Evidence-based selection of inhaled corticosteroid for treatment of chronic asthma

CARE: an observational study of adherence to home nebulizer therapy among children with asthma

Background:

The prevalence of pediatric asthma in China is approximately 3%, and asthma remains poorly controlled in many of these patients. This study assessed the rate of adherence to home nebulizer treatment in paediatric patients in China.

Methods:

The CARE study was a 12-week, multicentre, prospective, observational study across 12 tertiary hospitals in China. Patients were aged 0–14 years, clinically diagnosed with asthma and prescribed home nebulizer inhaled corticosteroid (ICS) therapy for ⩾3 months. The primary endpoint was electronically monitored treatment adherence. Patients attended onsite visits at 0, 4, 8 and 12 weeks to assess asthma control, severity and treatment adherence (recorded by electronic monitoring devices and caregivers).

Results:

The full analysis set included 510 patients. Median treatment adherence reported by electronic monitoring devices was 69.9%, and median caregiver-reported adherence was 77.9%. The proportion of patients with well-controlled asthma increased from 12.0% at baseline to 77.5% at visit 4. Increased time between asthma diagnosis and study enrolment was a significant predictor for better adherence [coefficient: 0.01, p = 0.0138; 95% confidence interval (CI): 0.00, 0.01] and asthma control (odds ratio = 1.001, p = 0.0498; 95% CI: 1.000, 1.002). Negative attitude to treatment by the caregiver was associated with poorer asthma control.

Conclusions:

Adherence to home nebulization, a widely used treatment for asthma, was high among Chinese pediatric patients. Asthma control improved with increasing treatment duration. These results suggest that home nebulization of ICS is an effective and recommendable long-term treatment for paediatric patients with asthma.

Trial registration

ClinicalTrials.gov identifier: NCT03156998

The reviews of this paper are available via the supplemental material section.

Clinical relevance of target identity and biology: implications for drug discovery and development

Many of the most commonly used drugs precede techniques for target identification and drug specificity and were developed on the basis of efficacy and safety, an approach referred to as classical pharmacology and, more recently, phenotypic drug discovery. Although substantial gains have been made during the period of focus on target-based approaches, particularly in oncology, these approaches have suffered a high overall failure rate and lower productivity in terms of new drugs when compared with phenotypic approaches. This review considers the importance of target identity and biology in clinical practice from the prescriber's viewpoint. In evaluating influences on prescribing behavior, studies suggest that target identity and mechanism of action are not significant factors in drug choice. Rather, patients and providers consistently value efficacy, safety, and tolerability. Similarly, the Food and Drug Administration requires evidence of safety and efficacy for new drugs but does not require knowledge of drug target identity or target biology. Prescribers do favor drugs with novel mechanisms, but this preference is limited to diseases for which treatments are either not available or suboptimal. Thus, while understanding of drug target and target biology is important from a scientific perspective, it is not particularly important to prescribers, who prioritize efficacy and safety.

Inhaled corticosteroid/long-acting β₂-agonist combination therapy for asthma: attitudes of specialists in Europe

BACKGROUND

As new combinations of inhaled corticosteroids (ICSs) and long-acting β(2)-agonists (LABAs) become available for the treatment of asthma, it will be important to determine criteria against which they can be evaluated. The aim of this study was to assess which attributes of combination therapy physicians consider most important.

METHODS

Primary and secondary care asthma specialists (n = 32) were recruited for an expert Delphi process that was performed over three rounds to determine attributes perceived to be important in the selection of combination therapy. A pan-European survey was carried out to assess the attitudes, perceptions and prescribing behaviour of a larger population (n = 1,861) of physicians with a specialist interest in asthma treatment.

RESULTS

The expert Delphi panel (response rate 59.4%) agreed that the availability of a range of doses (88% agreement in the final round), the efficacy of the combination (81%) and the safety and tolerability of the therapy (81%) were important attributes of ICS/LABA combination treatment. The potency of the ICS (69%) and the speed of onset of the LABA (69%) were also prioritized. The results of the attitudinal survey (eligibility rate 54.1%) showed that the same factors were considered important in everyday clinical practice.

CONCLUSIONS

These studies identified which attributes of an ICS/LABA treatment are considered most important by an expert panel and a broader group of physicians; further research is warranted to better understand the influences that drive physician opinions.

Inhaled corticosteroid therapy with nebulized beclometasone dipropionate

Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents for the management of chronic persistent asthma and are therefore recommended as first-line antiasthmatic therapy in children and adults. In various settings, the administration of ICS via nebulizer rather than hand-held inhaler (HHI) may have certain advantages, as many patients with HHI fail to use these devices properly or efficiently. In particular, young children, the elderly, the acutely ill, and those with restricted dexterity may be unable to coordinate inhalation with actuation of the device or to generate sufficient inspiratory flow to operate breath-actuated devices effectively. Compliance with nebulized therapy may also be better than that with a pressurized metered-dose inhaler (pMDI) plus spacer. Systematic reviews conclude that there is no significant difference in clinical effects between nebulizers and HHI. Performance and clinical effect of nebulization are influenced by several technical aspects such as the nebulizer-drug combination, nebulizer type, output and lung deposition. Among the currently available ICS, nebulized beclometasone dipropionate (BDP) has been in clinical use for more than 35 years, and has demonstrated marked clinical efficacy and a favorable tolerability profile in children and adults with chronic persistent asthma. The clinical efficacy of nebulized beclometasone is discussed in the present review using data from 13 published studies, which included a total of 1250 patients. Three multicenter, randomized, double-blind studies showed that nebulized BDP is as effective as BDP via pMDI plus spacer in a 2:1 dose ratio. Controlled trials involving 497 adults and children demonstrated similar clinical efficacy between nebulized BDP and either nebulized fluticasone propionate or nebulized budesonide. In all these trials, treatment-related adverse effects were generally uncommon, most were mild-to-moderate in severity, and most were associated with the respiratory system. Meta-analyses show that BDP, like other inhaled corticosteroids, has no major influence on patient height, urinary cortisol concentration, or bone metabolism, thus suggesting the absence of growth retardation or any marked effect on adrenal function or the hypothalamic-pituitary-adrenal axis when used in the approved dose range. Overall, nebulized BDP appears to have a particularly important place in asthma therapy: as a general alternative to HHIs (e.g. in patients with poor HHI compliance); when patients such as children or the elderly are unable to operate HHIs because of poor hand-lung coordination, lack of cooperation, or low inspiratory flow rate; and when high dosages of ICS are required, such as in adults with severe, corticosteroid-dependent asthma.

NT-702 (parogrelil hydrochloride, NM-702), a novel and potent phosphodiesterase 3 inhibitor, suppress the asthmatic response in guinea pigs, with both bronchodilating and anti-inflammatory effects

We evaluated the effects of NT-702 (parogrelil hydrochloride, NM-702, 4-bromo-6-[3-(4-chlorophenyl) propoxy]-5-[(pyridine-3-ylmethyl) amino] pyridazin-3(2H)-one hydrochloride), a selective phosphodiesterase 3 inhibitor, on the asthmatic response in guinea pigs. NT-702 at a concentration of 1 x 10(-7)M elevated the cyclic adenosine monophosphate content in prostaglandin E(2)-treated guinea pig tracheal smooth muscle cells. Leukotriene (LT) D(4)- and histamine-induced contraction of isolated guinea pig tracheal strips was inhibited by NT-702, with EC(50) values of 3.2 x 10(-7) and 2.5 x 10(-7)M, respectively. In an in vivo study, NT-702 suppressed LTD(4)-induced bronchoconstriction and the ovalbumin-induced immediate asthmatic response in guinea pigs through its bronchodilating effect. Furthermore, NT-702 also suppressed the ovalbumin-induced late asthmatic response, airway hyperresponsiveness, and the accumulation of inflammatory cells in the bronchoalveolar lavage fluid. These results suggest that NT-702 has an anti-inflammatory effect as well as a bronchodilating effect and might be useful as a novel potent therapeutic agent for the treatment of bronchial asthma, a new type of agent with both a bronchodilating and an anti-inflammatory effect.

Asthma in childhood

Management decisions for pediatric asthma (in patients younger than 12 years of age) based on extrapolation from available evidence in adolescents and adults (age 12 years and older) is common but rarely appropriate. This article addresses the disparity in response between the two age groups, presents the available pediatric evidence, and highlights the important areas in which further research is required. Evidence-based recommendations for acute and interval management of pediatric asthma are provided.

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.

Mometasone furoate dry-powder inhaler for the control of persistent asthma

Mometasone furoate dry-powder inhaler (MF-DPI) is an inhaled corticosteroid (ICS) used for the treatment of persistent asthma in patients aged >or= 12 years. MF-DPI has low systemic bioavailability and high glucocorticoid receptor affinity compared with most other ICSs and modifies inflammatory mediators involved in the pathogenesis of asthma. MF-DPI, unlike other available ICSs, is approved for initiation as a once-daily in the afternoon (q.d. PM) regimen. Studies show that MF-DPI 200 or 400 microg q.d. PM treatment significantly improves lung function and symptom control in patients with mild, moderate or severe asthma. MF-DPI 400 microg q.d. PM is reported to be equivalent to fluticasone propionate 250 microg b.i.d. and beclometasone dipropionate 168 microg b.i.d. and more efficacious than budesonide 400 microg, b.i.d. or q.d. MF-DPI is generally well tolerated, with minimal effects on the hypothalamic-pituitary-adrenal axis.

How useful are prescribing indicators based on the DU90% method to distinguish the quality of prescribing between pharmacotherapy audit meetings with different levels of functioning?

Objectives

The objective of the study was to assess the association between the quality of drug prescribing based on three indicator types derived from the DU90% method and different levels of functioning in pharmacotherapy audit meetings (PTAMs).

Materials and methods

The level of functioning in PTAMs in 2004 was assessed by a standard questionnaire. Data on prescriptions in 2004 by the GPs participating in the included PTAMs were extracted from the database of the Foundation for Pharmaceutical Statistics. Three types of DU90% indicators were computed for the seven mostly prescribed drug classes. With univariate and multivariate analyses of variance, differences in the results of three types of indicators for each of the seven drug classes were assessed according to the levels of PTAMs.

Results

For 84 PTAMs with varying levels of functioning, we found no association between the level of PTAM and the quality of prescribing for any of the indicators within the seven drug classes. In general, results gained of all PTAMs seemed to be high in quality for the aspects measured.

Conclusions

It is difficult to define indicators based on the DU90% method, which can readily distinguish differences in the quality of drug prescribing between PTAMs with different levels of functioning. Indicators for prescribing should specifically meet relevant items in the quality of prescribing for certain drug classes. Items for classification of PTAM levels may need some reconsideration.