Asthma exacerbations . 4: Prevention

Impact of online therapeutic education on asthma control in youth: an emergency department study

INTRODUCTION

Asthma is a widespread chronic respiratory disease. It affects all age groups, mainly youth. Its management aims to prevent exacerbations and ensure normal daily-life activity. Current international recommendations attach particular importance to the therapeutic education to improve asthma control and reduce emergency room visits.

AIM

To assess the impact of online therapeutic education for youth asthmatics initiated in the emergency department on the level of asthma's control.

METHODS

Descriptive-evaluative study conducted over six months including asthmatics aged 14 to 35 years old living in Ariana. Asthma control was evaluated according to the 2019 Global Initiative for Asthma recommendations with a reassessment at three months after online therapeutic education.

RESULTS

N=75; 18% of patients were adolescents, sex-ratio = 0.56. University education was noted in 73% of cases and high socioeconomic status in 48% of subjects. 55% of participants had no basic knowledge of the asthma's pathophysiology. Moderate classification of the last exacerbation was noted in 71% of patients and humidity was the most common exacerbation trigger (76%). A significant improvement in asthma control was observed after therapeutic education (p <0.001) with a positive correlation with female gender (p=0.048), basic knowledge of asthma's pathophysiology (p=0.001) and mild classification of the last exacerbation (p=0.039). Male gender and humidity as exacerbation trigger were independent factors negatively influencing control outcome after therapeutic education.

CONCLUSION

The emergency department is the referral unit of the management of asthmatics with acute events. This represents an important opportunity to share educational messages that have proven effective using an online model.

Impact of Anti-IL5 Therapies on Patients with Severe Uncontrolled Asthma and Possible Predictive Biomarkers of Response: A Real-Life Study

Severe Uncontrolled Asthma (SUA) counts for more than 25% of cases of severe asthma. The main factors that impair the quality of life of these patients are high doses of oral corticosteroids, the presence of exacerbations, and reduced lung function. The objective of this study was to evaluate, in real life, the clinical improvement of patients with SUA treated with anti-interleukin 5 (IL5) therapies: mepolizumab and benralizumab, together with the search for biomarkers associated with the response. We conducted a retrospective observational cohort study that included patients with severe uncontrolled eosinophilic asthma in a tertiary hospital receiving biological therapies. Three types of response were evaluated: improvement in lung function, reduction in exacerbations, and decrease in the use of oral corticosteroids. After 12 months of treatment, significant reductions were found in the number of exacerbations, the use of oral corticosteroids, and blood eosinophil levels for both biological therapies (p < 0.001). Lung function improved, achieving a significant improvement in %FEV1 (p < 0.001), as well as asthma control, with a significant increase in asthma control test (ACT) scores in both therapies. The markers associated with the corticosteroid-saving effect were the low doses of oral corticosteroids and absence of exacerbations for mepolizumab, and higher blood eosinophilia, absence of chronic obstructive pulmonary disease (COPD), and reduction in oral corticosteroid cycles for benralizumab. The greatest improvement in lung function in both therapies was linked to lower previous FEV1 levels and absence of other respiratory diseases. The reduction in exacerbations was associated with absence of exacerbations the previous year for mepolizumab and never smokers for benralizumab. The results of this real-life study confirm the clinical benefit obtained after the introduction of an anti-IL5 biological therapy and the possible predictive biomarkers of response to treatment.

Determining asthma endotypes and outcomes: Complementing existing clinical practice with modern machine learning

There is unprecedented opportunity to use machine learning to integrate high-dimensional molecular data with clinical characteristics to accurately diagnose and manage disease. Asthma is a complex and heterogeneous disease and cannot be solely explained by an aberrant type 2 (T2) immune response. Available and emerging multi-omics datasets of asthma show dysregulation of different biological pathways including those linked to T2 mechanisms. While T2-directed biologics have been life changing for many patients, they have not proven effective for many others despite similar biomarker profiles. Thus, there is a great need to close this gap to understand asthma heterogeneity, which can be achieved by harnessing and integrating the rich multi-omics asthma datasets and the corresponding clinical data. This article presents a compendium of machine learning approaches that can be utilized to bridge the gap between predictive biomarkers and actual causal signatures that are validated in clinical trials to ultimately establish true asthma endotypes.

Primary Care Management of Asthma Exacerbations or Attacks: Impact of the COVID-19 Pandemic

The COVID-19 pandemic has brought a renewed focus on appropriate management of chronic respiratory conditions with a heightened awareness of respiratory symptoms and the requirement for differential diagnosis between an asthma attack and COVID-19 infection. Despite early concerns in the pandemic, most studies suggest that well-managed asthma is not a risk factor for more severe COVID-related outcomes, and that asthma may even have a protective effect. Advice on the treatment of asthma and asthma attacks has remained unchanged. This article describes some challenges faced in primary care asthma management in adults and in teenagers, particularly their relevance during a pandemic, and provides practical advice on asthma attack recognition, classification, treatment and continuity of care. Acute attacks, characterised by increased symptoms and reduced lung function, are often referred to as exacerbations of asthma by doctors and nurses but are usually described by patients as asthma attacks. They carry a significant and underestimated morbidity and mortality burden. Many patients experiencing an asthma attack are assessed in primary care for treatment and continuing management. This may require remote assessment by telephone and home monitoring devices, where available, during a pandemic. Differentiation between an asthma attack and a COVID-19 infection requires a structured clinical assessment, taking account of previous medical and family history. Early separation into mild, moderate, severe or life-threatening attacks is helpful for continuing good management. Most attacks can be managed in primary care but when severe or unresponsive to initial treatment, the patient should be appropriately managed until transfer to an acute care facility can be arranged. Good quality care is important to prevent further attacks and must include a follow-up appointment in primary care, proactive regular dosing with daily controller therapy and an understanding of a patient's beliefs and perceptions about asthma to maximise future self-management.

Specialist Care in Individuals With Asthma Who Required Hospitalization: A Retrospective Population-Based Study

BACKGROUND

Patients who are at risk for severe asthma exacerbations should receive specialist care. However, the care pattern for such patients in the real world is unclear.

OBJECTIVE

To describe the pattern of care among individuals with asthma who required hospitalization, and to identify factors associated with receiving asthma specialist care.

METHODS

This was a retrospective population-based study using health administrative data from two Canadian provinces. Individuals aged 14 to 45 years who were newly diagnosed with asthma between 2006 and 2016 and had at least one hospitalization for asthma at or within 5 years after the initial asthma diagnosis were included. First, we calculated frequencies of primary and specialist care around the asthma diagnosis: 1 year before and 2 years after in a 6-month period. Next, among individuals diagnosed with asthma by a primary care physician, we used multivariable Cox regressions to identify factors associated with receiving specialist care.

RESULTS

For 1862 individuals included, we found that most (≥71% per time period) were cared for by primary care physicians 1 year before and 2 years after the asthma diagnosis; the percentage of individuals seen at least once by a specialist for asthma and/or asthma-related respiratory conditions during the first 6 months since the diagnosis did not exceed 40%. Among 1411 of 1862 individuals who were under primary care before the asthma diagnosis (76%), controlling for covariates, living in a rural area or a low-income neighborhood was associated with less likelihood of receiving specialist care.

CONCLUSIONS

Despite recommendations, more than half of individuals with asthma who required hospitalization did not receive specialist care during the first 2 years since the diagnosis. Identified factors associated with receiving asthma specialist care suggested that access is an important barrier to receiving recommended care.

Predictive factors of response to inhaled corticosteroids in newly diagnosed asthma: A real-world observational study

BACKGROUND

Asthma is characterized by chronic airway inflammation, and inhaled corticosteroids (ICSs) have been recommended as first-line treatment. However, response to ICS treatment is various, and the prediction of response to ICSs is still difficult, especially in individuals with newly diagnosed asthma.

OBJECTIVE

To assess the clinical factors and biomarkers associated with response to ICSs in newly diagnosed asthma.

METHODS

A total of 150 ICS-naive patients with newly diagnosed asthma in the allergy clinic of a single tertiary hospital in Korea from January 2014 to January 2019 were included in this study. All patients initially received moderate-dose ICSs and were treated for more than 1 year. We compared the clinical characteristics and parameters between patients with and without acute exacerbation (AE) during the study period.

RESULTS

In this study, 99 patients had no AE (stable asthma group), and 51 patients presented with more than 1 AE (unstable asthma group). The mean (SD) blood eosinophil count (635.7 [780.3] × 10³/μL vs 373.4 [266.8] × 10³/μL, P = .003) and sputum eosinophil count (15.2% [23.9%] vs 8.3% [15.4%], P = .051) were higher and the sputum neutrophil count (42.9% [35.1%] vs 61.3% [35.1%], P = .057) was lower in the stable asthma group than in the unstable asthma group.

CONCLUSION

High blood and sputum eosinophil counts can predict a good response to ICS treatment in terms of prevention of AE in individuals with newly diagnosed asthma. The sputum neutrophil count may be an effective predictor of response to ICSs, even though additional studies must be conducted.

A primary care database study of asthma among patients with and without opioid use disorders

Substance misuse is associated with poor asthma outcome and death. People with opioid use disorder (OUD) may be at particular risk, however, there have been no case-control studies of asthma care and outcomes in this patient group. A primary care database study of patients with asthma aged 16-65 years was conducted using a matched case-control methodology. The dataset comprised 275,151 adults with asthma, of whom 459 had a clinical code indicating a lifetime history of OUD. Cases with a history of OUD were matched to controls 1:3 by age, gender, smoking status and deprivation index decile. Attendance at annual review (30%) and for immunisation (25%) was poor amongst the overall matched study population (N = 1832). Compared to matched controls, cases were less likely to have attended for asthma review during the previous 12 months (OR = 0.60, 95% CI 0.45-0.80) but had similar immunisation rates. Higher rates of ICS (OR = 1.50, 1.13-1.98) and oral prednisolone use (OR = 1.71, 1.25-2.40) were seen amongst those with a history of OUD and 7.2% had a concurrent diagnosis of COPD (OR = 1.86, 1.12-2.40). We found that people with asthma and a history of OUD have worse outcomes on several commonly measured metrics of asthma care. Further research is required to identify reasons for these findings, the most effective strategies to help this vulnerable group access basic asthma care, and to better understand long-term respiratory outcomes.

Alignment of stakeholder agendas to facilitate the adoption of school-supervised asthma therapy

BACKGROUND

School-supervised inhaled corticosteroid (ICS) therapy improves pediatric asthma medication adherence, outcomes, and morbidity. However, school-supervised ICS therapy has not been widely adopted into practice. We developed Asthma Link™ as a sustainable, low-cost model of school-supervised asthma therapy, designed for real-world adoption. Initial outcomes of Asthma Link™ demonstrated a significant improvement in health outcomes.

OBJECTIVE

In this study, we examined the perspectives of Asthma Link™ participants to identify systems-level barriers and facilitators to refine the Asthma Link™ protocol and facilitate real-world uptake of school-supervised asthma therapy.

METHODS

Using qualitative research methods, we interviewed 29 participants in Asthma Link™ from 2016 to 2018. Semi-structured interviews were conducted over the phone. Interviews were transcribed and the transcripts were coded to identify major themes within and across stakeholder groups.

RESULTS

Stakeholders agreed on many facilitators for successful Asthma Link™ execution including the brief and easy to follow procedures and the perceived beneficial health impacts for children involved. Some of the barriers identified were deviations from the protocol and insurance companies denying coverage for two inhalers. However, the participants did propose solutions to address these barriers.

CONCLUSION

Asthma Link™ is a low-cost, sustainable model of school-supervised asthma therapy that leverages the established infrastructure and collaboration of medical providers, school staff, and families. In this study, we elicited the perspectives from these stakeholder groups and identified an agreement in several facilitators, barriers, and proposed solutions that will ultimately inform refinement of the program protocol and support real-world adoption of Asthma Link™ and other similar models.

Anti-IL-4/IL-13 for the treatment of asthma: the story so far

Introduction: Severe asthma is a global health concern with high morbidity and mortality. Understanding of its complex pathophysiology continues to increase, providing specific immune targets for therapeutic intervention.Areas covered: In this review, we focus on the role of IL-4 and IL-13 in severe asthma and on the biologic therapies developed to target them, particularly dupilumab, a monoclonal antibody against the IL-4 receptor α subunit and IL-4/IL-13 receptor complex. A literature search was undertaken for all studies of monoclonal antibodies against IL-4 and IL-13.Expert Opinion: Dupilumab decreases the rate of severe asthma exacerbations and improves symptoms, lung function, and quality of life. Importantly, these effects are also observed during reduction of maintenance oral corticosteroid doses. Those with the highest T2 biomarkers derive the greatest benefit and the presence of atopic dermatitis or chronic rhinosinusitis with or without nasal polyposis may recommend dupilumab as the preferred biologic treatment for a patient.

Development and validation of an asthma exacerbation prediction model using electronic health record (EHR) data

Objective: Asthma exacerbations are associated with significant morbidity, mortality, and cost. Accurately identifying asthma patients at risk for exacerbation is essential. We sought to develop a risk prediction tool based on routinely collected data from electronic health records (EHRs).Methods: From a repository of EHRs data, we extracted structured data for gender, race, ethnicity, smoking status, use of asthma medications, environmental allergy testing BMI status, and Asthma Control Test scores (ACT). A subgroup of this population of patients with asthma that had available prescription fill data was identified, which formed the primary population for analysis. Asthma exacerbation was defined as asthma-related hospitalization, urgent/emergent visit or oral steroid use over a 12-month period. Univariable and multivariable statistical analysis was completed to identify factors associated with exacerbation. We developed and tested a risk prediction model based on the multivariable analysis.Results: We identified 37,675 patients with asthma. Of those, 1,787 patients with asthma and fill data were identified, and 979 (54.8%) of them experienced an exacerbation. In the multivariable analysis, smoking (OR = 1.69, CI: 1.08-2.64), allergy testing (OR = 2.40, CI: 1.54-3.73), obesity (OR = 1.66, CI: 1.29-2.12), and ACT score reflecting uncontrolled asthma (OR = 1.66, CI: 1.10-2.29) were associated with increased risk of exacerbation. The area-under-the-curve (AUC) of our model in a combined derivation and validation cohort was 0.67.Conclusion: Despite use of rigorous methodology, we were unable to produce a predictive model with an acceptable degree of accuracy and AUC to be clinically useful.

Confounders of severe asthma: diagnoses to consider when asthma symptoms persist despite optimal therapy

Asthma can often be challenging to diagnose especially when patients present with atypical symptoms. Therefore, it is important to have a broad differential diagnosis for asthma to ensure that other conditions are not missed. Clinicians must maintain a high index of suspicion for asthma mimickers, especially when patients fail to respond to conventional therapy. The purpose of this review is to briefly review some of the more common causes of asthma mimickers that clinicians should consider when the diagnosis of asthma is unclear.

Identifying Asthma Exacerbation-Related Emergency Department Visit Using Electronic Medical Record and Claims Data

Background  Asthma exacerbation leading to emergency department (ED) visit is prevalent, an indicator of poor control of asthma, and is a potentially preventable clinical outcome.

Objective  We propose to utilize multiple data elements available in electronic medical records (EMRs) and claims database to create separate algorithms with high validity for clinical and research purposes to identify asthma exacerbation-related ED visit among the general population.

Methods  We performed a retrospective study with inclusion criteria of patients aged 4 to 40 years, a visit to Geisinger ED from January 1, 2006, to October 28, 2013, with asthma on their problem list. Different electronic data elements including chief complaints, vitals, season, smoking, medication use, and discharge diagnoses were obtained to create the algorithm. A stratified random sample was generated to select the charts for review. Chart review was performed to classify patients with asthma-related ED visit, that is, the gold standard. Two reviewers performed the chart review and validation was done on a small subset.

Results  There were 966 eligible ED visits in the EMR sample and 731 in the claims sample. Agreement between reviewers was 95.45% and kappa statistic was 0.91. Mean age of the EMR sample was 22 years, and mostly white (93%). Multiple models conventionally used in studies were evaluated and the final model chosen included principal diagnosis, bronchodilator, and steroid use for both algorithms, chief complaints for EMR, and secondary diagnosis for claims. Area under the curve was 0.93 (95% confidence interval: 0.91–0.94) and 0.94 (0.93–0.96), respectively, for EMR and claims data, with positive predictive value of > 94%. The algorithms are visually presented using nomograms.

Conclusion  We were able to develop two separate algorithms for EMR and claims to identify asthma exacerbation-related ED visit with excellent diagnostic ability and varying discrimination threshold for clinical and research purposes.

Assessment of predictors for acute asthma attack in asthmatic patients visiting an Ethiopian hospital: are the potential factors still a threat?

BACKGROUND

Recurrent exacerbations in patients with moderate or severe asthma are the major causes of morbidity, mortality and medical expenditure. Identifying predictors of frequent asthma attack might offer the fertile ground of asthma management. However, systematic data on asthma management is scarce in Ethiopia.

OBJECTIVE

The purpose of the present study was to determine predictors of acute asthma attack in patients with asthma attending emergency department of University of Gondar Comprehensive Specialized Hospital (UOGCSH) in Gondar, northwestern Ethiopia.

METHODS

An institutional-based cross-sectional self-administered survey was conducted on 108 asthmatic patients who came to the emergency department of UOGCSH following acute asthma attack. Data were collected through interviewer administered questionnaire. Logistic regression was done to see the possible association of potential factors that may lead to asthma exacerbation.

RESULT

About half of the respondents (51.9%) were female and one third of patients (38.9%) were within the age range of between 46 and 60 years. The leading potential predictor were frequent exposure to various ongoing allergen (68.5%) followed by revelation to occupational sensitizers (67.6%). Chronic sinusitis (AOR = 3.532, 95% CL = 1.116-11.178), obstructive sleep apnea (AOR = 3.425, 95% CL = 1.255-9.356) and psychological disfunctioning (3.689 (1.327-10.255)) were among the significantly associated factors of acute asthma exacerbation.

CONCLUSIONS

Now days, the backbone for long-term asthma management is to prevent exacerbations. Chronic sinusitis, obstructed sleep apnea and psychosocial dysfunction were originated to be considerably linked with repeated exacerbations of asthma. Among those significantly associated predictors, obstructed sleep apnea were the most prevalent one.

Targeting arginase and nitric oxide metabolism in chronic airway diseases and their co-morbidities

In the airways, arginase and NOS compete for the common substrate l-arginine. In chronic airway diseases, such as asthma and COPD, elevated arginase expression contributes to airway contractility, hyperresponsiveness, inflammation and remodeling. The disrupted l-arginine homeostasis, through changes in arginase and NOS expression and activity, does not only play a central role in the development of various airways diseases such as asthma or COPD. It possibly also affects l-arginine homeostasis throughout the body contributing to the emergence of co-morbidities. This review focusses on the role of arginase, NOS and ADMA in co-morbidities of asthma and COPD and speculates on their possible connection.

Efficacy and safety of benralizumab for eosinophilic asthma: A systematic review and meta-analysis of randomized controlled trials

CONTEXT

Benralizumab is a humanized monoclonal antibody that targets the α chain of the IL-5 receptor (IL-5Rα) and is currently being assessed in clinical trials for asthma control.

OBJECTIVE

Our systematic review and meta-analysis intends to evaluate the therapeutic efficacy and safety of benralizumab in patients with eosinophilic asthma.

DATA SOURCES AND EXTRACTION

Literature searches of PubMed, Embase, and the Cochrane Library were performed to identify randomized controlled trials of benralizumab and clinic outcomes in asthmatics.

RESULTS

In total, 7 articles with 2,321 subjects met our inclusion criteria. From this pooled analysis, we found that benralizumab significantly reduces exacerbations (RR: 0.63, 95% CI: 0.52-0.76, p < 0.00001; I² = 52%, p = 0.06) compared to placebo in eosinophilic asthma. There was no statistical trend for improvement in forced expiratory volume in 1 second or asthma control indices such as Quality of Life Assessment (AQLQ) and Asthma Control Questionnaire score in benralizumab-treated patients. In addition, safety data indicated that benralizumab administration resulted no increasing incidence of adverse events and was well tolerated (RR: 1.00, 95% CI: 0.95-1.05, p = 0.96; I² = 40%, p = 0.13).

CONCLUSION

These results demonstrate the efficacy and safety of benralizumab for asthma patients with severe or uncontrolled symptoms and elevated eosinophils and provide support for benralizumab as an ideal option to treat asthma in this patient population.

An early innate response underlies severe influenza-induced exacerbations of asthma in a novel steroid-insensitive and anti-IL-5-responsive mouse model

BACKGROUND

Acute worsening of asthma symptoms (exacerbation) is predominantly triggered by respiratory viruses, with influenza causing the most severe exacerbations. The lack of an adequate animal model hampers mechanistic insight and the development of new therapeutics.

AIM

We developed and characterized a robust, consistent, and reproducible mouse model of severe exacerbation of chronic allergic asthma.

METHODS

Chronic allergic airway inflammation was induced following a house dust mite (HDM) sensitization protocol. HDM-sensitized mice and controls were infected with influenza virus A/X31 H3N2 and either or not treated with inhaled fluticasone propionate (FP), systemic corticosteroids (Pred), or anti-IL-5. Mice were killed at different time points after infection: Cellular accumulation and cytokines levels in the airways, PenH as a measure of airway hyper-responsiveness (AHR), and lung histology and viral replication were assessed.

RESULTS

Infection with low-dose A/X31 H3N2 led to prolonged deterioration of lung function, aggravated mucus production, peri-vascular, peri-bronchial, and allergic inflammation that was unresponsive to inhaled corticosteroids, but responsive to systemic corticosteroids. The exacerbation was preceded at 14 h after virus exposure by a marked innate, but no Th2 and Th1 response subsequently followed by enhanced numbers of eosinophils, neutrophils, dendritic, and T cells into the lung lumen, parenchyma, and draining lymph nodes in HDM-sensitized mice. Anti-IL-5 treatment attenuated eosinophils and prevented the X31-induced exacerbation.

CONCLUSIONS

Together, these findings indicate that an early innate response that involves eosinophils underlies the exacerbation. This model recapitulates all major features of severe asthma exacerbations and can serve to discern driving mechanisms and promote the development of novel therapeutics.

Managing complex respiratory patients in the community: an evaluation of a pilot integrated respiratory care service

Introduction

In the UK, there is significant variation in respiratory care and outcomes. An integrated approach to the management of high-risk respiratory patients, incorporating specialist and primary care teams' expertise, is the basis for new integrated respiratory services designed to reduce this variation; however, this model needs evaluating.

Methods

To evaluate an integrated service managing high-risk respiratory patients, electronic searches for patients with asthma and chronic obstructive pulmonary disease at risk of poor outcomes were performed in two general practitioner (GP) practices in a local service-development initiative. Patients were reviewed at joint clinics by primary and secondary care professionals. GPs also nominated patients for inclusion. Reviews were delivered to best standards of care including assessments of diagnosis, control, spirometry, self-management, education, medication, inhaler technique and smoking cessation support. Follow-up of routine clinical data collected at 9-months postclinic were compared with seasonally matched 9-months prior to integrated review.

Results

82 patients were identified, 55 attended. 13 (23.6%) had their primary diagnosis changed. In comparison with the seasonally adjusted baseline period, in the 9-month follow-up there was an increase in inhaled corticosteroid prescriptions of 23.3%, a reduction in short-acting β₂-agonist prescription of 33.3%, a reduction in acute respiratory exacerbations of 67.6%, in unscheduled GP surgery visits of 53.3% and acute respiratory hospital admissions reduced from 3 to 0. Only 4 patients (7.3%) required referral to secondary care. Health economic evaluation showed respiratory-related costs per patient reduced by £231.86.

Conclusions

Patients with respiratory disease in this region at risk of suboptimal outcomes identified proactively and managed by an integrated team improved outcomes without the need for hospital referral.

Impact of asthma exacerbations and asthma triggers on asthma-related quality of life in patients with severe or difficult-to-treat asthma

BACKGROUND

Few data are available that evaluate the relationship among asthma exacerbations, asthma triggers, and asthma-related quality of life (QoL).

OBJECTIVE

To evaluate the impact of asthma exacerbations and asthma triggers on QoL.

METHODS

Patients with severe or difficult-to-treat asthma, ages ≥ 13 years (n = 2679) from the TENOR (The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens) 3-year observational study were included. Exacerbations were defined hierarchically in descending order of severity (hospitalization, emergency department [ED] visit, steroid burst, no exacerbation) by using data from months 6 and 12. The total number (frequency) of exacerbations was assessed. Asthma-related QoL was measured at month 12 by using the Mini-Asthma QoL Questionnaire (Mini-AQLQ); self-reported asthma triggers were collected at baseline and annually. We used 1-way ANOVA to test for differences in Mini-AQLQ domain scores across asthma exacerbation severity, the total number of asthma exacerbations, and the number of asthma triggers.

RESULTS

A significant decrease (P < .001) in Mini-AQLQ domain scores was seen with increasing severity of asthma exacerbation (no exacerbation, steroid burst, ED visit, and hospitalization); symptom (5.5, 4.8, 4.3, and 4.2), activity (5.8, 5.2, 4.6, and 4.4), emotional (5.6, 5.0, 4.4, and 4.2), exposure (5.0, 4.5, 4.0, and 3.9); and overall (5.5, 4.9, 4.3, and 4.1). Increasing exacerbation frequency and the number of baseline asthma triggers also were associated with significant decreases in Mini-AQLQ domain scores. An increasing number of asthma triggers were associated with an increase in severity and frequency of exacerbations.

CONCLUSION

Avoidance of asthma triggers may reduce exacerbation rates and improve asthma-related QoL in patients with severe or difficult-to-treat asthma. Interventional studies are warranted to further explore these outcomes.

Vitamins C and E for asthma and exercise-induced bronchoconstriction

BACKGROUND

The association between dietary antioxidants and asthma or exercise-induced bronchoconstriction (EIB) is not fully understood. Vitamin C and vitamin E are natural antioxidants that are predominantly present in fruits and vegetables; inadequate vitamin E intake is associated with airway inflammation. It has been postulated that the combination may be more beneficial than either single antioxidant for people with asthma and exercise-induced bronchoconstriction.

OBJECTIVES

To assess the effects of supplementation of vitamins C and E versus placebo (or no vitamin C and E supplementation) on exacerbations and health-related quality of life (HRQL) in adults and children with chronic asthma. To also examine the potential effects of vitamins C and E on exercise-induced bronchoconstriction in people with asthma and in people without a diagnosis of asthma who experience symptoms only on exercise.

SEARCH METHODS

Trials were identified from the Cochrane Airways Review Group Specialised Register and from trial registry websites. Searches were conducted in September 2013.

SELECTION CRITERIA

We included randomised controlled trials of adults and children with a diagnosis of asthma. We separately considered trials in which participants had received a diagnosis of exercise-induced bronchoconstriction (or exercise-induced asthma). Trials comparing vitamin C and E supplementation versus placebo were included. We included trials in which asthma management for treatment and control groups included similar background therapy. Short-term use of vitamins C and E at the time of exacerbation or for cold symptoms in people with asthma is outside the scope of this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of potential studies and subsequently screened full-text study reports for inclusion. We used standard methods as expected by The Cochrane Collaboration.

MAIN RESULTS

It was not possible to aggregate the five included studies (214 participants). Four studies (206 participants) addressed the question of whether differences in outcomes were seen when vitamin C and E supplementation versus placebo was provided for participants with asthma, and only one of those studies (160 children) included a paediatric population; the remaining three studies included a combined total of just 46 adults. An additional study considered the question of whether differences in outcomes were noted when vitamin C and E supplementation was compared with placebo for exercise-induced asthma; this trial included only eight participants. The randomisation process of the trials were unclear leading us to downgrade the quality of the evidence. Four of the studies were double blind while the other study was single blind.None of these studies provided data on our two prespecified primary outcome measures: exacerbations and HRQL. Lung function data obtained from the studies were inconclusive. The only studies that provided any suggestion of an effect, and only with some outcomes, were the paediatric study, especially for children with moderate to severe asthma, and the small study on exercise-induced asthma. Even so, this evidence was judged to be at moderate/low quality. Only one study contributed data on asthma symptoms and adverse events, reporting no evidence of an effect of the intervention for symptoms and that one participant in the treatment group dropped out due to cystitis.

AUTHORS' CONCLUSIONS

It is not possible to draw firm conclusions from this review with respect to the comparison of vitamin C and E supplementation versus placebo in the management of asthma or exercise-induced bronchoconstriction. We found only one study relevant to exercise-induced bronchoconstriction; most included participants came from studies designed to assess the effect of vitamin supplementation on the impact of atmospheric pollutants (such as ozone). Evidence is lacking on the comparison of vitamin C and E supplementation versus placebo for asthma with respect to outcomes such as HRQL and exacerbations, which were not addressed by any of the included studies.When compared with lung function tests alone, HRQL scores and exacerbation frequency are better indicators of the severity of asthma, its impact on daily activities and its response to treatment in a patient population. These end points are well recognised in good quality studies of asthma management. However, clinical studies of vitamins C and E in the management of asthma using these important end points of exacerbations and effects on quality of life are not available, and evidence is insufficient to support robust conclusions on the role of vitamin C and E supplementation in asthma and exercise-induced breathlessness.

Vitamin C for asthma and exercise-induced bronchoconstriction

BACKGROUND

Dietary antioxidants, such as vitamin C, in the epithelial lining and lining fluids of the lung may be beneficial in the reduction of oxidative damage (Arab 2002). They may therefore be of benefit in reducing symptoms of inflammatory airway conditions such as asthma, and may also be beneficial in reducing exercise-induced bronchoconstriction, which is a well-recognised feature of asthma and is considered a marker of airways inflammation. However, the association between dietary antioxidants and asthma severity or exercise-induced bronchoconstriction is not fully understood.

OBJECTIVES

To examine the effects of vitamin C supplementation on exacerbations and health-related quality of life (HRQL) in adults and children with asthma or exercise-induced bronchoconstriction compared to placebo or no vitamin C.

SEARCH METHODS

We identified trials from the Cochrane Airways Group's Specialised Register (CAGR). The Register contains trial reports identified through systematic searches of a number of bibliographic databases, and handsearching of journals and meeting abstracts. We also searched trial registry websites. The searches were conducted in December 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). We included both adults and children with a diagnosis of asthma. In separate analyses we considered trials with a diagnosis of exercise-induced bronchoconstriction (or exercise-induced asthma). We included trials comparing vitamin C supplementation with placebo, or vitamin C supplementation with no supplementation. We included trials where the asthma management of both treatment and control groups provided similar background therapy. The primary focus of the review is on daily vitamin C supplementation to prevent exacerbations and improve HRQL. The short-term use of vitamin C at the time of exacerbations or for cold symptoms in people with asthma are outside the scope of this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of potential studies, and subsequently screened full text study reports for inclusion. We used standard methods expected by The Cochrane Collaboration.

MAIN RESULTS

A total of 11 trials with 419 participants met our inclusion criteria. In 10 studies the participants were adults and only one was in children. Reporting of study design was inadequate to determine risk of bias for most of the studies and poor availability of data for our key outcomes may indicate some selective outcome reporting. Four studies were parallel-group and the remainder were cross-over studies. Eight studies included people with asthma and three studies included 40 participants with exercise-induced asthma. Five studies reported results using single-dose regimes prior to bronchial challenges or exercise tests. There was marked heterogeneity in vitamin C dosage regimes used in the selected studies, compounding the difficulties in carrying out meaningful analyses.One study on 201 adults with asthma reported no significant difference in our primary outcome, health-related quality of life (HRQL), and overall the quality of this evidence was low. There were no data available to evaluate the effects of vitamin C supplementation on our other primary outcome, exacerbations in adults. One small study reported data on asthma exacerbations in children and there were no exacerbations in either the vitamin C or placebo groups (very low quality evidence). In another study conducted in 41 adults, exacerbations were not defined according to our criteria and the data were not available in a format suitable for evaluation by our methods. Lung function and symptoms data were contributed by single studies. We rated the quality of this evidence as moderate, but further research is required to assess any clinical implications that may be related to the changes in these parameters. In each of these outcomes there was no significant difference between vitamin C and placebo. No adverse events at all were reported; again this is very low quality evidence.Studies in exercise-induced bronchoconstriction suggested some improvement in lung function measures with vitamin C supplementation, but theses studies were few and very small, with limited data and we judged the quality of the evidence to be low.

AUTHORS' CONCLUSIONS

Currently, evidence is not available to provide a robust assessment on the use of vitamin C in the management of asthma or exercise-induced bronchoconstriction. Further research is very likely to have an important impact on our confidence in the estimates of effect and is likely to change the estimates. There is no indication currently that vitamin C can be recommended as a therapeutic agent in asthma. There was some indication that vitamin C was helpful in exercise-induced breathlessness in terms of lung function and symptoms; however, as these findings were provided only by small studies they are inconclusive. Most published studies to date are too small and inconsistent to provide guidance. Well-designed trials with good quality clinical endpoints, such as exacerbation rates and health-related quality of life scores, are required.

Efficacy of anti-interleukin-5 therapy with mepolizumab in patients with asthma: a meta-analysis of randomized placebo-controlled trials

Background

Interleukin (IL)-5 is believed to be a key cytokine in eosinophil inflammatory infiltration in asthma. Previous clinical trials have evaluated the efficacy and safety of mepolizumab, a monoclonal antibody against IL-5, in patients with asthma. However, most of these studies were small, the conclusions were inconsistent, and the precise effects are therefore debatable.

Methods

A meta-analysis of randomized placebo-controlled trials was conducted to evaluate the effect of intravenous infusion of mepolizumab on clinical outcomes in patients with asthma. Trials were searched in PubMed, Embase, Web of Science, Cochrane CENTRAL, Scopus, reviews, and reference lists of relevant articles. The outcome variables analyzed included eosinophil counts in blood and sputum, airways outcome measures, exacerbations, asthma control, and quality of life scores.

Results

Seven studies met final inclusion criteria (total n = 1131). From the pooled analyses, mepolizumab significantly reduced eosinophils in blood (MD −0.29×10⁹/L, 95% CI −0.44 to −0.14×10⁹/L, P = 0.0001) and sputum (MD −6.05%, 95% CI −9.34 to −2.77%, P = 0.0003). Mepolizumab was also associated with significantly decreased exacerbation risk than placebo (OR 0.30, 95%CI 0.13 to 0.67, P = 0.004), and with a significant improvement in the scores on the Asthma Quality of Life Questionnaire (AQLQ) (MD 0.26, 95% CI 0.03 to 0.49, P = 0.03) in patients with eosinophilic asthma. There were no statistical differences between the groups with respect to FEV₁, PEF, or histamine PC₂₀ (all P>0.05)_, and a non-significant trend for improvement in scores on the Juniper Asthma Control Questionnaire (JACQ) (MD −0.21, 95% CI −0.43 to 0.01, P = 0.06) in the mepolizumab group was observed.

Conclusions

Mepolizumab reduces the risk of exacerbations and improves quality of life in patients with eosinophilic asthma, but no significant improvement in lung function outcomes was observed. Further research is required to establish the possible role of anti–IL-5 as a therapy for asthma.

Once-daily fluticasone furoate is efficacious in patients with symptomatic asthma on low-dose inhaled corticosteroids

BACKGROUND

Fluticasone furoate (FF) is an inhaled corticosteroid (ICS) with 24-hour activity in development as a once-daily treatment for the long-term management of asthma.

OBJECTIVE

To assess the efficacy and safety of 4 doses of once-daily FF administered using a dry powder inhaler in patients (≥12 years) with moderate asthma, uncontrolled on low-dose ICS (fluticasone propionate [FP] 200 μg/day or equivalent).

METHODS

This double-blind, placebo-controlled, dose-ranging study randomized 622 patients to 1 of 6 treatments: FF (100, 200, 300, or 400 μg) once daily in the evening, FP 250 μg twice daily (active control), or placebo for 8 weeks. The primary endpoint was the change from baseline in predose evening forced expiratory colume in 1 second (FEV1) at week 8.

RESULTS

At week 8, relative to placebo, all doses of FF once daily and FP twice daily demonstrated significantly (P < .001) greater increases from baseline and greater than 200-mL increases in predose FEV1. There was no evidence of a dose-response relationship between FF doses. Improvement with once-daily FF was similar to or greater than that for twice-daily FP. Secondary efficacy endpoint findings generally supported the efficacy of FF 100 to 400 μg once daily, although statistically significant improvements versus placebo in symptom-free 24-hour periods were only reported for FF 400 μg. There were few withdrawals due to lack of efficacy. Oral candidiasis was reported in 0 to 4% of patients; 24-hour urinary cortisol excretion ratios were similar across active treatment groups and not significantly different from placebo.

CONCLUSION

FF 100 to 400 μg once daily in the evening is effective and well tolerated in patients with asthma uncontrolled on low-dose ICS, with 100 μg and 200 μg, considered the most applicable doses in this asthma population.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00603278.

The effect of budesonide/formoterol maintenance and reliever therapy on the risk of severe asthma exacerbations following episodes of high reliever use: an exploratory analysis of two randomised, controlled studies with comparisons to standard therapy

BACKGROUND

Divergent strategies have emerged for the management of severe asthma. One strategy utilises high and fixed doses of maintenance treatment, usually inhaled corticosteroid/long-acting β2-agonist (ICS/LABA), supplemented by a short-acting β2-agonist (SABA) as needed. Alternatively, budesonide/formoterol is used as both maintenance and reliever therapy. The latter is superior to fixed-dose treatment in reducing severe exacerbations while achieving similar or better asthma control in other regards. Exacerbations may be reduced by the use of budesonide/formoterol as reliever medication during periods of unstable asthma. We examined the risk of a severe exacerbation in the period after a single day with high reliever use.

METHODS

Episodes of high reliever use were quantified and exacerbations occurring post-index day with these episodes were examined post hoc in two double-blind studies comparing the efficacy and safety of budesonide/formoterol maintenance and reliever therapy (Symbicort SMART™, Turbuhaler®) 160/4.5 μg twice daily plus as needed with similar or higher maintenance doses of ICS/LABA plus SABA or formoterol.

RESULTS

Budesonide/formoterol maintenance and reliever therapy significantly reduced the risk of episodes of high reliever use (>6 inhalations/day) vs. all alternative ICS/LABA regimens. With conventional fixed-dose treatment the need for exacerbation treatment within 21 days ranged from 6.0-10.1% of days post-index for all regimens compared with 2.5-3.4% of days with budesonide/formoterol maintenance and reliever therapy.

CONCLUSIONS

Budesonide/formoterol maintenance and reliever therapy reduces the incidence of high reliever episodes and the exacerbation burden immediately following these episodes vs. alternative ICS/LABA plus SABA regimens at up to double the maintenance dose of ICS.

TRIAL REGISTRATION

These studies do not have registration numbers as they were conducted before clinical trial registration was required.

[Asthma exacerbations: pharmacological prevention]

Asthma exacerbations are responsible for many emergency medical interventions and account for a significant proportion of the health costs of the disease. Increased airway inflammation is a key feature of exacerbations in asthma and therefore inhaled corticosteroids (ICS) are considered as first-line therapy for long-term asthma control. ICS have been demonstrated to reduce the risk of asthma exacerbations, as well as improving lung function. Oral leukotriene receptor antagonists also reduce the incidence of asthma exacerbations but are less effective than ICS. In patients with inadequately controlled persistent asthma despite low-dose ICS, the addition of a long-acting inhaled beta-agonist (LABA) should be considered. LABA should not be given alone and should always be associated with ICS in asthma. The anti-immunoglobulin E antibody, omalizumab, reduces severe exacerbations and emergency visits in patients with severe allergic asthma. In clinical trials measurement of the inflammatory response in induced sputum could provide information concerning appropriate drug therapy. Asthma-associated comorbidities should be investigated and treated, particularly in severe asthma. Despite a high prevalence of both gastro-oesophageal reflux and allergic rhinitis among patients with asthma, treatment with proton-pump inhibitors or nasal corticosteroids does not reduce the rate of asthma exacerbations.

Clinical benefits of 7 years of treatment with omalizumab in severe uncontrolled asthmatics

RATIONALE

Severe asthma is characterized by inadequate symptom control and by high rate of inflammation despite high doses of steroids. Omalizumab, a recombinant humanized monoclonal anti-IgE, provides a new therapeutic strategy in severe allergic asthma.

AIMS

This study was aimed to assess whether long-term treatment with omalizumab improved clinical control in severe asthmatics.

METHODS

We investigated omalizumab effects on asthma outcomes evaluating seven severe allergic asthmatic patients who were treated for 7 years with add-on omalizumab. Number of exacerbations, use of antibiotics, additional asthma medications (systemic steroids, nebulized steroids and bronchodilators), and spirometry were analyzed before and after omalizumab treatment.

RESULTS

Omalizumab was well tolerated by all the studied patients. It improved FEV1 and FEV1/FVC ratio and reduced symptom score, asthma exacerbations, use of antibiotics, and use of nebulized steroids, bronchodilators, and oral corticosteroids. These effects were evident after 4 years of treatment and more pronounced after 7 years of treatment.

CONCLUSIONS

This study underlines the utility of a long-term treatment with omalizumab to improve asthma clinical outcomes in severe asthmatics.

What's new in asthma pathophysiology and immunopathology?

Research on asthma pathophysiology over the past decade has expanded the complex repertoire involved in the pathophysiology of asthma to include inflammatory, immune and structural cells, as well as a wide range of mediators. Studies have identified a role for connective and other mesenchymal tissues involved in airway remodeling. Recent findings have implicated the innate immune response in asthma and have revealed interesting patterns of interaction between the innate and adaptive immune response and the associated complex chronic inflammatory reaction. New immune cell populations have also been added to this repertoire, including Tregs, natural killer T cells and Th17 cells. The role of the eosinophil, a prominent pathological feature in most asthma phenotypes, has also been expanding to include roles such as tissue modifiers and immune regulators via a number of fascinating and hitherto unexplored mechanistic pathways. In addition, new and significant roles have been proposed for airway smooth muscle cells, fibroblasts, epithelial and endothelial cells. Tissue remodeling is now considered an integral element of asthma pathophysiology. Finally, an intricate network of mediators, released from both immune and inflammatory cells, including thymus stromal lymphopoietin and matrix metalloproteinases, have added to the complex milieu of asthma immunity and inflammation. These findings have implications for therapy and the search for novel strategies towards better disease management. Sadly, and perhaps due to the complex nature of asthma, advances in therapeutic discoveries and developments have been limited. Thus, understanding the precise roles played by the numerous dramatis personae in this odyssey, both individually and collectively within the context of asthma pathophysiology, continues to pose new challenges. It is clear that the next stage in this saga is to embark on studies that transcend reductionist approaches to involve system analysis of the complex and multiple variables involved in asthma, including the need to narrow down the phenotypes of this condition based on careful analysis of the organs (lung and airways), cells, mediators and other factors involved in bronchial asthma.

Clinical pharmacist counseling improves outcomes for Taiwanese asthma patients

OBJECTIVE

To assess the impact of an asthma educational program provided by a nurse combined with asthma counseling provided by a pharmacist on asthma knowledge, quality of life and clinical outcomes in Taiwanese patients with asthma.

SETTING

All patients were recruited from Pulmonary Medicine outpatient clinic, the Tri-Service General Hospital, Taipei, Taiwan. Asthma education was given in three one-hour sessions offered during monthly clinic visits.

METHOD

A total of 91 asthma patients were randomly assigned to a nurse-administered education program (Group 1), the education program with additional pharmacist counseling (Group 2), or a control group receiving routine care only (control). Three questionnaires were used for assessment at months 0, 3 and 6. Outcomes were compared between groups to determine efficacy.

MAIN OUTCOME MEASURE

Asthma knowledge, health-related quality of life, and medication adherence were measured at baseline and 3 and 6 months after enrollment.

RESULTS

A total of 104 patients were enrolled; 91 completed the study. Knowledge scores of patients in Groups 1 and 2 increased significantly compared to control group. Both intervention groups showed significant increases in knowledge scores with longer follow-up. Group 2 showed a significant improvement in clinical symptoms between baseline (month 0) and month 6 (4.99 vs. 4.21, P=0.008). No significant differences in medication adherence were seen among groups.

CONCLUSION

Regular nurse-administered asthma education with additional pharmacist counseling improves asthma knowledge and clinical symptoms in asthma patients.

Measuring exacerbations in obstructive lung disease

PURPOSE

Using hospitalization always has been seen as a solid measurement for exacerbation in pharmacoepidemiology, but might lead to an underestimation of disease exacerbation because of a trend towards outpatient care. The aim of this study was to quantify the incidence of different exacerbation markers in obstructive lung disease and to identify predictors for these exacerbation markers.

METHODS

We conducted a cohort study using the PHARMO record linkage system, including demographic details and complete medication histories of more than two million community-dwelling residents in the Netherlands from 1985 onwards. Eligible patients were adult users of inhaled corticosteroids (ICS). Outcome parameters were hospitalization and short courses of systemic corticosteroids. Patients were allowed to have multiple exacerbations during follow-up.

RESULTS

We identified 5327 patients. During follow-up, 8635 exacerbations occurred in 2332 patients with a trend in time towards treating exacerbations out of the hospital (p-value 0.003). Of all patients with exacerbations, 73% was not hospitalized during follow-up. Exacerbations were associated with high-dose ICS use (adjusted RR 1.4; 95% CI 1.2-1.7) and chronic systemic corticosteroid use (adjusted RR 1.9; 95%CI 1.6-2.2).

CONCLUSIONS

Using hospitalization only as exacerbation marker leads to underestimating the exacerbation rate, because of exacerbation treatment out of the hospital. Patients with obstructive lung disease using chronic systemic corticosteroids or high-dose ICS use are more prone to exacerbations. This implies that these patients should be monitored carefully to prevent recurrent exacerbations which are detrimental for their prognosis and quality of life.

Budesonide/formoterol for maintenance and reliever therapy of asthma: a meta analysis of randomised controlled trials

OBJECTIVES

To compare the effectiveness of budesonide/formoterol (Symbicort) for Maintenance and Reliever Therapy (Symbicort SMART) Turbuhaler with twice daily inhaled corticosteroid (ICS) treatment, alone or in combination with a long-acting beta(2)-agonist (LABA).

METHODS

Meta analysis of randomised controlled trials (RCTs) using a fixed effects model. RCTs were included if the comparator with budesonide/formoterol for maintenance and relief had the equivalent, or up to fourfold higher, maintenance dose of ICS. The primary outcome was the incidence of severe exacerbation (oral glucocorticosteroid treatment for > or = 3 days, emergency visit and/or hospitalisation).

RESULTS

Of the seven RCTs available six met the inclusion criteria. Risk of severe exacerbations was significantly reduced: 41% vs. higher-dose budesonide alone [relative risk (RR) 0.59, 95% confidence interval (95% CI): 0.51-0.68, p < 0.00001]; 43% vs. equivalent dose budesonide/formoterol as maintenance twice daily (RR 0.57, 95% CI: 0.49-0.66, p < 0.00001); 24% vs. higher-dose salmeterol/fluticasone twice daily (RR 0.76, 95% CI: 0.64-0.90, p = 0.002); and 26% vs. higher-dose budesonide/formoterol twice daily (RR 0.74, 95% CI: 0.58-0.96, p = 0.02). Significant heterogeneity was not detected in the primary analyses (p > 0.1). Secondary analyses also demonstrated that budesonide/formoterol for maintenance and relief reduced the most severe exacerbations, resulting in less hospitalisations/accident and emergency visits than higher-dose budesonide, equivalent dose budesonide/formoterol and higher-dose salmeterol/fluticasone twice daily.

CONCLUSION

Budesonide/formoterol for maintenance and relief is significantly more effective at reducing severe exacerbations than higher-dose ICS alone, or in combination with a LABA. This has important implications for treating uncontrolled patients at steps 2 and 3 of the joint BTS/SIGN guidelines.

Achieving asthma control in patients with moderate disease

Patients with moderate asthma are symptomatic on an ongoing basis. They are usually treated initially with low-dose inhaled corticosteroids (ICSs) supplemented with a short-acting bronchodilator as a rescue medication. Most steroid-naive patients will achieve good control with this strategy. For patients in whom adherence, inhaler technique, environmental control, and comorbidities have been addressed but who still have uncontrolled symptoms, the addition of a long-acting beta-adrenergic agonist should be considered. Some patients might require a higher dose of ICS. Leukotriene receptor antagonists might be considered as alternate initial therapy or as an add-on to maintenance therapy with an ICS. All patients should receive a structured education program emphasizing the need for ongoing maintenance treatment, even when control is achieved. Patients should also be provided with a written action plan that clearly explains which additional anti-inflammatory therapy should be taken if asthma symptoms worsen. The most effective strategy in this situation has been shown to be the quadrupling of the maintenance dose of ICS.

Mepolizumab and exacerbations of refractory eosinophilic asthma

BACKGROUND

Exacerbations of asthma are associated with substantial morbidity and mortality and with considerable use of health care resources. Preventing exacerbations remains an important goal of therapy. There is evidence that eosinophilic inflammation of the airway is associated with the risk of exacerbations.

METHODS

We conducted a randomized, double-blind, placebo-controlled, parallel-group study of 61 subjects who had refractory eosinophilic asthma and a history of recurrent severe exacerbations. Subjects received infusions of either mepolizumab, an anti-interleukin-5 monoclonal antibody (29 subjects), or placebo (32) at monthly intervals for 1 year. The primary outcome measure was the number of severe exacerbations per subject during the 50-week treatment phase. Secondary outcomes included a change in asthma symptoms, scores on the Asthma Quality of Life Questionnaire (AQLQ, in which scores range from 1 to 7, with lower values indicating more severe impairment and a change of 0.5 unit considered to be clinically important), forced expiratory volume in 1 second (FEV(1)) after use of a bronchodilator, airway hyperresponsiveness, and eosinophil counts in the blood and sputum.

RESULTS

Mepolizumab was associated with significantly fewer severe exacerbations than placebo over the course of 50 weeks (2.0 vs. 3.4 mean exacerbations per subject; relative risk, 0.57; 95% confidence interval [CI], 0.32 to 0.92; P=0.02) and with a significant improvement in the score on the AQLQ (mean increase from baseline, 0.55 vs. 0.19; mean difference between groups, 0.35; 95% CI, 0.08 to 0.62; P=0.02). Mepolizumab significantly lowered eosinophil counts in the blood (P<0.001) and sputum (P=0.002). There were no significant differences between the groups with respect to symptoms, FEV(1) after bronchodilator use, or airway hyperresponsiveness. The only serious adverse events reported were hospitalizations for acute severe asthma.

CONCLUSIONS

Mepolizumab therapy reduces exacerbations and improves AQLQ scores in patients with refractory eosinophilic asthma. The results of our study suggest that eosinophils have a role as important effector cells in the pathogenesis of severe exacerbations of asthma in this patient population. (Current Controlled Trials number, ISRCTN75169762.)

Epidemiology of asthma exacerbations

Exacerbations of asthma sufficient to require urgent medical intervention are often, but not always, associated with viral infection, especially rhinovirus, with significant interaction with allergen sensitization and exposure. Seasonal patterns of exacerbations are seen especially in children, and may be aggravated by lack of adequate maintenance anti-inflammatory drug treatment during the high-risk viral season most well described in the Northern Hemisphere after school return in September. Age and sex differences in the epidemiology of exacerbations remain less than fully explained, but hormonal influences are demonstrable. Frequent exacerbations may be an indication of greater severity of disease, significant comorbidities, or poor compliance with therapy. Recognizing risk factors for exacerbations and implementing appropriate long-term management strategies coupled with improved compliance should reduce morbidity and mortality associated with asthma exacerbations.

Budesonide/formoterol for maintenance and reliever therapy in the management of moderate to severe asthma

The Global Initiative for Asthma (GINA) guidelines aim at improving asthma control and preventing future risk. For patients with moderate to severe asthma an inhaled corticosteroid (ICS) or an ICS/long-acting beta2-agonist (LABA) combination with a short-acting beta2-agonist (SABA) as reliever is recommended. Despite the availability of effective maintenance therapies, a large proportion of patients still fail to achieve guideline-defined asthma control, and overuse of SABA reliever medication at the expense of ICS is commonly observed. New simplified treatment approaches may offer a solution and assist physicians to achieve overall asthma control. One such treatment approach, which is recommended in the GINA guidelines, is budesonide/formoterol for both maintenance and reliever therapy. This treatment strategy significantly reduces the rate of severe asthma exacerbations compared with ICS/LABA plus SABA and achieves equivalent daily symptom control compared with higher doses of ICS/LABA plus separate SABA for relief. These benefits are achieved at a lower overall steroid load, and budesonide/formoterol maintenance and reliever therapy is well tolerated in patients with moderate to severe asthma. This review discusses current asthma management in patients with moderate to severe disease and examines the evidence for alternative asthma management approaches.

Long-acting beta(2) agonists in asthma and allergic rhinitis

BACKGROUND

Long-acting beta(2) agonists (LABAs) are effective second-line bronchodilator controller agents in asthma, although they may also increase the risk of hospitalization and asthma-related death in certain situations. Despite the interesting findings obtained with short-acting beta(2) agonists (SABAs), negative studies are available with LABAs in the treatment of allergic rhinitis. This is quite surprising given that there is now clear documentation of the link between asthma and allergic rhinitis.

OBJECTIVE

The aim of this review is to examine the role of beta(2) agonists in patients with asthma who also suffer from allergic rhinitis and to try to explain the differences observed between SABAs and LABAs in rhinitis.

METHODS

SCOPUS, GOOGLE SCHOLAR and MEDLINE were searched for abstracts and papers; the search was completed in March 2008. No restriction was placed on language.

CONCLUSION

The intriguing united airway concept led to the hypothesis that common therapies may influence both and asthma and allergic rhinitis. Consequently, better designed studies with LABAs in allergic rhinitis are now mandatory. In particular, further studies are necessary to investigate clinically relevant anti-inflammatory synergy between inhaled corticosteroids and LABAs in upper airways. It will also be interesting to assess whether ultra-LABAs (once-daily LABAs) are active in allergic rhinitis, although the information we have seems to exclude a role for these agents.

Budesonide/formoterol for maintenance and relief in uncontrolled asthma vs. high-dose salmeterol/fluticasone

BACKGROUND

Budesonide/formoterol maintenance and reliever therapy (Symbicort SMART) improves asthma control compared with fixed-dose inhaled corticosteroid/long-acting beta(2)-agonist (ICS/LABA) regimens, but its efficacy has not been assessed in comparison with sustained high-dose salmeterol/fluticasone (Seretide) plus a short-acting beta(2)-agonist (SABA).

METHODS

Patients (N=2309) with symptomatic asthma (aged 12 years; forced expiratory volume in 1s 50% predicted), who had experienced an asthma exacerbation in the previous year, were randomised to receive budesonide/formoterol 160/4.5 microg two inhalations twice daily and as needed, or one inhalation of salmeterol/fluticasone 50/500 microg twice daily plus terbutaline as needed, for 6 months.

RESULTS

Time to first severe exacerbation, the pre-specified primary outcome, was not significantly prolonged (risk ratio 0.82; 95% confidence interval 0.63, 1.05). Budesonide/formoterol maintenance and reliever therapy reduced total exacerbations from 31 to 25 events/100 patients/year (P=0.039), and exacerbations requiring hospitalisation/emergency room (ER) treatment from 13 to 9 events/100 patients/year (P=0.046). The treatments showed no difference in measures of lung function or asthma symptoms. The mean dose of ICS received was lower using budesonide/formoterol maintenance and reliever therapy (792 microg/day budesonide [1238 microg/day beclomethasone dipropionate (BDP) equivalent] versus 1000 microg/day fluticasone [2000 microg/day BDP equivalent] with salmeterol/fluticasone therapy; P<0.0001). Both treatments were well tolerated.

CONCLUSION

In the treatment of uncontrolled asthma, budesonide/formoterol maintenance and reliever therapy reduces the incidence of severe asthma exacerbations and hospitalisation/ER treatment with similar daily symptom control compared with sustained high-dose salmeterol/fluticasone plus SABA. This benefit is achieved with substantially less ICS exposure.

Budesonide/formoterol maintenance and reliever therapy: a new treatment approach for adult patients with asthma

BACKGROUND

An inhaled corticosteroid (ICS) or an ICS/long-acting beta(2)-agonist (LABA) combination plus short-acting beta(2)-agonist (SABA) as needed for symptom relief is recommended for persistent asthma. Additionally, budesonide/formoterol maintenance and reliever therapy (Symbicort SMART, AstraZeneca, Sweden) has been approved for adults in the European Union. This option is well tolerated and offers greater reductions in asthma exacerbations together with similar improvements in daily symptom control, at a lower overall steroid load, compared with fixed-dose ICS/LABA plus SABA.

SCOPE

Two large clinical trials investigated the use of budesonide/formoterol as maintenance and reliever compared with medium or high doses of an ICS/LABA combination as controller plus SABA as reliever in adults (aged > or = 12 years). COMPASS was a 6-month, double blind, randomized trial while COSMOS was a 1-year, dose titration study which reflected routine clinical practice. The current review focuses on the findings in both studies, among adult patients only (aged > or = 18 years).

FINDINGS

Among adults, the studies confirmed a 21-39% reduction in severe exacerbations in patients treated with budesonide/formoterol maintenance and reliever therapy compared with titrated salmeterol/fluticasone plus SABA (COSMOS) or fixed higher budesonide/formoterol or salmeterol/fluticasone plus SABA (COMPASS), respectively. Similar levels of daily asthma control were achieved with budesonide/formoterol maintenance and reliever therapy at a significantly lower overall steroid load compared with salmeterol/fluticasone or budesonide/formoterol plus SABA. Budesonide/formoterol maintenance and reliever therapy was as well tolerated as combination therapies.

CONCLUSIONS

In adult patients, budesonide/formoterol maintenance and reliever therapy is a safe and simplified approach to asthma management, using a single inhaler, which reduces severe exacerbations and maintains similar daily asthma control at a lower drug load compared with the traditional strategy of ICS/LABA plus SABA.