Substitution of beclomethasone aerosol for oral prednisolone in the treatment of chronic asthma

Glucocorticoid therapy in respiratory illness: bench to bedside

Each year, hundreds of millions of individuals are affected by respiratory disease leading to approximately 4 million deaths. Most respiratory pathologies involve substantially dysregulated immune processes that either fail to resolve the underlying process or actively exacerbate the disease. Therefore, clinicians have long considered immune-modulating corticosteroids (CSs), particularly glucocorticoids (GCs), as a critical tool for management of a wide spectrum of respiratory conditions. However, the complex interplay between effectiveness, risks and side effects can lead to different results, depending on the disease in consideration. In this comprehensive review, we present a summary of the bench and the bedside evidence regarding GC treatment in a spectrum of respiratory illnesses. We first describe here the experimental evidence of GC effects in the distal airways and/or parenchyma, both in vitro and in disease-specific animal studies, then we evaluate the recent clinical evidence regarding GC treatment in over 20 respiratory pathologies. Overall, CS remain a critical tool in the management of respiratory illness, but their benefits are dependent on the underlying pathology and should be weighed against patient-specific risks.

Oral corticosteroid-sparing effects of mepolizumab in severe eosinophilic asthma: evidence from randomized controlled trials and real-world studies

Oral corticosteroids (OCS) have long been a mainstay of treatment for asthma exacerbations and chronic severe asthma. However, it is increasingly recognized that both long-term and short-term OCS use are directly associated with a wide range of serious adverse effects, and as such OCS-sparing treatment alternatives are now widely recommended for patients with severe asthma. While several international guidelines recommend these treatments, guidance on OCS tapering, and which patients are most likely to tolerate OCS reduction and/or discontinuation, is still lacking. Several biologics have demonstrated efficacy in patients with OCS-dependent asthma. One OCS-sparing treatment is the anti-interleukin-5 monoclonal antibody mepolizumab, which is approved for the treatment of severe eosinophilic asthma. In addition to improved exacerbation rates, asthma control, quality of life, and lung function among patients with severe eosinophilic asthma, mepolizumab also has an OCS-sparing effect, which has been demonstrated in randomized controlled trials and real-world studies. Both physicians and patients express concerns about the adverse effects of OCS, and additional data from the randomized, controlled SIRIUS trial (NCT01691508) highlight the high level of concern among patients regarding OCS-related burden. In this article, we discuss current guidance on OCS-sparing strategies for patients with severe asthma, provide a summary of the available evidence of the OCS-sparing effect of mepolizumab, and highlight patient and physician perspectives on the use of OCS and OCS-sparing treatments in severe asthma.

[Strategies for prescription of inhaled corticosteroids in mild-to-moderate asthma]

Asthma is a common respiratory condition characterized by chronic inflammation of the airways. Most asthmatics have a mild-to-moderate form of the disease, but are still at risk of severe exacerbations and significantly impaired quality of life. This article reviews the strategies for prescription of inhaled corticosteroids in patients with mild-to-moderate asthma. The definition of asthma severity, the goals of asthma management and the adjustment of therapeutics are successively addressed. The major changes proposed by the GINA group in 2019 are also discussed.

Expert Consensus on the Tapering of Oral Corticosteroids for the Treatment of Asthma. A Delphi Study

Rationale: There is a need to minimize oral corticosteroid (OCS) use in patients with asthma to prevent their costly and burdensome adverse effects. Current guidelines do not provide recommendations for OCS tapering in patients with asthma.Objectives: To develop expert consensus on OCS tapering among international experts.Methods: A modified Delphi method was used to develop expert consensus statements relating to OCS use, tapering, adverse effects, adrenal insufficiency, and patient-physician shared decision-making. Initial statements proposed by experts were categorized, filtered for repetition, and presented back to experts over three ranking rounds to obtain consensus (≥70% agreement).Measurements and Main Results: One hundred thirty-one international experts participated in the study, and 296 statements were ranked. Numerous recommendations and guidance regarding appropriate OCS use were established. Experts agreed that OCS tapering should be attempted in all patients with asthma receiving maintenance OCS therapy, with personalization of tapering rhythm and speed. The importance of recognizing individual adverse effects was also established; however, a unified approach to the assessment of adrenal insufficiency was not reached. Shared decision-making was considered an important goal during the tapering process.Conclusions: In this Delphi study, expert consensus statements were generated on OCS use, tapering, adverse-effect screening, and shared decision-making, which may be used to inform clinical practice. Areas of nonconsensus were identified, highlighting uncertainty among the experts around some aspects of OCS use in asthma, such as adrenal insufficiency, which underscores the need for further research in these domains.

Dupilumab is effective in type 2-high asthma patients receiving high-dose inhaled corticosteroids at baseline

BACKGROUND

Dupilumab blocks the shared receptor component for interleukin (IL)-4/IL-13, key drivers of type 2 inflammation. In phase 2b (NCT01854047) and phase 3 LIBERTY ASTHMA QUEST (NCT02414854), add-on dupilumab 200/300 mg every 2 weeks (q2w) reduced severe exacerbations, improved prebronchodilator (pre-BD) forced expiratory volume in 1 second (FEV₁ ) and quality of life measures, and it was generally well tolerated in patients with uncontrolled, persistent (phase 2b), or moderate-to-severe (phase 3) asthma.

METHODS

In patients on high-dose inhaled corticosteroids (ICS) with type 2-high asthma (subgroups including baseline blood eosinophils ≥150/300 cells/µL and/or fractional exhaled nitric oxide [FeNO] ≥25 ppb), annualized severe exacerbation rates over the treatment period, changes from baseline in pre-BD FEV₁ and asthma control (5-item asthma control questionnaire [ACQ-5]) were analyzed.

RESULTS

In high-dose ICS type 2-high subgroups, dupilumab 200/300 mg q2w vs placebo in the phase 2b (24 weeks) and phase 3 (52 weeks) studies significantly reduced severe exacerbations by 55%-69%/57%-60% (all P<.05) and 53%-69%/48%-66% (all P < .001), respectively, except in patients with ≥ 300 eosinophils/µL in phase 2b study (24%/50% (P = .52/0.15). Across subgroups, pre-BD FEV₁ improved by 0.18-0.22 L/0.19-0.24 L (all P < .05) and 0.23-0.36 L/0.15-0.25 L (all P < .01) and ACQ-5 scores were reduced by 0.46-0.55/0.47-0.85 (all P < .05) and 0.38-0.50/0.24-0.30 (all P < .05), respectively, except dupilumab 200 mg q2w in phase 2b in patients with FeNO ≥ 25 ppb (0.41; P = .09). Dupilumab was also effective in patients taking medium-dose ICS.

CONCLUSION

Dupilumab significantly reduced severe exacerbations and improved lung function and asthma control in patients with type 2-high asthma on high-dose ICS at baseline.

Asthma maintenance and reliever therapy: Should this be the standard of care?

OBJECTIVE

The goal of asthma management is to achieve optimal asthma control, defined by the absence of daytime symptoms, nighttime waking, reliever use, functional limitation, and lung function stability, and to also reduce the future risks of asthma exacerbations, deterioration in lung function, and the medication's adverse effects. The most widely used maintenance therapy is inhaled corticosteroids (ICSs). This review considered the evidence in which the combination of the ICS budesonide and the rapid-onset long-acting β-agonist (LABA) formoterol can be used as a standard of care for maintenance and reliever therapy in moderate to severe asthma.

DATA SOURCES

The archival literature of peer-reviewed studies on the efficacy and safety of budesonide-formoterol as maintenance and reliever therapy in moderate to severe asthma.

RESULTS

The ICS-LABA combination containing budesonide-formoterol reduces future risk of severe asthma exacerbations and provides similar levels of day-to-day asthma control when compared with using high-dose ICS alone, or combination ICS-LABA therapy and short-acting β₂-agonist as a reliever.

CONCLUSION

Budesonide-formoterol as a single combination maintenance and reliever inhaler is effective in reducing asthma exacerbation risk, requires a lower maintenance dose of ICS, and results in a simplified approach to asthma management.

How can we minimise the use of regular oral corticosteroids in asthma?

Options to achieve oral corticosteroid (OCS)-sparing have been triggering increasing interest since the 1970s because of the side-effects of OCSs, and this has now become achievable with biologics. The Société de Pneumologie de Langue Française workshop on OCSs aimed to conduct a comprehensive review of the basics for OCS use in asthma and issue key research questions. Pharmacology and definition of regular use were reviewed by the first working group (WG1). WG2 examined whether regular OCS use is associated with T2 endotype. WG3 reported on the specificities of the paediatric area. Key “research statement proposals” were suggested by WG4. It was found that the benefits of regular OCS use in asthma outside episodes of exacerbations are poorly supported by the existing evidence. However, complete OCS elimination couldn’t be achieved in any available studies for all patients and the panel felt that it was too early to conclude that regular OCS use could be declared criminal. Repeated or prolonged need for OCS beyond 1 g·year⁻¹ should indicate the need for referral to secondary/tertiary care. A strategic sequential plan aiming at reducing overall exposure to OCS in severe asthma was then held as a conclusion of the workshop.

A yearly cumulative OCS dose above 1 g should be considered unacceptable in severe asthma and should make the case for referralhttp://bit.ly/34GAYLX

Asthma progression and mortality: the role of inhaled corticosteroids

Overall, asthma mortality rates have declined dramatically in the last 30 years, due to improved diagnosis and to better treatment, particularly in the 1990s following the more widespread use of inhaled corticosteroids (ICSs). The impact of ICS on other long-term outcomes, such as lung function decline, is less certain, in part because the factors associated with these outcomes are incompletely understood. The purpose of this review is to evaluate the effect of pharmacological interventions, particularly ICS, on asthma progression and mortality. Furthermore, we review the potential mechanisms of action of pharmacotherapy on asthma progression and mortality, the effects of ICS on long-term changes in lung function, and the role of ICS in various asthma phenotypes.

Overall, there is compelling evidence of the value of ICS in improving asthma control, as measured by improved symptoms, pulmonary function and reduced exacerbations. There is, however, less convincing evidence that ICS prevents the decline in pulmonary function that occurs in some, although not all, patients with asthma. Severe exacerbations are associated with a more rapid decline in pulmonary function, and by reducing the risk of severe exacerbations, it is likely that ICS will, at least partially, prevent this decline. Studies using administrative databases also support an important role for ICS in reducing asthma mortality, but the fact that asthma mortality is, fortunately, an uncommon event makes it highly improbable that this will be demonstrated in prospective trials.

There is compelling evidence of the value of ICS in improving asthma control and indirect evidence that ICS prevents lung function decline by preventing severe exacerbations. Registry-based studies support the role of ICS in reducing asthma mortality.http://bit.ly/2VcNjaz

Repurposing drugs as inhaled therapies in asthma

For the first 40 years of the 20th century treatment for asthma occurred in response to an asthma attack. The treatments were given by injection or orally and included the adrenergic agonists adrenalin/epinephrine and ephedrine and a phosphodiesterase inhibitor theophylline. Epinephrine became available as an aerosol in 1930. After 1945, isoprenaline, a non-selective beta agonist, became available for oral use but it was most widely used by inhalation. Isoprenaline was short-acting with unwanted cardiac effects. More selective beta agonists, with a longer duration of action and fewer side-effects became available, including orciprenaline in 1967, salbutamol in 1969 and terbutaline in 1970. The inhaled steroid beclomethasone was available by 1972 and budesonide by 1982. Spirometry alone and in response to exercise was used to assess efficacy and duration of action of these drugs for the acute benefits of beta₂ agonists and the chronic benefits of corticosteroids. Early studies comparing oral and aerosol beta₂ agonists found equivalence in bronchodilator effect but the aerosol treatment was superior in preventing exercise-induced bronchoconstriction. Inhaled drugs are now widely used including the long-acting beta₂ agonists, salmeterol and formoterol, and the corticosteroids, fluticasone, ciclesonide, mometasone and triamcinolone, that act locally and have low systemic bio-availability. Repurposing drugs as inhaled therapies permitted direct delivery of low doses of drug to the site of action reducing the incidence of unwanted side-effects and permitting the prophylactic treatment of asthma.

[Seasonality in asthma: Impact and treatments]

The role of seasons should be taken into account in the management of asthma. The environment varies between seasons and it is well documented that asthma is modulated by environment. Viruses cause asthma exacerbations peak, in winter, in adults while the peak is present in September in children. Allergens are probably a less powerful source of asthma exacerbation than viruses but pollen involvement in spring and summer and dust mites in autumn are indisputable. Air pollutants, present in summer during the hottest periods, are also highly involved in asthma exacerbations. Indoor air pollution, in winter, is also implicated in asthma disease. All these environmental factors are synergistic and increase the risk of asthma exacerbation. Therapies should be adapted to each season depending on environmental factors potentially involved in the asthma disease.

Epimedium flavonoids counteract the side effects of glucocorticoids on hypothalamic-pituitary-adrenal axis

Our previous studies demonstrated that the epimedium herb, when simultaneously used with GCs, counteracted suppressive effects of GCs on the HPA axis without adverse influence on the therapeutic action of GCs. Here, total flavones were extracted from the epimedium flavonoids (EFs) and then used to investigate whether EFs provide protective effects on the HPA axis. We found that GCs induced a significant decrease in body weight gain, adrenal gland weight gain, and plasma adrenocorticotropin (ACTH) and corticosterone levels. After treatment with EFs, body weight gain, adrenal gland weight gain, and plasma corticosterone level were significantly restored, whilst plasma ACTH level was partially elevated. EFs were also shown to promote cell proliferation in the outer layer of adrenal cortex and to enhance the migration of newly divided cells toward the inner layer. To elucidate the underlying mechanisms, the mRNA expression of insulin-like growth factor II (IGF-II) was measured, and EFs significantly upregulated IGF-II expression. Our results indicated that EFs counteract the suppression of the HPA axis induced by GCs. This may involve both the ACTH and IGF-II pathways and thereby promote regeneration of the adrenal cortex suggesting a potential clinical application of EFs against the suppressive effects of GCs on the HPA axis.

Inhaled corticosteroids for asthma: are they all the same?

OBJECTIVES

To assess similarities and differences among currently available inhaled corticosteroids (ICS) for treatment of asthma, with special emphasis on factors that may affect the relative safety of these medications.

METHODS

PubMed was searched for relevant reviews and original articles. Information from these studies was synthesized and critically assessed.

RESULTS

Differences in corticosteroid formulations and delivery systems can create variations in therapeutic efficacy. Chemical properties of the various corticosteroids may also affect their relative safety. Ciclesonide and beclomethasone dipropionate are administered as prodrugs activated by enzymes present in the lungs but not the oropharynx. Corticosteroid-specific adverse effects in the oropharynx are thus avoided, although formulation-specific effects may remain. Other adverse effects require systemic availability, either via the gastrointestinal tract or the lung. Once they enter the systemic circulation, all ICS are rapidly metabolized by the liver. Oral bioavailability of ICS such as fluticasone, ciclesonide and mometasone is minimal, as a result of their essentially complete first-pass metabolism in the liver. Ciclesonide also undergoes extrahepatic metabolism that eliminates it even more rapidly. Additionally, ciclesonide and mometasone exhibit very high levels of binding to serum proteins that reduces their ability to stimulate glucocorticoid receptors outside the lung.

CONCLUSIONS

Despite acting by similar mechanisms, currently available ICS and their delivery systems differ in ways that can potentially affect both safety and therapeutic effectiveness for individual patients.

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.

Inhaled beclomethasone versus placebo for chronic asthma

BACKGROUND

Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti-inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane-134a (HFA) propellant which is free from chlorofluorocarbon (CFC).

OBJECTIVES

The objectives of this review were to: (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies.

SEARCH STRATEGY

Electronic searches were current as of January 2003.

SELECTION CRITERIA

Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC-BDP or HFA-BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2.

MAIN RESULTS

60 studies recruiting 6542 participants met the inclusion criteria. CFC-BDP (57 studies): In non-oral steroid treated patients, at doses of 400 mcg/day or less CFC-BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta-2 agonist use compared with placebo of -2.32 puffs/d (95% CI -2.55 to -2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD -4.91 mg/d (95% CI -5.88 to -3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA-BDP (3 studies): In non-oral steroid-treated patients, HFA-BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2-agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA-BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported.

AUTHORS' CONCLUSIONS

This review has quantified the efficacy of CFC-BDP and HFA-BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose-response in people with severe asthma.

A meta-analysis of the dose-response relationship of inhaled corticosteroids in adolescents and adults with mild to moderate persistent asthma

BACKGROUND

Although inhaled corticosteroids (ICS) are commonly used in the treatment of persistent asthma, the relationship between dose and clinical response remains unclear.

OBJECTIVE

This study investigated whether ICS exhibit a dose-response relationship in the treatment of mild to moderate persistent asthma.

METHODS

This was a meta-analysis of published randomized clinical trials concerning the relationship between ICS dose and response in asthma. Relevant studies were identified through a search of PubMed and MEDLINE for articles on asthma and ICS published between January 1996 and January 2001. The search was limited to publications classified as clinical trials that included the text words asthma and corticosteroids, glucocorticoids, beclomethasone, budesonide, fluticasone, flunisolide, mometasone, or triamcinolone acetonide. Five clinical measures were considered: morning peak expiratory flow rate (AM PEFR), evening PEFR (PM PEFR), forced expiratory volume in 1 second (FEV(1)), beta-agonist use, and asthma symptom score (severity of symptoms on a given day, as evaluated by patients).

RESULTS

Forty-three studies were identified, of which 16 met the criteria for inclusion in the meta-analysis. These studies involved 4 agents: fluticasone propionate, triamcinolone acetonide, budesonide, and mometasone furoate. A statistically significant dose response in AM PEFR was observed with fluticasone propionate, triamcinolone acetonide, and budesonide (respective 95% CIs, 4.9 to 11.5, 4.7 to 18.0, and 5.8 to 24.9). A statistically significant dose response to fluticasone propionate and triamcinolone acetonide was also observed in PM PEFR (95% CIs, 2.0 to 8.7 and 2.4 to 13.7) and asthma symptom score (95% CI, -0.069 to -0.002 and -0.60 to -0.10). In terms of FEV(1), the dose response was statistically significant only with budesonide (95% CI, 0.025 to 0.17). Dose-response relationships were not disproportionately driven by the highest doses, and the greatest effects on response were seen at doses below or at the low end of the recommended range, suggesting that use of high doses of ICS may contribute only marginally to efficacy.

CONCLUSIONS

Dose-response relationships were not uniformly observed with all drugs or for all measures of response. Use of higher doses of ICS in patients with mild to moderate persistent asthma does not appear to increase the efficacy of these drugs.

Inhaled beclomethasone versus placebo for chronic asthma

BACKGROUND

Inhaled beclomethasone diproprionate (BDP) has been, together with inhaled budesonide, the mainstay of anti-inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP is now frequently used as the reference treatment against which these newer agents are being compared.

OBJECTIVES

The objectives of this review were to: a) Compare the efficacy of BDP with placebo in the treatment of chronic asthma. b) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. c) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trial Register (1999) and reference lists of articles. We contacted trialists and Glaxo Wellcome for additional studies and searched abstracts of major respiratory society meetings (1997-1999).

SELECTION CRITERIA

Randomised trials in children and adults comparing BDP to placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data; authors were contacted to clarify missing information. Quantitative analyses where undertaken using Review Manager (Revman) 4.0.3 with Metaview 3.1.

MAIN RESULTS

52 studies were selected for inclusion (3459 subjects). The studies were generally of high methodological quality. In non-oral steroid treated patients, BDP produced significant improvements in a number of efficacy measures compared to placebo including FEV1 weighted mean difference (WMD) 340ml (95% CI 190-500ml); FEV1 (% predicted) WMD 6% (95% CI 0.4 to 11.5%) and morning PEFR WMD 50 L/min (95% CI 8 to 92 L/min). BDP also led to reductions in rescue beta2 agonist use compared to placebo WMD 1.75 puffs/d (95% CI 1.4 to 2.4 puffs/d) and reduced the likelihood of trial withdrawal due to asthma exacerbation relative risk (RR) 0.26 (95% CI 0.15 to 0.43). In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD 5 mg/d (95% CI 4 to 6 mg/d) and a higher likelihood of discontinuing oral prednisolone RR 0.54 (95% CI 0.43 to 0.67). There was little evidence for a clincially worthwhile dose response effect, but few studies recruited patients with more severe asthma.

REVIEWER'S CONCLUSIONS

This review has quantified the efficacy of BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose-response in patients with severe disease.

Effects of inhaled corticosteroids on the consequences of asthma

Asthma is a chronic inflammatory disease of the airways involving a characteristic pattern of airway infiltration with lymphocytes, eosinophils, and mast cells, subepithelial deposition of collagen, and hypertrophy and hyperplasia of smooth muscle and of goblet cells and submucosal glands. The consequences of this chronic process include episodic or persistent symptoms, bronchial hyperreactivity, attacks of bronchoconstriction that may require emergency care or hospitalization and can lead to death, impairment in quality of life, and the development of irreversible airflow obstruction. Careful pathologic studies have shown that inhaled corticosteroid therapy can reverse or suppress airway inflammation, and prospective controlled clinical trials have proven that it can also improve symptoms, reduce bronchial hyperreactivity, and reduce the frequency and severity of attacks. It is also highly likely, although it is not yet proven, that inhaled corticosteroid therapy reduces the risk of asthma fatality and prevents or retards airway wall remodeling. These beneficial effects are easily shown in patients with moderate or severe asthma. Although inhaled corticosteroid therapy also benefits patients with mild asthma, it is less certain that the costs and risks of continuous therapy are justified. For these patients, the most important issues that remain to be resolved are the nature of the risk of development of permanent airflow obstruction and the effects of early, sustained treatment on the chances of sustained remission of asthma after all therapy has been stopped.

Immune therapy in respiratory disease

Pharmacologic manipulation of pulmonary immunity plays an important role in primary and adjunct therapy for equine respiratory disease. Frequent exposure to respiratory viral pathogens, strenuous exercise, long distance transport, and inhalation of harmful substances destroy various aspects of the pulmonary defense system and predispose performance horses to development of infectious and noninfectious respiratory disease. Pulmonary immunity may be bolstered by nonspecific immunostimulants to combat primary or secondary immunodeficiency. State of the art technology improves active and passive-specific immunity for prevention of common infectious respiratory diseases in horses. Immuno-suppressive therapy can attenuate hyperreactive pulmonary immune responses in horses with allergic airway disease.

New insights into the pathogenesis and management of steroid-resistant asthma

A population of difficult-to-control asthmatics exists who, despite high-dose daily GC therapy, continue to display evidence for active disease. This group has been termed steroid resistant since they fail to adequately respond to aggressive courses of high-dose oral and inhaled GC therapy. Persistent immune activation and airway inflammation which to varying degrees is resistant to GC therapy appears to define the immunological abnormality underlying SR asthma. Recent studies utilizing molecular biological techniques have identified both ligand- and DNA-binding defects that could possibly account for steroid resistance at a molecular level. The evaluation of the SR asthmatic must be comprehensive in its scope as several confounding factors can contribute to this symptom complex. Among others, these include poor compliance, improper medication technique, inadequate anti-inflammatory therapy, unrecognized contributing diseases, incorrect diagnoses, environmental factors, and psychosocial disturbances. The management of the SR asthmatic is challenging, and every attempt should be made to maximize conventional therapy in these patients prior to embarking on alternative therapies as all of the alternative anti-inflammatory/immunomodulatory modalities are associated with significant toxicity or cost. Second-generation inhaled GC therapy, methotrexate, cyclosporine, IVIG, and leukotriene antagonists are potential alternative therapies, and although they remain viable options, they have been used in small numbers, and for short periods of time, and fail to result in long-term remissions. Although much insight into the pathogenesis of SR asthma has been gained, several issues remain unresolved. Ongoing airway inflammation is thought to contribute to steroid resistance, but at present, we have no standard method of determining the degree of inflammation. The incorporation of bronchoscopy with transbronchial biopsy has the potential to provide the greatest amount of information regarding the presence or absence of ongoing airway inflammation, but the invasive nature of the procedure precludes its use in pediatric patients and the most severe adult asthmatics. Large multicenter, placebo-controlled studies evaluating the available alternative therapies that incorporate markers of airway inflammation are needed, as are studies that evaluate these therapies over longer periods of time. It is hoped that by better understanding the mechanisms involved and the natural history of the SR asthmatic, specific treatment modalities will be developed for this challenging group of severe asthmatics.

The efficacy and tolerability of fluticasone propionate aqueous nasal spray in children with seasonal allergic rhinitis

Fluticasone propionate aqueous nasal spray (FPANS) contains fluticasone propionate, which is a new topically active glucocorticoid with approximately twice the potency of belcomethasone dipropionate. In this European multicentre study, 143 children with seasonal allergic rhinitis were recruited: 47 received FPANS 100 micrograms once a day (od), 46 received FPANS 200 micrograms od, and 50 patients received placebo od, for 4 weeks. Treatment efficacy was assessed using diary card nasal symptom scores for sneezing, rhinorrhoea, blockage and itching, and eye watering/irritation. Patients receiving FPANS 100 micrograms or FPANS 200 micrograms demonstrated statistically significant improvements in median nasal symptom scores in all the symptoms recorded, when compared with placebo. There were no statistically significant differences between the FPANS 100 micrograms and FPANS 200 micrograms groups in improvement in nasal symptom scores. There was no effect on eye watering/irritation symptoms which could be attributed to either FPANS 100 micrograms or FPANS 200 micrograms when compared with placebo. Use of rescue antihistamine medication was significantly reduced in the FPANS 100 micrograms group when compared with placebo. The adverse events profile was similar in all three treatment groups, and the events reported were generally mild and related to the patients' rhinitis.

A self management plan in the treatment of adult asthma

To determine whether routine assessment of peak expiratory flow (PEF) in association with a self management plan based on inhaled corticosteroid use is effective in the management of chronic asthma, 36 consecutive adult patients with asthma attending an outpatient chest clinic were admitted to an open prospective study. Patients were treated with inhaled salbutamol and beclomethasone dipropionate in an attempt to achieve normal lung function. Each patient had a "potential normal value," which was either the predicted normal or the maximum PEF value achieved by the patient, whichever was the higher. Patients measured PEF at home and if it fell by more than 30% from the potential normal value the dose of beclomethasone was doubled until PEF returned to the potential normal value, then continued at 20 mg/day for the same number of days. If PEF fell to below 150-200 l/min patients were asked to obtain emergency medical assistance. In the 30 patients who completed the trial the six months before and the six months after intervention with the self management plan were compared. There was a substantial improvement in both subjective and objective measurements of asthma severity, with a significant reduction in nights woken, days lost from work, and requirement for oral corticosteroids and a significant increase in baseline lung function. Routine measurement of PEF in association with a self management plan appears to be effective in reducing symptoms of asthma and improving lung function.

Effect of prednisone and beclomethasone dipropionate on airway responsiveness in asthma: a comparative study

To examine the effect of corticosteroids on bronchial hyperresponsiveness, a randomised, double dummy, single blind crossover study was performed in 18 subjects with chronic asthma, comparing the effect of three weeks' treatment with inhaled beclomethasone dipropionate, 1200 micrograms daily, and oral prednisone 12.5 mg daily. The 12 week study began with a three week run in period of baseline treatment, which was continued unchanged throughout the study, and the two treatment periods were separated by a three week washout period. Patients kept daily Airflometer readings and attended the laboratory every three weeks for spirometry and a histamine inhalation test for determining the provocative dose of histamine causing a 20% fall in FEV1 (PD20). The mean FEV1 at the start was 1.9 litres (56% predicted). There was no significant change in PD20 with prednisone treatment, the mean PD20 being 0.56 and 0.59 mumol before and after treatment. There was, however, a significant improvement in PD20 with beclomethasone dipropionate treatment, the geometric mean PD20 being 0.38 and 1.01 mumol before and after treatment (p less than 0.001). There was a small but significant improvement in mean FEV1 after beclomethasone dipropionate treatment--from 1.9 to 2.2 litres--but no change after prednisone. Both medications produced significant and similar improvements in morning and evening Airflometer readings, post-bronchodilator improvement, and diurnal variation. Thus at doses that had similar beneficial effects on lung function beclomethasone dipropionate caused a significant improvement in bronchial hyperresponsiveness whereas prednisone caused no change. The superior topical anti-inflammatory effect of beclomethasone dipropionate may account for the different effects on bronchial hyperresponsiveness.

Twice or four times daily beclomethasone dipropionate in mild stable asthma?

A double-blind cross-over study lasting 16 weeks was conducted to establish if a twice daily regimen of beclomethasone dipropionate (BDP) was as effective in controlling asthma as a four times daily regimen. The patient's need for inhaled steroids (100 mcg BDP qds) was confirmed prior to entering the study by deterioration of peak expiratory flow rates and/or increased bronchodilator usage during a single-blind placebo period of 6 weeks. Thirty six asthmatics were eligible to enter the study and completed both treatment periods. Daily record cards of symptom scores, four times daily peak expiratory flow rate measurements and inhaled bronchodilator usage were recorded throughout the study. There was no significant difference between the mean PEFR measurements taken four times each day and the variability in PEFR, between the two treatment groups. Symptom scores for cough, wheeze, breathlessness and overall disability also showed no significant difference. Symptomatic inhaler usage for the two groups was similar. Lung function measurements of FEV1, FVC and VC were almost identical; FEV1 being 2.1 l on twice daily regimen and 2.2 l on four times daily regimen. A slight variation was observed in PEFR taken at the end of each treatment period at the clinic visits, being 361 l/min on twice daily and 380 l/min on four times daily drug dosage. In stable asthmatics, the control of asthma measured both symptomatically and by daily lung function was independent of dosing schedule, but twice daily treatment may well lead to better compliance.

High dose inhaled budesonide in the treatment of severe steroid-dependent asthmatics. A two-year study

Thirty-eight patients with chronic asthma requiring continuous oral corticosteroid treatment took part in a 2-year study. Budesonide, a new inhalation steroid with high topical activity and low systemic effects, was given in stepwise increasing doses from 200 micrograms daily up to 800-1600 micrograms daily and prednisolone doses were decreased gradually on an individual basis. After 2 years, 18 patients had been able to cease oral prednisolone treatment, 11 had decreased the dose by greater than or equal to 50%, three by less than or equal to 50% and two patients had increased their dose. At the end of the study the majority of patients (26) were using 800 micrograms budesonide daily and seven, 1200 micrograms or more daily. There were two dropouts, one due to local side effects and one to a severe pulmonary eosinophilia. Ten patients had local side effects in the form of hoarseness and/or sore throat, and 13 patients had steroid withdrawal symptoms such as arthralgia and myalgia. The asthma condition in all patients was improved, as indicated by the reduced need for hospital admissions. The results indicate that high doses of budesonide should be tried before starting maintenance therapy with oral steroids.

Recovery of hypothalamo-pituitary-adrenal function in asthmatics whose oral steroids have been stopped or reduced

Hypothalamo-pituitary--adrenal (HPA) function was studied using tetracosactrin and insulin hypoglycemia tests in eleven asthmatic patients who were receiving or had taken oral steroids. The patients had been on prednisone, 5--20 mg/day for 2--17 years. As the dose was reduced they used beclomethasone inhalation, up to 800 micrograms/day. Seven insulin hypoglycemia tests were performed when the patients had been off oral steroids for 15--37 months. Plasma cortisol responses were normal in all seven, three had subnormal responses of ACTH. In five patients serial tetracosactrin and insulin hypoglycaemia tests were performed during reduction of steroid dose. Two patterns of recovery of HPA function were observed. In one, both hypothalamo--pituitary and adrenal function seemed to return simultaneously, in the other normal response to tetracosactrin appeared before that to insulin hypoglycaemia. One patient had normal ACTH and cortisol responses to the stress of a vasovagal attack, but failed to respond to subsequent hypoglycaemia. We conclude that a normal response to tetracosactrin does not indicate recovery of the HPA axis after stopping prolonged oral steroid therapy for asthma, and that patients should continue to carry steroid therapy cards for at least 5 years after such treatment has been discontinued.

The endocrinometabolic effects of beclomethasone dipropionate in asthmatic patients

The endocrinometabolic effects of the aerosol administration of beclomethasone dipropionate (100 microng four times daily) were evaluated in 20 asthmatic patients (11 corticodependent and nine noncorticodependent) during one month. In the noncorticodependent group, aerosol administration of beclomethasone had no statistically significant effect on the results of the glucose tolerance test and the plasma levels of insulin; there was a slight decrease in basal levels of cortisol, but the response of the cortisol level to administration of ACTH remained quite normal. In corticodependent patients, after substitution of aerosol therapy with beclomethasone for the oral therapy with steroids, the depression of adrenal function disappeared, usually quickly (in less than one month), whereas the abnormalities in the results of the glucose tolerance test persisted. Thus, at the dosage used, beclomethasone dipropionate might have minor systemic endocrinometabolic effects.

Beclomethasone dipropionate aerosol in the treatment of steroid-dependent asthmatic patients. An assessment of 18 months of therapy

Twenty-nine of 33 steroid-dependent asthmatic patients received 18 months of therapy with beclomethasone dipropionate. Only four of 29 subjects required concurrent oral therapy with steroids. Twenty-six of 29 patients noted a marked improvement in their asthma; three of 29 described an indeterminate response. A statistically significant improvement in many of the symptoms, the plasma cortisol level, the first-second forced expiratory volume, and the forced expiratory flow at 50 percent of the observed forced vital capacity was present only at the end of three months of therapy with beclomethasone dipropionate. Steroid-withdrawal symptoms, particularly those related to the nose and sinuses, were initially troublesome but decreased with the passage of time. No oropharyngeal fungal infections were observed. At a dose below the hypothalamic-pituitary-adrenal suppressive level, therapy with beclomethasone dipropionate appears to be safe and effective for treating patients with steroid-dependent asthma.

A controlled trial of inhaled corticosteroids in patients receiving Prednisone tablets for asthma

The theraprutic efficacy of inhaled beclomethasone dipropionate and inhaled betamethasone valerate in chronic asthma has been studied in 14 treatment centres in 158 patients who had previously been taking prednisone tablets regularly. Doses of 400 mug daily of beclomethasone dipropionate and a dose of 800 mug daily of betamethasone valerate allowed approximately 80% of patients to discontinue prednisone initially and 60% to remain off daily prednisone for 24 weeks. A mean reduction in daily prednisone dose of 8 mg was achieved by patients inhaling corticosteroids whilst placebo inhaler permitted a 5 mg reduction. The three inhaled corticosteroid preparations were equally effective in facilitating prednisone reduction and provided equally good control of asthma, alone or as an ancillary to prednisone. The higher dose of beclomethasone dipropionate was superior to the lower in permitting more patients to remain off daily prednisone for the period of the trial. Although 82% of patients recovered a normal adrenal response to tetracosactrin 24 weeks after prednisone was discontinued and inhaled corticosteroids subsituted, 18% still showed some suppression of adrenal function. There was no significant difference between the treatment groups in this.

Clinical and physiological assessment of asthmatic children treated with beclomethasone dipropionate

Forty-two perennial asthmatic children were selected for a 12-wk study using beclomethasone dipropionate. The groups included 21 steroid-dependent children (Group I) and 21 patients (Group II) whose disease was of sufficient severity that corticosteroid therapy was contemplated. All children received the drug in a dose of 100 mug 4 times daily. During the study, oral prednisone was withdrawn from the steroid-dependent children while other therapy was essentially unchanged. Group II children underwent a double-blind trial, receiving beclomethasone for 6 wk and placebo for 6 wk. Objective assessment of adrenal and pulmonary function was obtained at regular intervals. For the latter, total lung capacity and its subdivisions, airways resistance, maximum expiratory flow volume, and oxygen tension, were measured in both groups. In Group II static elastic recoil was measured also. For most tests the results were statistically significant. In both groups, 18 of 21 patients demonstrated an excellent clinical response, no evidence of adrenal suppression, and improvement in pulmonary function. Forty of 42 patients were followed for another 12 wk, and 19 of each group did well. After 20-24 wk of therapy, 16% of patients harbored monilia in their oropharynx, and 1 patient had clinical monilial stomatitis. Within the limits of the time of the study, beclomethasone dipropionate appeared to provide adequate clinical control in many chronic, severe, steroid-dependent and nonsteroid-dependent asthmatic children.

Triamcinolone acetonide aerosols for asthma. I. Effective replacement of systemic corticosteroid therapy

Triamcinolone acetonide, a water-insoluble corticosteroid preparation in a Freon-propelled metered-dose aerosol, was administered via a specially designed nebulizer to 22 adult patients with severe, chronic asthma. All patients had required oral corticosteroid therapy, daily, for several years, in order to control their incapacitating obstructive airways disease. During 4 wk of treatment with triamcinolone acetonide, taken in 4 daily doses totaling 8 to 28 inhalations (400-1,400 mcg) per day: (1) asthma remained under satisfactory control; (2) oral corticosteroids were stopped in 19 patients and reduced in 2, and 1 patient withdrew from the study; (3) adrenal cortical function returned to normal or near normal levels; (4) spirometric and plethysmographic measurements improved significantly; (5) daily self-measurements of peak expiratory flow showed a marked improvement in median weekly levels, as well as a reduction in daily variability. No immediate undesirable side effects were noted. These observations indicated that more extensive applications of topical corticosteroid therapy are justified as an effective, convenient, and relatively safe method for the preventive management of severe, persistent asthma.

Beclomethasone dipropionate aerosol in reversible obstructive airways disease. A clinical evaluation of one year's treatment

Seven patients with reversible obstructive airways disease, who were unsatisfactorily relieved by conventional bronchodilating drugs, were admitted to a 1-year-long therapeutic trial with beclomethasone dipropionate aerosol, 400 mug a day. After 3 weeks of treatment the mean values of VC, FEV, and PEFR were increased by about 100 per cent of the pretreatmetn values, and the consumption of self-administered bronchodilators was markedly diminished. Throughout the trial the occupationa diability and need for hospitalization were negligible compared with the previous year. Development of tolerance to the drug was not observed during the trial. The adrenocortical function remained unaffected, as judged by the plasma cortisol levels and adrenocortical stimulation tests. Continuously low normal levels of excreted urinary 17-ketogenic-steroids might indicate a very slight adrenal suppression.

Betamethasone valerate in corticosteroid-dependent asthmatics. The integrity of the hypothalamic pituitary adrenal axis

In a single-blind trial 29 patients with corticosteroid-dependent asthma reduced their daily dose of oral prednisolone by 1 mg/week while using a placebo inhaler until an unacceptable degree of asthma occurred. Betamethasone-17-vlaerate in a dose of 800 mug/day and if necessary 1600 mug/day was then substituted for the placebo inhaler and the reduction of oral prednisolone continued until the prednisolone was withdrawn completely or an unacceptable degree of asthma recurred. In 22 patients (76%) prednisolone was withdrawn completely, 11 on 800 mug and 11 on 1600 mug betamethasone-17-valerate. The mean reduction of prednisolone was 3-8 mg on placebo, 5-4 mg on 800 mug and a further 1-8 mg in patients requiring 1600 mug of betamethasone-17-valerate. The hypothalamic pituitary adrenal (HPA) axis was assessed by tetracosactrin and insulin stress tests at the start of the study and after withdrawal of oral prednisolone. The results indicate that an HPA axis which is completely suppressed by systemic corticosteroids can regain normal integrity when the systemic steroid is replaced by betamethasone-17-valerate in a dose of either 800 mug/day or 1600 mug/day. Candidiasis was observed, but will be reported later.

Beclomethasone dipropionate inhaler: a review of its pharmacology, therapeutic value and adverse effects. I: Asthma

Beclomethasone dipropionate is a topically active corticosteroid used as an adjuvant in the control of chronic asthma when given by inhalation as an aerosol. It is not intended for treatment of acute attacks. It appears that the main difference between beclomethasone dipropionate and other corticosteroids previously used by inhalation is its high topical activity together with a lower systemic activity due to metabolic inactivation of the swallowed portion of the dose. Clinical experience has shown that at doses of 200 to 600mug daily, beclomethasone dipropionate inhaler is preferable to oral corticosteroids, because of lack of side-effects, when adult patients and children who are inadequately controlled by full doses of sodium cromoglycate and bronchodilators, are first considered to need maintenance corticosteroids. Inhaled beclomethasone dipropionate can allow a worthwhile reduction in maintenance doses of systemic corticosteroids in many patients already receiving these drugs and can replace systemic steroids entirely in some patients, particularly when their initial dose of steroids is less than 10mg daily of prednisone or its equivalent. Substitution should be attempted when the patient's asthma is well controlled on their usual doses of systemic steroids and full doses of other adjuvant therapy. Withdrawal of systemic corticosteroids should be performed slowly and carefully. Because recovery from impaired adrenocortical function caused by prolonged systemic steroid therapy is usually slow, special care is necessary for 9 to 12 months after transfer to beclomethasone dipropionate aerosol until the hypothalamo-pituitary-adrenal axis has sufficiently recovered to cope with emergencies such as trauma, surgery, severe infections or an acute attack of asthma. It is essential that additional therapy including high doses of systemic corticosteroids be used immediately to control any acute exacerbation of asthma which occurs during maintenance therapy with beclomethasone dipropionate aerosol. Tests of adrenal function suggest that beclomethasone dipropionate at dosages of 400 to 800 mug daily has little or no adverse effect. The most common side-effect associated with the continuous use of beclomethasone dipropionate inhaler has been oropharyngeal candidiasis, which appears to be dose-related and more common in women than in men. Systemic steroid withdrawal effects, like being generally unwell, and exacerbation of underlying allergic diseases such as allergic rhinitis, have been reported after substitution of beclomethasone dipropionate inhaler for systemic steroids. However, systemic withdrawal effects seldom occur if systemic steroids are withdrawn slowly.