus fluticasone propionate twice daily in patients with persistent asthma

This 12-week, double-blind, parallel-group study compared the efficacy and safety of once daily ciclesonide and twice daily fluticasone propionate in patients aged 12-75 years with persistent asthma. Patients were randomized to once-daily ciclesonide 80 micro g (n = 278) or 160 micro g (n = 271), or twice daily fluticasone propionate 88 micro g (n = 259) (all ex-actuator). Significant improvements from baseline were seen in all three treatment groups for forced expiratory volume in 1 second, asthma symptom scores and rescue medication use (all p < 0.0001). Asthma exacerbation rates were low (each ciclesonide group, n = 2; fluticasone group, n = 1). Adverse event reporting indicated good tolerability. Once daily ciclesonide 80 micro g or 160 micro g showed comparable efficacy and tolerability to twice daily fluticasone propionate 88 micro g in persistent asthma.

Relationship among pulmonary function, bronchial hyperresponsiveness, and atopy in children with clinically stable asthma

Pulmonary function testing plays a key role in the diagnosis and management of asthma in children. However, the literature does not clearly show whether children with clinically stable asthma have significantly reduced lung function when compared with normal children. We compared the lung function of 242 clinically stable asthmatic children who were initially diagnosed with mild intermittent or mild persistent asthma with the lung function of 100 nonasthmatic controls. The lung function was assessed using FEV1, FEV1/FVC, FEF25-75 and PEF. In addition, we measured bronchial hyperresponsiveness (BHR) using the provocation concentration of methacholine needed to produce a 20% fall in FEV1. All measures of pulmonary function were significantly decreased in the children with asthma. Pulmonary function was not influenced by atopy, serum IgE, or total eosinophil count (TEC). However, the likelihood ratio for trends revealed a significant association between our pulmonary parameters and the degree of BHR. Children with mild-to-severe BHR had greatly decreased lung function compared with those with normal BHR, the control group. In addition, a direct correlation was found between PC20 and our pulmonary parameters in asthmatic children. However, only atopic children with asthma had a significant correlation between PC20 and TEC. We found children with clinically stable asthma to have pulmonary obstruction, which associated strongly with their degree of BHR.

Effects of corticosteroid-induced apoptosis on airway epithelial wound closure in vitro

Damage to the airway epithelium is common in asthma. Corticosteroids induce apoptosis in and suppress proliferation of airway epithelial cells in culture. Whether apoptosis contributes to impaired epithelial cell repair after injury is not known. We examined whether corticosteroids would impair epithelial cell migration in an in vitro model of wound closure. Wounds (approximately 0.5-1.3 mm2) were created in cultured 1HAEo- human airway epithelial cell monolayers, after which cells were treated with up to 10 microM dexamethasone or budesonide for 24 h. Cultured cells were pretreated for 24 or 48 h with dexamethasone to observe the effect of long-term exposure on wound closure. After 12 h, the remaining wound area in monolayers pretreated for 48 h with 10 microM dexamethasone was 43+/-18% vs. 10+/-8% for untreated control monolayers. The addition of either corticosteroid immediately after injury did not slow closure significantly. After 12 h the remaining wound area in monolayers treated with 10 microM budesonide was 39+/-4% vs. 43+/-3% for untreated control monolayers. The proportion of apoptotic epithelial cells as measured by terminal deoxynucleotidyltransferase-mediated dUTP biotin nick end labeling both at and away from the wound edge was higher in monolayers treated with budesonide compared with controls. However, wound closure in the apoptosis-resistant 1HAEo-.Bcl-2+ cell line was not different after dexamethasone treatment. We demonstrate that corticosteroid treatment before mechanical wounding impairs airway epithelial cell migration. The addition of corticosteroids after injury does not slow migration, despite their ability to induce apoptosis in these cells.

Targeting memory Th2 cells for the treatment of allergic asthma

Th2 memory cells play an important role in the pathogenesis of allergic asthma. Evidence from patients and experimental models indicates that memory Th2 cells reside in the lungs during disease remission and, upon allergen exposure, become activated effectors involved in disease exacerbation. The inhibition of memory Th2 cells or their effector functions in allergic asthma influence disease progression, suggesting their importance as therapeutic targets. They are allergen specific and can potentially be suppressed or eliminated using this specificity. They have distinct activation, differentiation, cell surface phenotype, migration capacity, and effector functions that can be targeted singularly or in combination. Furthermore, memory Th2 cells residing in the lungs can be treated locally. Capitalizing on these unique attributes is important for drug development for allergic asthma. The aim of this review is to present an overview of therapeutic strategies targeting Th2 memory cells in allergic asthma, emphasizing Th2 generation, differentiation, activation, migration, effector function, and survival.

Do current treatment protocols adequately prevent airway remodeling in children with mild intermittent asthma?

BACKGROUND

Asthma treatment per Global Initiative for Asthma (GINA) guidelines targets airway remodeling and achievement of normal lung function.

OBJECTIVE

To study inhaled steroid therapy on airway remodeling and achievement of normal lung function. SUBJECTS AND SET UP: Asthmatic patients were followed over 5 years . The children were divided into two groups. Group I (148 children-treated group) consisted of all the children using inhaled steroids on a regular basis and group II (50 children-untreated group) included patients with mild intermittent asthma who did not use inhaled steroids and were treated with bronchodilators as needed. Detailed medication and compliance history were recorded and the children underwent regular pre- and post-bronchodilator spirometry and physician examination.

RESULTS

The incidence of airways remodeling as defined by the low FEV1/FVC post-bronchodilator was markedly increased over the 5-year period in the untreated group compared to the treated group. In the treated group the FEV1/FVC ratio post-bronchodilator decreased from 35% to 20.9% (P<0.009%) compared with the untreated group where the number of children with low FEV(1)/FVC post-bronchodilator increased from 10% to 28% by the end of the study period.

CONCLUSION

Patients with mild asthma who do not receive regular inhaled steroids are at increased risk for airway remodeling. Therefore, we recommend that children with mild intermittent asthma undergo regular pulmonary function testing and that if any deterioration is detected in the FEV1/FVC ratio post-bronchodilators; preventative inhaled corticosteroid therapy be initiated.

Bias in observational study of the effectiveness of nasal corticosteroids in asthma

BACKGROUND

A recent observational study suggests that intranasal corticosteroids used to treat allergic rhinitis are effective at preventing asthma outcomes, such as emergency visits. The approach to data analysis may have led to biased results because of misclassification of immortal time.

OBJECTIVE

To illustrate the bias in the cohort approach and to present the proper time-dependent analysis by replicating the recent study using data from another source.

METHODS

From an existing cohort of 30,569 patients with asthma age 5 to 44 years and identified from the Saskatchewan Health databases (1975-1997), we formed the cohort of all subjects who were in the source population between January 1, 1989, and December 31, 1991. Subjects were followed to the first asthma hospitalization. All prescriptions dispensed during follow-up were identified. We replicated the time-fixed approach to data analysis used in the recent study and compared it with time-dependent approaches.

RESULTS

The cohort included 20,173 subjects, of whom 1849 were hospitalized for asthma between January 1, 1989, and December 31, 1991. The time-fixed approach misclassified more than 5000 person-years of follow-up, corresponding to 44% of the exposed person-time. As a result, the rate ratio of asthma hospitalization after any use of nasal corticosteroids (NCSs) was 0.57 by the biased time-fixed approach compared with 1.13 by the proper time-dependent approach. The time-fixed approach produced a paradoxical protective effect of NCS with 1 or less canisters dispensed per year (odds ratio, 0.47), which was further exaggerated when the cohort was extended to 5 years (odds ratio, 0.33). Adjusted time-dependent analyses found no protective effect, even when NCSs were dispensed regularly (rate ratio, 1.10; 95% CI, 0.54-2.21).

CONCLUSION

The time-fixed approach to the analysis of the effectiveness of NCSs on asthma outcomes leads, by its inherent misclassification of immortal time, to a considerable exaggeration of the protective effect of these medications in preventing severe asthma exacerbations.

Effect of fluticasone/salmeterol administered via a single device on exercise-induced bronchospasm in patients with persistent asthma

BACKGROUND

Exercise is a common trigger of asthma symptoms in patients with persistent asthma.

OBJECTIVE

To evaluate the protective effect of fluticasone/salmeterol against exercise-induced bronchospasm.

METHODS

Multicenter, randomized, double-blind, parallel-group trial of 192 asthma patients who used moderate-dose inhaled corticosteroids. Patients (aged 12-50 years; mean forced expiratory volume in 1 second [FEV1], 78% of predicted at baseline) were randomized to receive fluticasone/salmeterol (250/50 microg twice daily) or fluticasone alone (250 microg twice daily) via Diskus for 4 weeks. Exercise challenge tests were performed 1 and 8.5 hours after administration of the first (day 1) and last (week 4) doses of blinded study medication.

RESULTS

On day 1 and at week 4, mean +/- SEM values for the maximal percentage decline in FEV1 1 hour after drug administration were 11.4% +/- 1.5% and 10.9% +/- 1.5% for fluticasone/salmeterol compared with 20.0% +/- 1.7% and 18.4% +/- 1.8% for fluticasone (P < .001). At 8.5 hours, mean +/- SEM values on day 1 and at week 4 were 11.6% +/- 1.4% and 8.9% +/1.1%, respectively, for fluticasone/salmeterol and 12.6% +/- 1.6% and 12.9% +/- 1.4%, respectively, for fluticasone (P = .01 at week 4). More fluticasone-treated patients did not complete the 8.5-hour exercise challenges (36% on day 1 and 33% at week 4) compared with the fluticasone/salmeterol group (18% each) (P < or = .01). Improvements in peak expiratory flow rate and albuterol rescue-free days were significantly greater with fluticasone/salmeterol vs fluticasone over weeks 1 to 4 (P < or = .03).

CONCLUSIONS

Consistent with the improvements in other measures of asthma control, long-term fluticasone/salmeterol therapy also provided protection against exercise-induced bronchospasm in patients with persistent asthma.

Benefit from anti-inflammatory treatment during clinical remission of atopic asthma

STUDY OBJECTIVES

Subjects with atopic asthma often experience a disappearance of symptoms around puberty. However, airway inflammation and remodeling may persist. It is unknown whether those findings warrant prolonged anti-inflammatory treatment despite the absence of symptoms. In this study, we investigated whether a short course of combined anti-inflammatory treatment would, also in this specific patient population, diminish airway inflammation and/or remodeling.

DESIGN

A double-blind, randomized placebo-controlled trial was conducted in 28 asymptomatic subjects with a history of atopic asthma, with established bronchial hyperresponsiveness to methacholine (MCh) as non-invasive indicator of ongoing airway pathology.

INTERVENTIONS

Intervention consisted of the salmeterol/fluticasone propionate combination (SFC) product (50/250 microg bid via the Diskus inhaler) or placebo for 3 months.

MEASUREMENTS

The change in lung function (FEV1), bronchial response to MCh and adenosine monophosphate (AMP), the fraction of nitric oxide in exhaled air (FENO) and quality of life (QOL) scores were measured. Also, bronchial biopsies were taken and cryo sections immunostained for eosinophils (major basic protein, MBP) and mast cells (tryptase and chymase) before and after treatment. The change in reticular basement membrane (RBM) thickness, one of the parameters of airway remodeling, was also determined.

RESULTS

SFC treatment improved hyperresponsiveness to MCh (P = 0.014) as well as AMP (P = 0.011), and reduced FENO (P < 0.001) significantly as compared with placebo. Lung function tended to improve (NS). Furthermore, SFC treatment reduced tryptase in the subepithelium of bronchial biopsy specimens (P = 0.01), and slightly reduced RBM thickness (P = 0.05). However, eosinophils in (sub)epithelium were not significantly affected; neither were chymase levels, blood eosinophils or QOL scores.

CONCLUSIONS

We found that 3 months of treatment with fluticasone propionate and salmeterol reduced airway hyperresponsiveness, FENO and tryptase density in the airway mucosa as markers of airway inflammation. MBP density in the airway mucosa and QOL were, however, unchanged. The clinical relevance of these findings, especially with respect to the long-term outcome, has not been determined yet.

Fluticasone induces T cell apoptosis in the bronchial wall of mild to moderate asthmatics

BACKGROUND

Cytokines which signal via the gamma chain of the interleukin (IL)-2 receptor and the interferons (IFNs) have been shown to enhance T cell survival in vitro by rescuing cells from apoptosis.

METHODS

A study was undertaken to determine whether treatment with inhaled fluticasone propionate (FP; 250 microg twice daily) for 2 weeks could modulate production of IL-15 or IFN-beta and thereby affect T cell survival in bronchial tissue of 10 patients with mild/moderate asthma. Bronchial biopsy specimens were taken before and on completion of treatment.

RESULTS

The mean (95% CI) number of T cells per unit area decreased in the asthmatic group following 2 weeks of treatment with FP (from 7.0 (5.6 to 8.4) to 4.5 (4.0 to 5.1); p = 0.001). There was an increase in the percentage of T cells undergoing apoptosis following FP treatment as assessed by T cell/TUNEL staining (from 4.5 (2.6 to 6.4) to 8.7 (6.6 to 10.8); p = 0.0001). The percentage of cells staining for IL-15 and IFN-beta in the lamina propria, determined by an alkaline phosphatase biotin streptavidin technique, decreased significantly from baseline values of 31.6 (23.4 to 39.7) to 19.6 (12.5 to 26.7), p = 0.039 for IL-15 and from 18.9 (13.5 to 24.4) to 9.5 (5.9 to 13.1), p = 0.007 for IFN-beta following 2 weeks of treatment with FP. However, only the decrease in the percentage of cells staining for IL-15 was significantly correlated with an increased number of apoptotic T cells following treatment (p = 0.008).

CONCLUSION

These findings support a novel mechanism for the ability of inhaled corticosteroids to decrease T cell numbers, possibly by downregulation of the cytokine IL-15.

The use of inhaled corticosteroids for persistent asthma in infants and young children

OBJECTIVE

To review pediatric trials of inhaled corticosteroid (ICS) therapy and summarize data on the pediatric use of devices to facilitate delivery of ICSs.

DATA SOURCES

Relevant articles regarding ICS treatment of persistent asthma in children younger than 5 years were identified from MEDLINE and reference lists of review articles.

STUDY SELECTION

Key articles were selected by the authors.

RESULTS

Clinical trials from the United States and Europe consistently demonstrated that ICS therapy is the most favorable treatment option with regard to safety and efficacy for infants and young children with persistent asthma. This contention is supported by numerous trials of budesonide inhalation suspension in children ranging from 6 months through 8 years of age and data from older children treated with fluticasone propionate.

CONCLUSIONS

As the only corticosteroid available in the United States as a nebulized formulation and the only ICS product extensively studied in young children and infants, budesonideinhalation suspension is an appropriate first-line therapy for treatment of persistent asthma in this population.

Treatment of childhood asthma: how do the available options compare?

The National Asthma Council of Australia suggests that "the aim of preventive therapy should be to enable patients to enjoy a normal life (comparable with that of non-asthmatic children), with the least amount of medication and at minimal risk of adverse events. The level of maintenance therapy should be determined by symptom control and lung function in the interval periods." The British Thoracic Society/Scottish Intercollegiate Guidelines Network states that the aims of the pharmacological treatment of asthma should be to control symptoms, prevent exacerbations and achieve the best possible lung function with minimal adverse effects. We have used the current published international guidelines to highlight the international differences in management recommendations, and compared the possible pharmacological options with a focus on the above ideals. Cromones have been used for many years in childhood asthma. Most evidence suggests they now have little role. Regarding inhaled corticosteroids (ICS), beclomethasone and budesonide are essentially similar in their efficacy. Fluticasone propionate is equally as effective at one-half the equivalent dose of budesonide or beclomethasone. Adverse effects are rare in dosages <400 microg/day of budesonide and beclomethasone or <200 microg/day of fluticasone propionate, but may occur in individual patients. Relevant clinical adverse effects are rare and pharmacological systemic effects are less noticeable with budesonide and fluticasone propionate than with beclomethasone, but data are conflicting. Long-acting beta2-adrenoceptor agonists (beta2-agonists) are recommended once low-dose ICS have failed to control symptoms. The main pharmacological difference between the agents is that formoterol is a full beta2-adrenergic agonist, whereas salmeterol is a partial agonist at the beta2-adrenoceptor and has a unique pharmacological action. The main clinical distinction between these two agents is that their onset of bronchodilation differs. Bronchodilation begins at about 3 minutes after inhalation of formoterol, which is similar to the short-acting agents, whereas salmeterol has a much slower onset of action at about 15-30 minutes. The many in vitro differences between the two drugs are probably not clinically relevant. There are no comparative pediatric data on the leukotriene modifiers to make clear recommendations.

The role of T lymphocytes in the pathogenesis of asthma

There is considerable evidence to support a role for T cells in asthma, particularly the involvement of T(H)2 cells both in atopic allergic asthma and in nonatopic and occupational asthma. There might also be a minor contribution from T(C)2 CD8+ T cells. Several T(H)2 cytokines have the potential to modulate airway inflammation, particularly IL-13, which induces airway hyperresponsiveness independently of IgE and eosinophilia in animal models. The identification of transcription factors controlling T(H)1 and T(H)2 development further support the T(H)2 hypothesis because GATA3 is overexpressed and T-bet is underexpressed in the asthmatic airway. Specific T cell directed immunotherapy might allow induction, modulation, or both of T-cell responses, and elucidation of the mechanisms of regulatory T cells might allow further optimization of immunotherapy. Recent advances in our understanding of dendritic cell function in directing T-cell responses might uncover further therapeutic targets. The efficacy of cyclosporin A and anti-CD4 treatment in patients with chronic severe asthma argues for continued T-cell involvement, but whether remodeling contributes to pathology inaccessible to anti-inflammatory treatment or T-cell immunotherapy will be an important future question.

Corticosteroid-induced apoptosis in mouse airway epithelium: effect in normal airways and after allergen-induced airway inflammation

BACKGROUND

Damage to the airway epithelium is one prominent feature of the damage seen in chronic asthma. Cortico-steroids induce apoptosis in inflammatory cells, which in part explains their ability to suppress airway inflammation. However, corticosteroid therapy does not necessarily reverse the epithelial damage seen in asthmatic airways.

OBJECTIVE

We hypothesized that corticosteroids might induce airway epithelial cell apoptosis as one potential explanation for this persistent damage.

METHODS

BALB/c mice were treated with 1 mg/kg dexamethasone by means of intraperitoneal injection for 3 days to 4 weeks. Additional mice were sensitized and challenged with ovalbumin and then followed for 14 days with or without dexamethasone treatment starting on day 4 after challenge. Apoptosis was measured by using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling and immunohistochemistry for the p85 cleavage product of poly (adenosine diphosphate-ribose) polymerase. Shed epithelial cells were counted in bronchoalveolar lavage fluid.

RESULTS

In a time-dependent manner dexamethasone treatment increased epithelial cell apoptosis and shedding into the airway lumen. This was not associated with any change in the abundance of the apoptotic regulator Bcl-x(L). In animals sensitized and challenged with ovalbumin, treatment with 1 mg/kg dexamethasone starting 4 days after challenge reversed the inflammatory changes but did not reverse either epithelial cell shedding or apoptosis seen after allergen challenge.

CONCLUSION

Corticosteroids might induce apoptotic cell death of airway epithelium in vivo and fail to mitigate epithelial cell shedding and apoptosis elicited by means of allergen challenge. This raises the possibility that at least one of the major components of chronic airway damage in asthma, epithelial shedding, might in part result from a major therapy used for disease control.

[Cortisone therapy today]

Five decades of experimental and clinical experience have changed corticoid therapy thoroughly. Corticoides have two modes of action. The first is a genomic effect through which anti-inflammatory proteins are formed which inhibit pro-inflammatory cytokines. This effect is initiated even by small doses, but is of late onset. The use of high doses initiates non-genomic effects through alterations of the cell membrane; these effects are found early after initiation of treatment. The risk of adverse corticoid effects are extremely rare when modern application forms and therapy regimens are used: Very high doses for a short time in case of acute states of illness, very low doses in long-term therapy of chronic illnesses, and the use of topical substances wherever this is possible. As for the dose regimen, one should start with an initial dose which suffices to treat the acute state, and subsequently reduce the dosage after the first positive results are obtained. In long-term therapy a daily dose of 5 mg prednisolone should not be exceeded; usually even lower doses are sufficient. These very low doses can only be reached by reducing in steps of one half to one milligram over very long periods of time. During long-term therapy osteoporosis prophylaxis is mandatory. Due to these new therapeutic concepts treatment of rheumatoid arthritis with corticoids is experiencing a revival. Low-dose corticoid therapy is of lower risk than nonsteroidal antirheumatic treatment and slows down disease progression, i.e. joint destruction is significantly inhibited. Corticoids have also undergone a new development in the treatment of asthma. Previously used only in acute systemic therapy, they have now been established in basic therapy, i.e. long term therapy using special topic applications.

Corticosteroid-induced apoptosis of airway epithelium: a potential mechanism for chronic airway epithelial damage in asthma

Damage to the airway epithelium is one prominent feature of chronic asthma. Mucosal damage includes gap openings, partial denudation, and loss of ciliated cells. Apoptosis of the airway epithelium is increasingly recognized as a potential mechanism by which damage may occur. Corticosteroids (CSs) induce apoptosis in inflammatory cells, which in part explains their ability to suppress airway inflammation. However, CS therapy does not necessarily reverse epithelial damage. We examined whether CS therapy actually could induce airway epithelial apoptosis using culture models of primary airway epithelial cells and cell lines. The administration of CSs in low-micromolar concentrations induces apoptosis that involves the disruption of mitochondrial polarity, the activation of caspases, and the involvement of Bcl-2. Clear differences exist between CS-induced apoptosis in the cultured epithelium vs cultured hematopoietic cells in regard to time course and resistance to apoptosis. Our data suggest that the use of CSs, in concentrations that could be attained in vivo with the inhalation of potent preparations or with systemic administration, may be one factor in the airways remodeling and epithelial damage that is seen in many patients with chronic, persistent asthma.

Effects of varying doses of fluticasone propionate on the physiology and bronchial wall immunopathology in mild-to-moderate asthma

OBJECTIVES

Inhaled corticosteroids (ICS) are typically associated with a flat dose-response curve when traditional efficacy values are examined (eg, FEV(1)). The aim of the present study was to investigate if a dose-response relationship exists for lung function and inflammatory cell numbers in bronchial biopsy specimens.

METHODS

Bronchial biopsy specimens were obtained from 36 patients randomized to receive 100 micro g, 500 microg, or 2,000 microg/d of fluticasone propionate (FP). Lung physiology and bronchial biopsies were performed at baseline and after 2 weeks of treatment.

RESULTS

Improvement in lung function and suppression of airway inflammation were optimal at a dose of 500 microg/d of FP. Significant changes from baseline following treatment were documented in FEV(1) (p = 0.02), forced expiratory flow (p = 0.002), FEV(1)/FVC (p = 0.007), provocative concentration of histamine causing a 20% fall in FEV(1) (PC(20)) [p = 0.02], T-cell numbers (p = 0.0005), activated eosinophils (p = 0.01), and numbers of macrophages (p = 0.01) in the group treated with 500 microg/d of FP. Comparison between groups administered different doses of FP failed to demonstrate a dose-response relationship for change from baseline in PC(20) (p = 0.43), any of the lung function parameters, T-cell numbers (p = 0.64), activated T cells (p = 0.46), eosinophils (p = 0.53), activated eosinophils (p = 0.48), or macrophage numbers (p = 0.68).

CONCLUSION

The apparent lack of a dose-response for ICS treatment in patients with asthma further validates the preferential use of add-on therapy over increasing the dose of ICS.

Bioengineering of therapeutic aerosols

The new field of therapeutic aerosol bioengineering (TAB), driven primarily by the medical need for inhaled insulin, is now expanding to address medical needs ranging from respiratory to systemic diseases, including asthma, growth deficiency, and pain. Bioengineering of therapeutic aerosols involves a level of aerosol particle design absent in traditional therapeutic aerosols, which are created by conventionally spraying a liquid solution or suspension of drug or milling and mixing a dry drug form into respirable particles. Bioengineered particles may be created in liquid form from devices specially designed to create an unusually fine size distribution, possibly with special purity properties, or solid particles that possess a mixture of drug and excipient, with designed shape, size, porosity, and drug release characteristics. Such aerosols have enabled several high-visibility clinical programs of inhaled insulin, as well as earlier-stage programs involving inhaled morphine, growth hormone, beta-interferon, alpha-1-antitrypsin, and several asthma drugs. The design of these aerosols, limited by partial knowledge of the lungs' physiological environment, and driven largely at this stage by market forces, relies on a mixture of new and old science, pharmaceutical science intuition, and a degree of biological-impact empiricism that speaks to the importance of an increased level of academic involvement.

Regular use of inhaled corticosteroids and the long term prevention of hospitalisation for asthma

BACKGROUND

Inhaled corticosteroids are effective at preventing asthma morbidity and mortality. Most studies, however, have focused on short term effects, raising uncertainty about their effectiveness in the long term.

METHODS

The Saskatchewan Health databases were used to form two population based cohorts of asthma patients aged 5-44 between 1975 and 1991. The first cohort included all subjects from the start of asthma treatment, while the second included subjects hospitalised for asthma from the date of discharge. Subjects were followed up, starting 1 year after cohort entry and continuing until 1997, 54 years of age, or death. The outcome was the first asthma hospital admission and readmission, respectively, to occur during follow up. A nested case-control design was used by which all cases were matched on calendar time and several markers of asthma severity to all available controls within the cohort.

RESULTS

The full cohort included 30 569 asthmatic subjects of which 3894 were admitted to hospital for asthma and 1886 were readmitted. The overall rate of asthma hospitalisation was 42.4 per 1000 asthma patients per year. Regular use of inhaled corticosteroids was associated with reductions of 31% in the rate of hospital admissions for asthma (95% confidence interval (CI) 17 to 43) and 39% in the rate of readmission (95% CI 25 to 50). The rate reduction found during the first 4 years of follow up was sustained over the longer term. Regular use of inhaled corticosteroids can potentially prevent between five hospital admissions and 27 readmissions per 1000 asthma patients per year.

CONCLUSION

Regular use of low dose inhaled corticosteroids prevents a large proportion of hospital admissions with asthma, both early and later on in the course of the disease.

Inhaled corticosteroids and the risk of diabetes among the elderly

AIMS

There is evidence that large doses of inhaled corticosteroids lead to an increased risk of glaucoma, cataracts and other problems associated with oral corticosteroid use. However, no formal investigation so far has been conducted into the relationship between inhaled corticosteroids and diabetes.

METHODS

Our nested case-control design studied the association between current use of inhaled corticosteroids and the risk of using antidiabetic medications among a cohort of 21 645 elderly subjects. We also investigated the possibility of a dose-response relationship in users of beclomethasone. Data were obtained from the medical and pharmaceutical databases of the Regie de l'assurance maladie du Québec.

RESULTS

Within the cohort, we identified 1494 cases and we selected 14 931 controls using density sampling. The unadjusted rate ratio (and 95% confidence interval, CI) for developing diabetes among current users of inhaled corticosteroids was 1.4 (1.2, 1.5). After adjusting for covariates, the rate ratio (95% CI) decreased to 0.9 (0.8, 1.1). The loss of statistical significance was due in large part to adjusting for the current use of oral corticosteroids. We also did not observe a statistically significant increase in risk among users of high-dose beclomethasone compared to nonusers, after adjusting for covariates.

CONCLUSIONS

Our results do not indicate an increased risk of diabetes among current users of inhaled corticosteroids.

Twice-daily budesonide inhalation suspension in infants and children < 4 and > or = 4 years of age with persistent asthma

A retrospective analysis, based on a randomized, placebo-controlled, 12-week study in children 6 months to 8 years of age with persistent asthma, was performed to compare the efficacy and safety of budesonide inhalation suspension 0.25 mg and 0.5 mg twice daily vs. placebo in children < 4 and > or = 4 years of age. Both age groups demonstrated significant (p < or = 0.050) improvement in nighttime and daytime asthma symptom scores and decreased bronchodilator use compared with placebo. In addition, the safety profile of twice-daily budesonide inhalation suspension was favorable in both age groups.

Irreversible airway obstruction in childhood asthma? A clinician's viewpoint

Even though childhood asthma is assumed to comprise reversible airway obstruction, some children develop irreversible airway obstruction (not reversed by a bronchodilator or corticosteroids); this may be due to inflammation that has caused remodeling. Lately, it has been claimed that in the absence of treatment with inhaled corticosteroids, most patients will develop progressive irreversible obstruction. Several studies culminating with the Childhood Asthma Management Program (CAMP) study, which was the first randomized placebo-controlled prospective long-term study designed to test for irreversible obstruction, did not show the development of such progressive irreversible obstruction. Nevertheless, deterioration in pulmonary function does occur in some patients, probably due to inadequate anti-inflammatory treatment, and possibly also due to maintenance adrenergic treatment. Most previous studies concentrated on forced expiratory volume in 1 sec (FEV(1)), a test assessing mostly large airway obstruction. More studies are needed to investigate the presence of small airway obstruction.

Budesonide but not nedocromil sodium reduces exhaled nitric oxide levels in asthmatic children

Exhaled nitric oxide (ENO) has been proposed as a marker of airway inflammation in asthma and could be useful to evaluate the response to anti-inflammatory treatment. We investigated the effect of budesonide and nedocromil sodium on ENO levels and lung function in asthmatic children. Twenty stable steroid-naïve asthmatic children were randomized in a single blind, cross-over study to receive inhaled budesonide (group A) or nedocromil sodium (group B) for 6 weeks. ENO was measured with a chemiluminescence analyser at baseline and at the end of each treatment period. Repeated-measures ANOVA was carried out. In asthmatic baseline ENO levels [mean 32.5 ppb, 95% confidence interval (CI) 26.4 to 38.7] were significantly higher compared to reference values (8.7 ppb, 95% CI 8.1 to 9.2, P<0.001). There were no treatment-order effect, no carry-over effect and in both groups the response pattern was the same: budesonide significantly lowered ENO levels from 41.0 ppb to 22.8 ppb in group A (mean, P<0.01) and from 22.6 ppb to 13.0 ppb in group B, (mean, P<0.05), while nedocromil did not reduce ENO values (from 24.4 ppb to 22.6 ppb in group B and from 22.8 ppb to 38.0 ppb in group A, mean, P = NS and P<0.01 respectively). After budesonide treatment ENO values of asthmatics were still significantly higher than in healthy children The baseline values of FEV1 and FEF(25-75) were normal in both groups and no significant changes were observed during the study. In conclusion, our study shows that budesonide, but not nedocromil sodium, significantly reduces ENO levels in stable asthmatic children even in absence of changes in the lung function.

The anti-IgE antibody omalizumab reduces exacerbations and steroid requirement in allergic asthmatics

The clinical benefit and steroid-sparing effect of treatment with the anti-immunoglobulin-E (IgE) antibody, omalizumab, was assessed in patients with moderate-to-severe allergic asthma. After a run-in period, 546 allergic asthmatics (aged 12-76 yrs), symptomatic despite inhaled corticosteroids (500-1,200 microg daily of beclomethasone dipropionate), were randomized to receive double-blind either placebo or omalizumab every 2 or 4 weeks (depending on body weight and serum total IgE) subcutaneously for 7 months. A constant beclomethasone dose was maintained during a 16-week stable-steroid phase and progressively reduced to the lowest dose required for asthma control over the following 8 weeks. The latter dose was maintained for the next 4 weeks. Asthma exacerbations represented the primary variable. Compared to the placebo group, the omalizumab group showed 58% fewer exacerbations per patient during the stable-steroid phase (p<0.001). During the steroid-reduction phase, there were 52% fewer exacerbations in the omalizumab group versus the placebo group (p<0.001) despite the greater reduction of the beclomethasone dosage on omalizumab (p<0.001). Treatment with omalizumab was well tolerated. The incidence of adverse events was similar in both groups. These results indicate that omalizumab therapy safely improves asthma control in allergic asthmatics who remain symptomatic despite regular use of inhaled corticosteroids and simultaneous reduction in corticosteroid requirement.

Inhalation therapy of the future--how will it change the way we treat asthma?

Inhalation of drugs has made a great difference in terms of optimizing asthma therapy. The challenge for the next generation of inhalers will be to provide still greater benefits to patients in terms of efficacy, safety, and convenience. Dry powder inhalers (DPIs) are innovative new inhalation devices and comparisons with pressurized metered dose inhalers (pMDIs) show that DPIs are at least as efficient at delivering drugs, and may be a superior delivery device for some drugs. To compare different inhaler devices, drug dose comparisons that lie on the slope of the dose-response curve should be selected, and it is important to analyze the risk:benefit ratio (therapeutic ratio). Some of the new devices contain aerosols with a smaller particle size than current designs. Monodispersed aerosols with a very narrow range of particle sizes may target drug delivery to specific areas of the lung where it is most effective. However, as smaller particles are more easily absorbed into the pulmonary circulation via the alveoli, these formulations may be associated with a higher incidence of systemic side effects. The optimal particle size required to maximize the therapeutic ratio of a molecule may be different for a beta2-agonist than for an inhaled corticosteroid. A greater understanding of this relationship will be required if we are to achieve better drug targeting with future inhalers.

Inhaled corticosteroids: impact on asthma morbidity and mortality

Inhaled corticosteroids are now recommended as first-line therapy for asthma. Although these drugs clearly improve the symptoms of the disease and the associated physiologic abnormalities, epidemiologic studies provide important information on their effectiveness in preventing asthma morbidity and mortality. We review the evidence regarding the role of inhaled corticosteroids in the prevention of asthma fatality and hospitalization. In the process, we discuss the methodologic complexities of the nonexperimental studies and the implications of the methodologic issues on the evaluation of the impact of these drugs. Eight of the cohort and ecologic studies conducted to date strongly suggest that inhaled corticosteroids, when taken regularly, decrease the number of hospitalizations for asthma by up to 80%. For asthma death, the results of 11 investigations appear less consistent, especially those of several cohort and case-control studies whose principal objective was to examine not the benefit of inhaled corticosteroids but the adverse effects of other drug classes. Much of the inconsistency in the results, however, can be explained by weaknesses in study design and analysis-in particular, the failure to consider exposure in terms of regular use of inhaled corticosteroids. When the most recent study involving the use of the Saskatchewan databases is considered, it is evident that regular treatment with conventional or low-dose inhaled cortico-steroids results in a significant reduction in fatalities due to asthma. In all, the evidence to date strongly indicates that regular use of inhaled corticosteroids, even at low doses, would prevent the major portion of asthma hospitalizations and deaths.

How to manage difficult asthma cases. An action plan for physicians and patients

Patients with difficult-to-manage asthma represent one of the greatest challenges in primary care practice. Because these patients are at risk for life-threatening attacks, close monitoring is essential to ensure compliance and to control attacks or medication side effects. In this article, Dr Hunt discusses the many aspects of management, including assessment, identification of triggers, treatment planning, and patient and family education. An "action plan" that outlines the management program is described.

Inhaled corticosteroids as first-line therapy for asthma. Why they work--and what the guidelines and evidence suggest

Despite a plethora of clinical guidelines and evidence outlining the efficacy of inhaled corticosteroids, these medications continue to be underused in the treatment of asthma. This article reviews the justification for prescribing inhaled steroids as first-line therapy, discusses indications for their use, and compares potencies of the various products now available. In addition, the authors address the adverse effects commonly associated with these agents and provide evidence supporting early intervention with inhaled steroids in the treatment of persistent asthma.

Advair: combination treatment with fluticasone propionate/salmeterol in the treatment of asthma

Several classes of medications are available for the treatment of asthma, and often they must be taken concurrently to achieve asthma control. Based on the understanding of asthma as an inflammatory disease, the National Heart Lung and Blood Institute guidelines provide a stepwise approach to pharmacologic therapy. Corticosteroid therapy, principally inhaled corticosteroid (ICS) therapy, is considered the most effective anti-inflammatory treatment. In cases of moderate-to-severe persistent asthma, the addition of a second long-term control medication to ICS therapy is one recommended treatment option. A combination-product inhaler (Advair, Seretide) was developed to treat both the inflammatory and bronchoconstrictive components of asthma by delivering a dose of the ICS, fluticasone propionate, and a dose of the long-acting beta2-adrenergic (LABA) bronchodilator, salmeterol. The Advair Diskus is available in 3 strengths of fluticasone propionate (100, 250, and 500 microg) and a fixed dose (50 microg) of salmeterol. Combination treatment with both ICS and LABA provides greater asthma control than increasing the ICS dose alone, while at the same time reducing the frequency and perhaps the severity of exacerbations. Furthermore, salmeterol added to ICS therapy provides superior asthma control compared with the addition of leukotriene modifiers or theophylline. The superior control is likely a consequence of the complementary actions of the drugs when taken together, including the activation of the glucocorticoid receptor by salmeterol. By combining anti-inflammatory treatment with a long-acting beta2-agonist in a single inhaler (1 inhalation twice daily), physicians can provide coverage for both the inflammatory and bronchoconstrictive aspects of asthma without introducing any new or unexpected adverse consequences. The most common drug-related adverse events were those known to be attributable to the constituent medications (ICS therapy and/or LABA therapy). Although the benefits of combined ICS plus LABA therapy can be achieved with separate inhalers, the convenience of the combination product may improve patient adherence and may therefore reduce the morbidity of asthma.

Mometasone furoate administered once daily is as effective as twice-daily administration for treatment of mild-to-moderate persistent asthma

BACKGROUND

Despite current recommendations, many patients with persistent asthma are still treated with bronchodilators alone.

OBJECTIVE

The safety and efficacy of two once daily dosing regimens (200 microg and 400 microg) of mometasone furoate (MF) administered in the morning by using a dry-powder inhaler (DPI) were compared with those of a twice daily dosing regimen (200 microg administered twice daily) in patients with mild-to-moderate persistent asthma previously taking only inhaled beta(2)-adrenergic agonists.

METHODS

All patients (306 patients; age range, 12-70 years) were given a diagnosis of asthma for at least 6 months before enrollment in this 12-week, placebo-controlled, double-blind, randomized study. The primary efficacy variable was change in FEV(1) from baseline to endpoint (last evaluable visit).

RESULTS

At endpoint, FEV(1) was significantly improved (P < or =.02) after MF-DPI 400 microg once daily morning treatment and MF-DPI 200 microg twice daily treatment (16.0% and 16.1%, respectively) compared with placebo (5.5%). The improvement seen with MF-DPI 200 microg once daily morning treatment (10.4%) was not significantly different from that with placebo. Secondary efficacy variables also showed significant improvement for the MF-DPI 400 microg once daily morning treatment group and the MF-DPI 200 microg twice daily treatment group compared with the placebo group. All doses of MF administered by means of a DPI were well tolerated.

CONCLUSION

This is the first study to demonstrate that a total daily dose of 400 microg of MF administered by means of a DPI is an effective treatment for patients with mild-to-moderate persistent asthma previously taking only inhaled beta(2)-adrenergic agonists. This treatment was equally effective when administered either as a once daily or twice daily regimen.

Low-dose inhaled corticosteroids and the prevention of death from asthma

BACKGROUND

Although inhaled corticosteroids are effective for the treatment of asthma, it is uncertain whether their use can prevent death from asthma.

METHODS

We used the Saskatchewan Health data bases to form a population-based cohort of all subjects from 5 through 44 years of age who were using antiasthma drugs during the period from 1975 through 1991. We followed subjects until the end of 1997, their 55th birthday, death, emigration, or termination of health insurance coverage; whichever came first. We conducted a nested case-control study in which subjects who died of asthma were matched with controls within the cohort according to the length of follow-up at the time of death of the case patient (the index date), the date of study entry, and the severity of asthma. We calculated rate ratios after adjustment for the subject's age and sex; the number of prescriptions of theophylline, nebulized and oral beta-adrenergic agonists, and oral corticosteroids in the year before the index date; the number of canisters of inhaled beta-adrenergic agonists used in the year before the index date; and the number of hospitalizations for asthma in the two years before the index date.

RESULTS

The cohort consisted of 30,569 subjects. Of the 562 deaths, 77 were classified as due to asthma. We matched the 66 subjects who died of asthma for whom there were complete data with 2681 controls. Fifty-three percent of the case patients and 46 percent of the control patients had used inhaled corticosteroids in the previous year, most commonly low-dose beclomethasone. The mean number of canisters was 1.18 for the patients who died and 1.57 for the controls. On the basis of a continuous dose-response analysis, we calculated that the rate of death from asthma decreased by 21 percent with each additional canister of inhaled corticosteroids used in the previous year (adjusted rate ratio, 0.79; 95 percent confidence interval, 0.65 to 0.97). The rate of death from asthma during the first three months after discontinuation of inhaled corticosteroids was higher than the rate among patients who continued to use the drugs.

CONCLUSIONS

The regular use of low-dose inhaled corticosteroids is associated with a decreased risk of death from asthma.