Inhaled corticosteroids moderate lung function decline in adults with asthma

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

Effects of inhaled corticosteroids on the expression of TNF family molecules in murine model of allergic asthma

BACKGROUND

The tumor necrosis factor superfamily member LIGHT (the official gene symbol approved by NCBI Gene Database), an inflammatory factor secreted by T cells after allergen exposure, recently discovered to play crucial roles in asthmatic airway remodeling. However, it is unclear whether LIGHT could be controlled by inhaled corticosteroids, a key component of asthma management. This study was to investigate the effects and potential mechanisms of inhaled budesonide on the expressions of LIGHT and its receptors (LTβR and HVEM) of lung tissues in ovalbumin-sensitized mice.

MATERIALS AND METHODS

Thirty-three BALB/c mice were randomly divided into the control, asthma model, and budesonide treatment groups (11 in each group). Mice were sensitized and challenged by OVA to develop mouse model of chronic asthma, and treated with aerosolized budesonide before OVA challenge. Bronchoalveolar lavage fluid (BALF) and lungs were obtained after the final OVA challenge. Protein and mRNA Levels of LIGHT, LTβR, and HVEM in the lungs were investigated by immunohistochemistry, image analysis, and real-time PCR. Expressions of IL-6 and IFN-γ in BALF were measured by ELISA.

RESULTS

Inhaled budesonide significantly reduced protein and mRNA levels of lung LIGHT, LTβR, and HVEM in asthmatic mice. Correspondingly, the number of eosinophils and neutrophils and IL-6 levels in BALF after budesonide treatment were found to be decreased, whereas the IFN-γ levels in BALF were increased. Moreover, the expressions of LIGHT and HVEM mRNA showed positive correlation with IL-6 levels in the treatment group.

CONCLUSIONS

Inhaled budesonide can down-regulate the expressions of LIGHT, LTβR, and HVEM in the lungs of asthmatic mice, and LIGHT/LTβR/HVEM interactions may be a potentially key target for asthma treatment.

[Targeted therapies in severe asthma: the discovery of new molecules]

The pathophysiological mechanisms involved in the chronicity and phenotypic heterogeneity of asthma offer the prospect of new therapeutic opportunities. A better clinical and biological characterisation of selected patients has led to the development of targeted therapies. Studies are under way to demonstrate their efficacy and tolerance and also their impact on the natural history of the disease. This revue aims to examine the therapies, developed during the last ten years, that are based on the immunological mechanisms involved in the pathophysiology of asthma, essentially in its severe form. The rapid expansion of human monoclonal antibodies has allowed testing of various immunological pathways. Anti-IgE, anti- IL-5, and anti-IL-13 strategies seem the most promising. Antagonists to TNF-alpha and I'IL-4 have not succeeded in reducing the events related to severe asthma in a convincing manner. Molecules targeted against thymic stromal lymphopoietin (TSLP) and I'IL-9 are under development. These approaches are involved in the development of therapeutic programmes adapted to the patient's phenotype, that is to say a personalised approach to care.

Immunologic therapeutic interventions in asthma: impact on natural history

The discovery of new pathobiological pathways involved in asthma chronicity and reliefs offers novel therapeutic avenues. Enhanced phenotyping criteria associated with simple biologic characterization allowed to test targeted interventions in selected patients. Long-term studies are de facto lacking but required to address their impact on the natural history of the disease. Here, the authors review all potential available therapeutics based on immunologic pathways involved in asthma pathophysiology during the last decade.

Inhaled corticosteroids and risk of tuberculosis in patients with respiratory diseases

RATIONALE

Treatment with substantial doses of oral corticosteroids (OCS) for prolonged periods increases the risk of tuberculosis (TB). However, little is known about the effect of inhaled corticosteroids (ICS) in this respect.

OBJECTIVES

We quantified the independent contribution of ICS to the risk of TB in a population of patients with airway diseases.

METHODS

A population-based cohort design with a nested case-control analysis was used. A cohort of patients with airways disease was formed using the Quebec databases. TB cases were identified and age-matched control subjects were selected from all subjects who entered the cohort in the same month as the cases. TB incidence among the cohort was compared with the general population of Quebec using the standardized incidence ratio.

MEASUREMENTS AND MAIN RESULTS

The cohort consisted of 427,648 subjects. There were 564 cases of TB identified between 1990 and 2005. The standardized incidence ratio was 3.9 (95% confidence interval [CI], 2.6-5.4). Any and current users of ICS are at an increased risk of TB (rate ratio [RR], 1.27; 95% CI, 1.05-1.53; and RR, 1.33; 95% CI, 1.04-1.71, respectively). Among users of OCS, no significant relationship could be demonstrated. Among subjects without OCS exposure, adjusted RRs were significant for any ICS use (RR, 1.26; 95% CI, 1.02-1.56) and current use (RR, 1.48; 95% CI, 1.11-1.97) and at the current high dose exposure level (RR, 1.97; 95% CI, 1.18-3.3).

CONCLUSIONS

Exposure to ICS is not associated with risk of TB in the presence of OCS but is associated with increased TB risk in nonusers of OCS.

Effects of inhaled corticosteroids in monotherapy or combined with long-acting {beta}2-agonists on mortality among patients with chronic obstructive pulmonary disease

BACKGROUND

The benefits of inhaled corticosteroids (ICS) in reducing the mortality related to chronic obstructive pulmonary disease (COPD) are controversial.

OBJECTIVE

To estimate whether ICS in monotherapy or in combination with long-acting beta(2)-agonists (LABA) reduces the mortality rate among COPD patients compared to those treated with LABA monotherapy.

METHODS

Using data from the Canadian province of Quebec's health administrative databases, a nested case-control study was conducted. A cohort of COPD patients aged 50 years and over between 1996 and 2000 was initially formed. Patients were included if they filled at least 6 prescriptions of an inhaled bronchodilator, received at least 1 medical service for COPD, and did not receive any diagnosis of asthma over a 12-month period. For each case of death identified in the cohort, up to 37 controls were time matched. For cases and controls, the exposure to ICS and LABA was assessed within the 3 months prior to the date of death for cases and date of selection for controls. Adjusted mortality rate ratios were estimated by conditional logistic regression comparing patients using ICS monotherapy or ICS/LABA combination therapy with patients using LABA monotherapy.

RESULTS

This study included 5996 cases of death and 54,750 controls. The mortality rates were found to be lower among users of ICS monotherapy than users of LABA monotherapy (OR 0.69; 95% CI 0.53 to 0.88) and lower among users of an ICS/LABA combination than users of LABA monotherapy (OR 0.73; 95% CI 0.56 to 0.96). No significant differences were observed between users of ICS/LABA combination therapy and users of ICS monotherapy (OR 1.07; 95% CI 0.93 to 1.23).

CONCLUSIONS

ICS were found to be associated with a reduction in mortality rate when compared to LABA among patients with COPD. However, the ICS/LABA combination therapy did not provide any additional benefit on mortality when compared to ICS monotherapy.