Oral corticosteroid-sparing effects of inhaled corticosteroids in the treatment of persistent and acute asthma

Use of Dupilumab in Glucocorticoid-Dependent Asthma

Of the patients with asthma, 20% to 25% progress to severe symptoms, resulting in poor quality of life and increased episodes of exacerbation. There is a broad range of drugs used for asthma; the most used medications for severe asthma are inhaled glucocorticoids with or without long-acting β-agonists. Systemic glucocorticoids and other treatments as add-on therapies are also given as needed. Chronic glucocorticoid use is associated with numerous adverse effects, including diabetes mellitus, osteoporosis, anxiety, depression, and cataracts. The occurrence of these side effects has been reduced because of the emergence of new biological therapies. One such treatment is dupilumab, which helps in the reduction of type 2 inflammation involved in the pathophysiology of asthma. We conducted a literature review to assess the efficacy, adverse effects, and pharmacological benefits of dupilumab in glucocorticoid-dependent asthma. In most randomized controlled trials, dupilumab has shown significant efficacy and safety profile in patients with severe asthma with corticosteroid dependence. Associated adverse effects such as injection site reaction and transient eosinophilia have been reported. Our review of the literature indicates that dupilumab has proven to improve lung function, reduce the rate of asthma exacerbations, and reduce the use of corticosteroids.

Type 2 inflammation in asthma and other airway diseases

Chronic inflammatory airway diseases, including asthma, chronic rhinosinusitis, eosinophilic COPD and allergic rhinitis are a global health concern. Despite the coexistence of these diseases and their common pathophysiology, they are often managed independently, resulting in poor asthma control, continued symptoms and poor quality of life. Understanding disease pathophysiology is important for best treatment practice, reduced disease burden and improved patient outcomes. The pathophysiology of type 2 inflammation is driven by both the innate immune system triggered by pollutants, viral or fungal infections involving type 2 innate lymphoid cells (ILC2) and the adaptive immune system, triggered by contact with an allergen involving type 2 T-helper (Th2) cells. Both ILC2 and Th2 cells produce the type-2 cytokines (interleukin (IL)-4, IL-5 and IL-13), each with several roles in the inflammation cascade. IL-4 and IL-13 cause B-cell class switching and IgE production, release of pro-inflammatory mediators, barrier disruption and tissue remodelling. In addition, IL-13 causes goblet-cell hyperplasia and mucus production. All three interleukins are involved in trafficking eosinophils to tissues, producing clinical symptoms characteristic of chronic inflammatory airway diseases. Asthma is a heterogenous disease; therefore, identification of biomarkers and early targeted treatment is critical for patients inadequately managed by inhaled corticosteroids and long-acting β-agonists alone. The Global Initiative for Asthma guidelines recommend add-on biological (anti IgE, IL-5/5R, IL-4R) treatments for those not responding to standard of care. Targeted therapies, including omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab and tezepelumab, were developed on current understanding of the pathophysiology of type 2 inflammation. These therapies offer hope for improved management of type 2 inflammatory airway diseases.

Step-up and step-down approaches in the treatment of asthma

Introduction: Significant intraindividual and temporal variability in symptom control is a feature of asthma that requires careful monitoring and the need to periodically review and adjust therapy. Both NHLBI/NAEPP and GINA offer helpful algorithms for a stepping approach to asthma.Areas covered: The problems arisen in applying the stepwise approach to the treatment of asthma proposed by NHLBI/NAEPP and GINA algorithms and their possible alternatives.Expert opinion: The current therapeutic stepping approach to asthma, which takes into account lung function, symptoms and quality of life, is certainly useful, but it does not consider the underlying mechanisms. Furthermore, patient's overestimation or underestimation of the severity of the disease and differences in the opinions on the level of asthma control required between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks. A reassessment of the conventional stepping approach to management of asthma is now needed. A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma which, when therapeutically targeted, will in many cases help to achieve the goals, seems more reasonable than the present stepping approach.

The Asthma Controller Step-down Yardstick

Asthma guidelines recommend a control-based approach to disease management in which the assessment of impairment and risk is linked to step-based therapy. Using this model, controller treatment is adjusted-upward or downward-according to a patient's level of asthma control over time. Strategies for stepping up controller therapy are well described, and the adult and pediatric Asthma Yardsticks provide operational recommendations based on patient profiles. Strategies for stepping down controller treatment are less clear, although stepping down to the minimum effective therapy is important and should be considered when a patient's asthma has been well controlled for an adequate period as defined by risk and impairment. This Yardstick presents recommendations for when and how to step down asthma controller therapy according to guideline-defined control levels. The objective is to provide clinicians who treat patients with asthma with a practical and clinically relevant framework for implementing a step-down in controller therapy.

Long-term effects of inhaled corticosteroids on bone mineral density in older women with asthma or COPD: a registry-based cohort study

We assessed the association between long-term inhaled corticosteroid (ICS) use and bone mineral density (BMD) in older women with chronic respiratory disease. Women with > 50% adherence to ICS use had very slightly accelerated BMD loss at the total hip compared with those with lower or ICS use.

INTRODUCTION

This study evaluated the impact of long-term ICS therapy on bone loss in older women with asthma or chronic obstructive pulmonary disease (COPD).

METHODS

We used a population-based bone densitometry registry linked with administrative health data covering the province of Manitoba, Canada (1999-2013), to identify women aged > 40 years who had diagnosed asthma or COPD. ICS exposure was defined as cumulative dispensed days and medication possession ratio (MPR). Associations were examined both cross-sectionally and longitudinally, and results were covariate adjusted.

RESULTS

Among 6561 women with asthma and/or COPD (mean age 65 years [SD = 11]), compared to no ICS treatment, those in the highest tertile of prior ICS use (≥ 720 days) had lower BMD at the femoral neck (- 0.09 T-score, 95% CI - 0.16, - 0.02) and total hip (- 0.14 T-score, 95% CI - 0.22, - 0.05), but not at the lumbar spine. Over a mean of 5 years of follow-up, the highest tertile of ICS exposure (MPR > 0.5) was associated with a - 0.02 SD/year (95% CI - 0.04, - 0.01) greater decline in total hip BMD relative to non-users, with no significant effect at the femoral neck or lumbar spine. Middle and lower tertiles of ICS use were not associated with baseline or longitudinal change in BMD.

CONCLUSIONS

The highest tertile of ICS use was associated with a slightly lower hip BMD at baseline and slightly greater reduction in total hip BMD over time in older women with asthma or COPD. No adverse effects on BMD were seen from low to moderate ICS exposure.

Efficacy and Safety of Dupilumab in Glucocorticoid-Dependent Severe Asthma

BACKGROUND

Dupilumab is a fully human anti-interleukin-4 receptor α monoclonal antibody that blocks both interleukin-4 and interleukin-13 signaling. Its effectiveness in reducing oral glucocorticoid use in patients with severe asthma while maintaining asthma control is unknown.

METHODS

We randomly assigned 210 patients with oral glucocorticoid-treated asthma to receive add-on dupilumab (at a dose of 300 mg) or placebo every 2 weeks for 24 weeks. After a glucocorticoid dose-adjustment period before randomization, glucocorticoid doses were adjusted in a downward trend from week 4 to week 20 and then maintained at a stable dose for 4 weeks. The primary end point was the percentage reduction in the glucocorticoid dose at week 24. Key secondary end points were the proportion of patients at week 24 with a reduction of at least 50% in the glucocorticoid dose and the proportion of patients with a reduction to a glucocorticoid dose of less than 5 mg per day. Severe exacerbation rates and the forced expiratory volume in 1 second (FEV₁) before bronchodilator use were also assessed.

RESULTS

The percentage change in the glucocorticoid dose was -70.1% in the dupilumab group, as compared with -41.9% in the placebo group (P<0.001); 80% versus 50% of the patients had a dose reduction of at least 50%, 69% versus 33% had a dose reduction to less than 5 mg per day, and 48% versus 25% completely discontinued oral glucocorticoid use. Despite reductions in the glucocorticoid dose, in the overall population, dupilumab treatment resulted in a severe exacerbation rate that was 59% (95% confidence interval [CI], 37 to 74) lower than that in the placebo group and resulted in an FEV₁ that was 0.22 liters (95% CI, 0.09 to 0.34) higher. Injection-site reactions were more common with dupilumab than with placebo (9% vs. 4%). Transient blood eosinophilia was observed in more patients in the dupilumab group than in the placebo group (14% vs. 1%).

CONCLUSIONS

In patients with glucocorticoid-dependent severe asthma, dupilumab treatment reduced oral glucocorticoid use while decreasing the rate of severe exacerbations and increasing the FEV₁. Transient eosinophilia was observed in approximately 1 in 7 dupilumab-treated patients. (Funded by Sanofi and Regeneron Pharmaceuticals; LIBERTY ASTHMA VENTURE ClinicalTrials.gov number, NCT02528214 .).

Glucocorticoid genes and the developmental origins of asthma susceptibility and treatment response

Antenatal corticosteroids enhance lung maturation. However, the importance of glucocorticoid genes on early lung development, asthma susceptibility, and treatment response remains unknown. We investigated whether glucocorticoid genes are important during lung development and their role in asthma susceptibility and treatment response. We identified genes that were differentially expressed by corticosteroids in two of three genomic datasets: lymphoblastoid cell lines of participants in the Childhood Asthma Management Program, a glucocorticoid chromatin immunoprecipitation/RNA sequencing experiment, or a murine model; these genes made up the glucocorticoid gene set (GCGS). Using gene expression profiles from 38 human fetal lungs and C57BL/6J murine fetal lungs, we identified developmental genes that were in the top 5% of genes contributing to the top three principal components (PCs) most highly associated with post-conceptional age. Glucocorticoid genes that were enriched in this set of developmental genes were then included in the developmental glucocorticoid gene set (DGGS). We then investigated whether glucocorticoid genes are important during lung development, and their role in asthma susceptibility and treatment response. A total of 232 genes were included in the GCGS. Analysis of gene expression demonstrated that glucocorticoid genes were enriched in lung development (P = 7.02 × 10(-26)). The developmental GCGS was enriched for genes that were differentially expressed between subjects with asthma and control subjects (P = 4.26 × 10(-3)) and were enriched after treatment of subjects with asthma with inhaled corticosteroids (P < 2.72 × 10(-4)). Our results show that glucocorticoid genes are overrepresented among genes implicated in fetal lung development. These genes influence asthma susceptibility and treatment response, suggesting their involvement in the early ontogeny of asthma.

Nebulised budesonide using a novel device in patients with oral steroid-dependent asthma

This phase 2/3 randomised, parallel-group, placebo-controlled trial investigated oral corticosteroid (OCS)-sparing efficacy, safety and tolerability of nebulised budesonide (Bud) administered with a novel computer-controlled, compressor-driven inhalation system (AKITA) as add-on therapy to Global Initiative for Asthma step 5. Patients (18-65 years) with OCS-dependent asthma were randomised (2:1:1:1) to receive 18-week, twice-daily, double-blind treatment with AKITA inhaled corticosteroid (AICS)-Bud 1 mg, AICS-Bud 0.5 mg, AICS-placebo or open-label Bud 1 mg administered by conventional nebuliser (CN-Bud). OCS doses were tapered until week 14. 199 patients started treatment. More AICS-Bud 1 mg (80.0%) than placebo-treated (62.5%) patients had daily OCS doses reduced ≥50%, with clinical stability to week 18 (one-sided p=0.02; treatment difference: 17.5% (95% CI 0.1-34.9%), two-sided p=0.04). Mean±sd forced expiratory volume in 1 s improved (from baseline to week 18) for AICS-Bud 1 mg (239±460 mL, p<0.001) and AICS-Bud 0.5 mg (126±345 mL, p=0.01) but not placebo (93±419 mL, p=0.36) or CN-Bud (137±459 mL, p=0.18). Fewer AICS-Bud 1 mg-treated patients experienced asthma exacerbations (7.5%) compared with placebo (17.5%) or CN-Bud (22.5%). All treatments were well tolerated. Budesonide applied with AKITA allowed significant meaningful OCS reduction in OCS-dependent asthma patients while improving pulmonary function and maintaining exacerbation control.

Relative oral corticosteroid-sparing effect of 7 inhaled corticosteroids in chronic asthma: a meta-analysis

BACKGROUND

The relative efficacy of various inhaled corticosteroids (ICSs) for oral corticosteroid (OCS)-sparing effect in asthma is not known. To our knowledge, no randomized controlled trial directly comparing 2 ICSs has been reported, but several randomized controlled trials have reported comparison of various ICSs with placebo.

OBJECTIVE

To conduct an adjusted indirect comparison of 7 ICSs for their OCS-sparing effect.

METHODS

PubMed and bibliographies of relevant articles. Eighteen placebo-controlled randomized trials of 7 ICSs were analyzed using a random-effect model. Pooled benefit ratios (BRs) (ICS/placebo) for elimination of OCS and weighted mean differences (ICS - placebo) for OCS dose change by each ICS vs placebo were determined. Pairwise adjusted indirect comparisons of various ICSs were then made.

RESULTS

For OCS elimination, all ICSs were more effective than placebo (BR: mometasone, 17.2; budesonide, 8.2; beclomethasone and fluticasone, 5.4; triamcinolone, 4.6; ciclesonide, 2.8; and flunisolide, 2.2). On pairwise adjusted indirect comparison, the BR of mometasone was significantly higher than that of triamcinolone (P = .02), ciclesonide (P = .01), and flunisolide (P = .01) and that of budesonide was significantly higher than that of ciclesonide (P = .02) and flunisolide (P = .03). For OCS dose change, beclomethasone achieved a significantly lower final mean OCS dose than fluticasone or flunisolide (P < .001). In all other comparisons, the differences were not statistically significant.

CONCLUSIONS

All ICSs studied were significantly more effective than placebo for OCS sparing, but mometasone seemed to be more effective than others. However, because of very few trials for some ICSs, more placebo-controlled trials for adjusted indirect comparison or randomized trials for direct comparison of these ICSs are needed for definitive conclusions.

Oral corticosteroid-dependent asthma: a 30-year review

OBJECTIVE

To identify novel aspects of the pathogenesis, therapeutic options, and prophylaxis measures of corticosteroid-dependent asthma.

DATA SOURCES

PubMed searches were undertaken of studies published between 1966 and 2006 on the pathogenesis of and corticosteroid-sparing therapies for corticosteroid-dependent asthma. Identified review articles were surveyed for additional and earlier citations. Recent American Academy of Asthma, Allergy, and Immunology meeting abstracts were also searched to identify other recently published and unpublished studies.

STUDY SELECTION

Inclusion of studies in the review was decided by simple agreement of both reviewers, who independently read the "Methods" and "Discussion" sections of articles identified using the search strategy. Quality assessment was performed by the 2 reviewers.

RESULTS

High-dose inhaled corticosteroids are the first-line option for corticosteroid-dependent asthmatic patients with clear efficacy. Omalizumab is effective in reducing oral corticosteroid requirements in allergic asthma. Methotrexate, gold, and cyclosporine have corticosteroid-sparing effects clinically that must be weighed against a serious adverse effect profile. Nebulized diuretics and lidocaine, with a low adverse effect profile, offer promising results but require further study. Clarithromycin and telithromycin seem to have an independent mechanism of inflammatory modulation, but their effect on corticosteroid-dependent asthma remains to be seen. Etanercept offers only early clinical evidence of a role in corticosteroid-dependent asthma.

CONCLUSIONS

With no clear consensus on corticosteroid-sparing treatment in corticosteroid-dependent asthmatic patients, systemic glucocorticoids remain the foremost therapy, with adverse effects that require monitoring and prophylaxis.

Benefit versus risk for oral, inhaled, and nasal glucocorticosteroids

Many factors affect the benefit-to-risk analysis of the use of the glucocorticosteroids in the treatment of allergic inflammation. For most patients the benefit-to-risk ratio favors topical over oral administration, but in severe disease oral administration may be required. It is clear from pharmacokinetic and pharmacodynamic studies that inhaled glucocorticosteroids in particular are absorbed into the systemic circulation and that they can have clinical adverse effects when given in high doses. Therefore, with inhaled and nasal glucocorticosteroids, the dose that will achieve the optimal benefit/risk ratio is the lowest dose that controls symptoms and prevents exacerbations requiring treatment with oral glucocorticosteroids. This optimal dose needs to be determined on an individual basis and is likely to vary as disease severity changes over time.

Effects of inhaled corticosteroids on bone

OBJECTIVE

To discuss the effects of inhaled corticosteroids on bone and their potential public health implications.

DATA SOURCES

The MEDLINE and EMBASE databases were searched to identify articles published between 1966 and January 2004 with the following keywords in the title: inhaled corticosteroid, beclomethasone, budesonide, flunisolide, fluticasone, mometasone, triamcinolone plus bone, fracture, osteoporosis, osteocalcin, growth, or height.

STUDY SELECTION

Key studies of adequate size and duration that allowed for potential confounding factors where required were selected.

RESULTS

Inhaled corticosteroids are absorbed into the systemic circulation and therefore have the potential to cause adverse effects on bone. Several of the larger studies showed that inhaled corticosteroids cause a dose-related reduction in bone mineral density. Three cross-sectional studies found a dose-related increase in fractures in people taking an inhaled corticosteroid compared with controls. Prospective studies found a short-term reduction in growth velocity in children taking an inhaled corticosteroid, although target adult height is usually achieved.

CONCLUSION

Since osteoporotic fracture is common in elderly patients and up to 5% of the population in more developed countries take an inhaled corticosteroid, these findings have public health implications. Strategies are needed to reduce the systemic effects of inhaled corticosteroids.