As-needed anti-inflammatory reliever therapy for asthma management: evidence and practical considerations

Biomarkers in asthma, potential for therapeutic intervention

Asthma is a heterogeneous disease characterized by multiple phenotypes with varying risk factors and therapeutic responses. This Commentary describes research on biomarkers for T2-"high" and T2-"low" inflammation, a hallmark of the disease. Patients with asthma who exhibit an increase in airway T2 inflammation are classified as having T2-high asthma. In this endotype, Type 2 cytokines interleukins (IL)-4, IL-5, and IL-13, plus other inflammatory mediators, lead to increased eosinophilic inflammation and elevated fractional exhaled nitric oxide (FeNO). In contrast, T2-low asthma has no clear definition. Biomarkers are considered valuable tools as they can help identify various phenotypes and endotypes, as well as treatment response to standard treatment or potential therapeutic targets, particularly for biologics. As our knowledge of phenotypes and endotypes expands, biologics are increasingly integrated into treatment strategies for severe asthma. These treatments block specific inflammatory pathways or single mediators. While single or composite biomarkers may help to identify subsets of patients who might benefit from these treatments, only a few inflammatory biomarkers have been validated for clinical application. One example is sputum eosinophilia, a particularly useful biomarker, as it may suggest corticosteroid responsiveness or reflect non-compliance to inhaled corticosteroids. As knowledge develops, a meaningful goal would be to provide individualized care to patients with asthma.

Mild asthma: Conundrums, complexities and the need to customize care

Mild and moderate asthma cover a wide range of asthma presentations, phenotypes and symptom burden, and account for the majority of people with asthma worldwide. Mild asthma has been difficult to define because of its heterogeneity and wide spectrum of impact and outcomes, including being associated with severe exacerbations. Assessment of mild-moderate asthma is best made by combining asthma symptom control and exacerbation risk as the principle means by which to determine treatment needs. Incontrovertible evidence and guidelines support treatment initiation with anti-inflammatory medication, completely avoiding reliever-only treatment of mild asthma. Shared decision making with patients and a treatable traits approach will ensure that a holistic approach is taken to maximize patient outcomes. Most importantly, mild asthma should be regarded as a reversible, potentially curable condition, remaining in long-term remission through minimizing triggers and optimizing care.

Preparation of Budesonide-Loaded Liposomal Nanoparticles for Pulmonary Delivery and Their Therapeutic Effect in OVA-Induced Asthma in Mice

Purpose

Inhaled corticosteroids, including budesonide (BUD), are widely employed for the treatment of asthma. However, the frequent use of corticosteroids is associated with numerous adverse effects and poses challenges to ongoing drug therapy and patient adherence. Budesonide liposomal nanoparticles (BUD-LNPs) were developed to improve the bioavailability of the drug and thereby improve the effectiveness of asthma treatment.

Methods

BUD-LNPs were prepared via thin-film hydration, and the characterizations, stability, and in vitro release of BUD-LNPs were studied. In vitro cellular uptake was observed by laser-scanning confocal microscope (LSCM) and flow cytometry. And the in vitro anti-inflammatory activity of BUD-LNPs was evaluated by measuring the expression of pro-inflammatory cytokines in activated macrophages. Besides, the accumulation time in the lung of drugs delivered via liposomal carriers and free drugs was compared in vivo. And the in vivo therapeutic efficacy of BUD-LNPs was assessed in OVA-induced asthmatic mice. Finally, in vivo biosafety assessment was performed.

Results

The particle size, PDI, and zeta potential of BUD-LNPs were 127.63±1.33 nm, 0.27±0.02, and 3.33±0.13 mV, respectively. BUD-LNPs exhibited excellent biosafety and anti-inflammatory activity in vitro. Furthermore, compared with the free drugs, the utilization of liposomal nano-vehicles for drugs delivery could effectively extend the duration of drugs accumulation in the pulmonary system. Additionally, treatment with BUD-LNPs alleviated airway hyperresponsiveness, reduced airway mucus secretion, and mitigated pulmonary inflammation in OVA-induced asthmatic mice. And the BUD-LNPs demonstrated superior therapeutic efficacy compared to free BUD.

Conclusion

BUD-LNPs was successfully prepared with excellent stability and sustained release for 24 h in vitro. The data of anti-inflammatory activity, asthma therapeutic effects and safety studies indicated that drug delivery mediated by liposomal nano-vehicles was a feasible and desirable strategy for medical strategy and showed great promise in the clinical therapy of asthma.

Landscape of short-acting beta-agonists (SABA) overuse in Europe

This review article provides an overview of short-acting beta-agonist (SABA) use and prescribing trends in Europe, summarizing updated data on the results from the industry-funded SABINA program (SABA use IN asthma) and other studies on this matter. SABA use continues to increase worldwide. Overuse has been defined as ≥3 canisters/year. Almost a third of European patients with asthma, at all severity levels, overuse SABA. Guidelines recommend close monitoring of patients who overuse SABA and avoiding over-reliance on SABA monotherapy. SABA overuse is associated with increased risk of asthma exacerbations and mortality, increased use of health services and negative physical and mental health outcomes. Reliance on SABA monotherapy can be unsafe and therefore it is necessary to change asthma treatment approaches and policies. Changes in physician and patient behaviours towards SABA use are required to ensure that patients with asthma are not over-reliant on SABA monotherapy. Notwithstanding, the limitations of the studies on the use of SABA should be considered, taking into account that the prescription/purchase of medication canisters does not always represent the actual use of the medication and that associations between SABA overuse and poor asthma outcomes may not be directly causal. National health systems and asthma guidelines must align asthma management with global recommendations and adjust them to local needs.

ICS/Ultra LABA in the Treatment of Obstructive Airway Diseases: A Consensus of Indian Experts

Inhaled corticosteroid and ultra-long-acting beta-agonist (ICS/uLABA) combination is a recent advancement in the armamentarium against obstructive airways diseases (OADs). The combination of ICS/uLABA has several advantages, creating a favorable landscape for its utilization. Fluticasone furoate/vilanterol trifenatate (FF/Vi) is one such example of an ICS/uLABA. It offers several benefits from both drugs, such as a convenient once daily dosing schedule; high lipophilicity; high receptor affinity of fluticasone furoate along with high functional selectivity and a quick onset of action of vilanterol. However, the Global Initiative for Asthma (GINA) as well as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines do not clearly define the positioning of ICS/uLABA compared to conventional ICS/LABAs. There are a few areas of uncertainty especially around the appropriate reliever strategy with ICS/uLABA in Asthma. The current consensus was planned with a group of Indian pulmonology experts to provide more clarity on the potential use of FF/Vi in Asthma and COPD. The clinical statements highlighted in this consensus manuscript address crucial clinical questions revolving around the efficacy and safety of FF/Vi as compared to conventional ICS/LABAs and identify the ideal patient profile for its use. This consensus paper also sheds light upon the appropriate reliever to be used along with FF/Vi in Asthma and the utilization of FF/Vi-based triple therapy in OADs. Expert recommendations mentioned in this paper will serve as guidance to pulmonologists as well as consultant physicians who are involved in providing care to OAD patients and will help them weigh the various factors that need to be taken into account while prescribing ICS/uLABA combination.

Is It Really Feasible to Use Budesonide-Formoterol as Needed for Mild Persistent Asthma? A Systematic Review and Meta-Analysis

Background: Previous studies suggest that inhaled budesonide-formoterol used as needed could effectively reduce the severe exacerbation of mild persistent asthma. However, there are some differences between these studies, so we conducted a meta-analysis. Methods: We searched PubMed, Ovid MEDLINE, Cochrane Library and several web search engines to screen the literature until March 25, 2020 and used risk ratios (RR), odds ratios, hazard ratios (HR) and weighted mean differences with 95% confidence intervals (CI) to evaluate the pooled effects. Adolescent/adult patients with mild persistent asthma who used budesonide-formoterol as needed were included in this study. The primary outcome was to investigate the superiority of budesonide-formoterol as needed in reducing severe exacerbations in patients with mild persistent asthma. STATA 12.0 software was used for statistical analysis. Results: Across all 4 articles, 4,023 patients used budesonide-formoterol as needed (budesonide-formoterol group), 4,042 patients used budesonide maintenance plus short-acting β2-agonist (SABA) as needed (budesonide group), and 1,500 patients used SABA as needed (SABA group). The results showed that the incidence of severe exacerbations and the time to first severe exacerbation in the budesonide-formoterol group were significantly different from those for the SABA group (RR = 0.46, 95% CI = 0.36-0.59, p < 0.001; HR = 0.43, 95% CI = 0.33-0.56, p < 0.001; respectively), but there was no difference between the budesonide-formoterol group and budesonide group (RR = 0.86, 95% CI = 0.62-1.04, p = 0.093; HR = 0.77, 95% CI = 0.57-1.03, p = 0.079; respectively). There were statistically significant differences in the forced expiratory volume in 1 second and in the responses to the Asthma Control Questionnaire-5 between the budesonide-formoterol group and the SABA group, but the differences were not clinically significant. In addition, the daily dose of budesonide in the budesonide-formoterol group was significantly lower than that in the budesonide group, and there was no difference in the incidence of adverse events among the three groups. Conclusion: In summary, budesonide-formoterol used as needed may reduce severe exacerbation in adolescent/adult patients with mild persistent asthma.