Persistent asthma: disease control, resource utilisation and direct costs

Effect of biologic therapies on quality of life in severe asthma: Findings from the PRISM study

Background

Anti-type 2 (T2) biologic therapies (biologics) improve exacerbation rates, lung function, and asthma-related quality of life (QoL) in patients with severe T2 asthma. However, studies comparing different biologics are lacking. We evaluated the QoL in patients with severe asthma comprehensively and compare the efficacy of different T2-directed biologics using QoL questionnaires.

Methods

We compared the QoL between severe and mild-to-moderate asthma and between severe asthma with and without biologics treatment. Data of mild-to-moderate were extracted from the Cohort for Reality and Evolution of Adult Asthma in Korea, and data of severe asthma were collected from the Precision Medicine Intervention in Severe Asthma. We included 183 patients with severe asthma treated with T2 biologics or conventional therapy between April 2020 and May 2021 and assessed QoL of them using the Questionnaire for Adult Korean Asthmatics (QLQAKA), Severe Asthma Questionnaire (SAQ), and EuroQoL-5Dimensions (EQ-5D) at baseline and 6 months.

Results

The EQ-5D index (0.803) of severe asthma was lower than that of other chronic diseases representing a worse QoL. The scores for all questions of QLQAKA, except "cough," were lower (less control) in the severe asthma group than in the mild-to-moderate asthma group at baseline and 6 months (P < 0.05). The total scores and subscores of all domains of the QLQAKA, SAQ, and EQ-5D improved significantly 6 months after biologic therapy but not after conventional therapy. The total QLQAKA, SAQ, and EQ-5D scores improved after 6 months in the anti-IL-5 (P < 0.05) and anti-IL-4/IL-13 (P < 0.05) treatment groups with no significant difference between groups (P > 0.05).

Conclusion

QoL was worse in severe asthma than in mild-to-moderate asthma and other chronic diseases. T2 biologics equally improved QoL in patients with severe asthma.

GPR120/FFAR4 stimulation attenuates airway remodeling and suppresses IL-4- and IL-13-induced airway epithelial injury via inhibition of STAT6 and Akt

BACKGROUND

Airway remodeling is associated with severity and treatment insensitivity in asthma. This study aimed to investigate the effects of G protein-coupled receptor 120 (GPR120) stimulation on alleviating allergic inflammation and remodeling of airway epithelium.

RESEARCH DESIGN AND METHODS

Ovalbumin (OVA)-challenged BALB/c mice and type-2-cytokine (IL-4 and IL-13)-exposed 16HBE human bronchial epithelial cells were treated with GSK137647A, a selective GPR120 agonist. Markers of allergic inflammation and airway remodeling were determined.

RESULTS

GSK137647A attenuated inflammation and mucus secretion in airway epithelium of OVA-challenged mice. Stimulation of GPR120 in 16HBE suppressed expression of asthma-associated cytokines and cytokine-induced expression of pathogenic mucin-MUC5AC. These effects were abolished by co-treatment with AH7614, a GPR120 antagonist. Moreover, GPR120 stimulation in 16HBE cells reduced expression of fibrotic markers including fibronectin protein and ACTA2 mRNA and inhibited epithelial barrier leakage induced by type-2 inflammation via rescuing expression of zonula occludens-1 protein. Furthermore, GPR120 stimulation prevented the cytokine-induced airway epithelial remodeling via suppression of STAT6 and Akt phosphorylation.

CONCLUSIONS

Our findings suggest that GPR120 activation alleviates allergic inflammation and remodeling of airway epithelium partly through inhibition of STAT6 and Akt. GPR120 may represent a novel therapeutic target for diseases associated with remodeling of airway epithelium, including asthma.

Trajectories of Controller Therapy Use Before and After Asthma-Related Hospitalization in Children and Adults: Population-Based Retrospective Cohort Study

BACKGROUND

Inappropriate use of inhaled corticosteroids (ICSs) for asthma impairs control and may cause exacerbation, including asthma-related hospitalization (ARH). In prospective studies, ICS use peaked around ARH, but information on routine care use is limited. Since ARH is a major outcome, controller therapy use in routine care before and after ARH should be documented.

OBJECTIVE

This study aimed to distinguish ICS use typologies (trajectories) before and after ARH, and assess their relationships with sociodemographic, disease, and health care characteristics.

METHODS

A retrospective cohort study was performed using a 1% random sample of the French claims database. All patients hospitalized for asthma between January 01, 2013, and December 31, 2015, were classified as either children (aged 1-10 years) or teens/adults (aged ≥11 years). Health care resource use was assessed between 24 and 12 months before ARH. ICS use was computed with the Continuous Measures of Medication Acquisition-7 (CMA7) for the 4 quarters before and after ARH. Initially, the overall impact of hospitalization on the CMA7 value was studied using a segmented regression analysis in both children and teens/adults. Then, group-based trajectory modeling differentiated the groups with similar ICS use. We tested different models having 2 to 5 distinct trajectory groups before selecting the most appropriate trajectory form. We finally selected the model with the lowest Bayesian Information Criterion, the highest proportion of patients in each group, and the maximum estimated probability of assignment to a specific group.

RESULTS

Overall, 863 patients were included in the final study cohort, of which 447 (51.8%) were children and 416 (48.2%) were teens/adults. In children, the average CMA7 value was 12.6% at the start of the observation period, and there was no significant quarter-to-quarter change in the value (P=.14) before hospitalization. Immediately after hospitalization, the average CMA7 value rose by 34.9% (P=.001), before a significant decrease (P=.01) of 7.0% per quarter. In teens/adults, the average CMA7 value was 31.0% at the start, and there was no significant quarter-to-quarter change in the value (P=.08) before hospitalization. Immediately after hospitalization, the average CMA7 value rose by 26.9% (P=.002), before a significant decrease (P=.01) of 7.0% per quarter. We identified 3 and 5 trajectories before ARH in children and adults, respectively, and 5 after ARH for both groups. Trajectories were related to sociodemographic characteristics (particularly, markers of social deprivation) and to potentially inappropriate health care, such as medical management and choice of therapy.

CONCLUSIONS

Although ARH had an overall positive impact on ICS use trajectories, the effect was often transient, and patient behaviors were heterogeneous. Along with overall trends, distinct trajectories were identified, which were related to specific patients and health care characteristics. Our data reinforce the evidence that inappropriate use of ICS paves the way for ARH.

Treatment of Allergic Rhinitis and Asthma in Primary Care: Dispensations Do Not Align with Prescriptions

Background

Appropriate use of effective treatments is required for satisfactory control of allergic symptoms. Coherent medical care -regular prescribing by the same Health Care Professionals- is a preliminary need.

Objective

We investigated the numbers of distinct prescribers, the regularity of medical visits, and the agreement between prescriptions and associated dispensations in individual patients with perennial allergic rhinitis (PAR) and asthma.

Methods

In primary care electronic health records (EHRs), a cohort of patients with PAR and asthma was identified. Individual EHRs were linked to corresponding claims recording all dispensations. Prescribing patterns were analyzed for the major treatment classes, and the dispensations linked to individual prescriptions were retrieved to compute the proportions of days covered (PDCs) for asthma and PAR therapy.

Results

A total of 3654 patients were included, with 62% being female (mean age, 46.1 years). At inclusion, asthma control was not optimal in 51% of the patients and 48% had received oral corticosteroids. The mean interval between successive prescriptions varied between 93 (leukotriene receptor antagonists, LTRAs) and 103 (inhaled corticosteroids, ICS) days, and 97 (antihistamines, AHs) and 103 days (nasal corticosteroids, NCS). On average, individual prescriptions lead to 1.2, 1.5, 1.7 and 1.8 dispensations of ICS, ICS/Long-Acting Beta-Agonist (LABA) fixed-dose combinations, LABAs, and LTRAs, respectively, and to 1.3 and 1.6 dispensations of NCS and AHs, respectively. PDCs then varied between 37.8% for ICS and 58.6% for LTRAs, and between 39.7% for NCS and 50.4% for AHs. Care was nonetheless coherent, with >90% of all dispensations related to prescriptions issued by single General Practitioners (GPs).

Conclusion

Despite regular healthcare visits and medication prescriptions, allergic patients only partly and selectively refilled their treatments, preferring the less effective therapy, in a context of poor control of asthma symptoms.

Gulf Asthma Diagnosis and Management in Adults: Expert Review and Recommendations

The prevalence and incidence of asthma are increasing globally because of genetic and environmental influences. Prevalence of asthma in the Gulf has been reported to range from 4.7% to 32.0% and has a substantial economic burden. In this paper, we summarize current asthma management guidance for adults, present insights, and recommendations by key opinion leaders (KOLs) in the Gulf region, and key performance indicators for guiding clinical practice for asthma diagnosis, management, and treatment in the Gulf. While it is recommended that the Global Initiative for Asthma (GINA) guidelines should be followed wherever possible for the management of asthma, KOLs in the Gulf region have presented additional recommendations based on regional challenges and insights. There is a need for better diagnosis using objective testing, increased efforts in tackling the burden of comorbidities in the region, and greater provision of the necessary tools for phenotyping severe asthma. Furthermore, there is a need for greater education for physicians regarding asthma treatment, including the importance of inhaled-corticosteroid-containing controller medication. Regionally, there is also a need for specialist asthma clinics and asthma educators, which would serve to educate physicians and their patients as well as to improve the management of patients. Finally, the use of asthma registries, digital devices, and electronic templates would be of benefit in the management of asthma patients in the region.

Health outcomes after stopping long-term mepolizumab in severe eosinophilic asthma: COMET

Asthma worsening and symptom control are clinically important health outcomes in patients with severe eosinophilic asthma. This analysis of COMET evaluated whether stopping versus continuing long-term mepolizumab therapy impacted these outcomes.

Patients with severe eosinophilic asthma with ≥3 years continuous mepolizumab treatment (via COLUMBA (NCT01691859) or COSMEX (NCT02135692) open-label studies) were eligible to enter COMET (NCT02555371), a randomised, double-blind, placebo-controlled study. Patients were randomised 1:1 to continue mepolizumab 100 mg subcutaneous every 4 weeks or to stop mepolizumab, plus standard of care asthma treatment. Patients could switch to open-label mepolizumab following an exacerbation. Health outcome endpoints included time to first asthma worsening (composite endpoint: rescue use, symptoms, awakening at night and morning peak expiratory flow (PEF)), patient and clinician assessed global rating of asthma severity and overall perception of response to therapy, and unscheduled healthcare resource utilisation.

Patients who stopped mepolizumab showed increased risk of and shorter time to first asthma worsening compared with those who continued mepolizumab (hazard ratio (HR) 1.71; 95% CI 1.17–2.52; p=0.006), including reduced asthma control (increased risk of first worsening in rescue use (HR 1.36; 95% CI 1.00–1.84; p=0.047) and morning PEF (HR 1.77; 95% CI 1.21–2.59; p=0.003). There was a higher probability of any unscheduled healthcare resource use (HR 1.81; 95% CI 1.31–2.49; p<0.001), and patients and clinicians reported greater asthma severity and less favourable perceived response to therapy for patients who stopped versus continued mepolizumab.

These data suggest that patients with severe eosinophilic asthma continuing long-term mepolizumab treatment sustain clinically important improvements in health outcomes.

The COMET study investigated whether stopping long-term mepolizumab had an impact on health outcomes in patients with severe eosinophilic asthma; data suggest those who continue long-term mepolizumab treatment sustain clinically important improvementshttps://bit.ly/3A0bvwu

Uncontrolled Asthma: Unmet Needs in the Management of Patients

The recent scientific research has provided clinicians with the tools for substantially upgrading the standard of care in the field of bronchial asthma. Nevertheless, satisfactory asthma control still remains an unmet need worldwide. Identifying the major determinants of poor control in different asthma severity levels represents the first step towards the improvement of the overall patients' management. The present review aims to provide an overview of the main unmet needs in asthma control and of the potential tools for overcoming the issue. Implementing a personalized medicine approach is essential, not only in terms of pharmacological treatments, biologic drugs or sophisticated biomarkers. In fact, exploring the complex profile of each patient, from his inflammation phenotype to his preferences and expectations, may help in filling the gap between the big potential of currently available treatments and the overall unsatisfactory asthma control. Telemedicine and e-health technologies may provide a strategy to both optimize disease assessment on a regular basis and enhance patients' empowerment in managing their asthma. Increasing patients' awareness as well as the physicians' knowledge about asthma phenotypes and treatment options besides corticosteroid probably represent the key and more difficult goals of all the players involved in asthma management at every level.

Management of Severe Asthma Beyond the Guidelines

PURPOSE OF REVIEW

Asthma is one of the most common chronic respiratory diseases worldwide, yet only a small percentage of patients are categorized as having severe disease. Severe asthmatics, however, are responsible for the largest burden of healthcare costs and lost productivity. Several recent guidelines have addressed disease pathogenesis and treatment modalities for these complex patients. Herein, we review the severe asthma guidelines, compare the existing guidelines, address key areas that are yet to be addressed in the guidelines, and discuss future directions for severe asthma research.

RECENT FINDINGS

This is a narrative review of the 2019 European Respiratory Society/American Thoracic Society (ERS/ATS) and Global Initiative for Asthma (GINA) guidelines that specifically address the diagnosis and management of severe asthma. The pathophysiological mechanisms that underlie severe asthma are reviewed, and novel therapies that target specific pathophysiological pathways in severe asthma are discussed in detail. Although the guidelines address the use of novel biological therapies for patients with T2-mediated disease, data comparing these agents remain sparse. This review addresses several areas that are topics beyond the guidelines and highlight key areas where future research is warranted. This review provides a comprehensive overview of the current state of severe asthma treatment and discusses potential avenues for future research for this patient population.

Exploring the relationship between generalised anxiety/depression scales and asthma-specific quality of life/control questionnaires in a specialist asthma clinic

INTRODUCTION

Psychological issues are common in patients with chronic disabling diseases such as asthma. National guidance recommends that specialist asthma clinic attendees should complete questionnaires screening for psychological comorbidities. However, completing these in addition to asthma specific questionnaires can be burdensome. In order to investigate whether anxiety and depression questionnaires can be used in a targeted manner, this study investigates the correlation between the respective scores. We hypothesize that there is correlation between asthma-specific and anxiety/depression questionnaire scores.

METHODS

Three-hundred individuals with poorly controlled asthma attending a specialist clinic were asked to complete Asthma Control Questionnaire (ACQ), mini-Asthma Quality of Life Questionnaire (mini-AQLQ), Generalized Anxiety Disorder (GAD-7) and Patient Health Questionnaires (PHQ-9). A Pearson correlation coefficient was generated and area under ROC and confusion matrices were used to assess correlation.

RESULTS

49% and 47% of patients completing the GAD-7 or PHQ-9 questionnaires, respectively had scores above the screening level for co-morbid anxiety and depression. Additional questionnaires were often incomplete (GAD-7 = 150 and PHQ-9 = 140). GAD-7 and PHQ-9 correlated with ACQ and mini-AQLQ (all p = <0.001, r values 0.53-0.65). Asthma-specific questionnaire scores were predictive of GAD-7 and PHQ-9 scores (AUCs of 0.78 to 0.84). 75% of patients with a mini-AQLQ score of <3 met the threshold GAD-7 and PHQ-9 score of 10.

CONCLUSIONS

ACQ and mini-AQLQ correlate with GAD-7 and PHQ-9 amongst specialist asthma clinic attendees. A mini-AQLQ >3 suggests patients are unlikely to have anxiety or depression. These findings could be used to identify patients requiring formal screening for psychological co-morbidity.

Asthma patients' perception on their care pathway: a qualitative study

Because of insufficient asthma control in many patients, the collaboration between stakeholders is regarded as a promising strategy to improve asthma outcomes. This study explored the perceptions of French adult asthma patients on their care pathway. We conducted a qualitative study based on the interviews of 30 asthma patients aged 18–40 years, recruited in French primary care. We performed a thematic analysis of the data collected, using the NVivo software. According to the patients, the stakeholders involved in asthma management included those visible to healthcare professionals (patient, general practitioner, specialist(s), pharmacist, physiotherapist, family and friends) and those concealed by the patients (complementary and alternative practitioners); other stakeholders, such as nurses and occupational physicians, were not involved. Asthma management at diagnosis and follow-up phases proved to be unstructured, and were associated with poor patient education. This was supported by patients’ ambivalence (in relation to illness and treatments), poor communication between patients and healthcare professionals (lack of listening and use of inappropriate vocabulary by physicians, underreporting of alternative medicine use by patients) and weak cooperation between professionals (limited to interaction between the general practitioner and the specialist, either pulmonologist or allergist). Asthma management would probably benefit from a more coordinated care pathway at each phase of the disease that is consistent with the expectations and goals of the patients. It should be based on improved organization (involvement of other healthcare professionals and the patient as partners) and processes (regular follow-up, specific tools such as peak flow meter or action plan).

Costs of perennial allergic rhinitis and allergic asthma increase with severity and poor disease control

BACKGROUND

Perennial allergic rhinitis (PAR) represents a global and public health problem, due to its prevalence, morbidity, and impact on the quality of life. PAR is frequently associated with allergic asthma (AA). Costs of PAR with or without AA are poorly documented.

OBJECTIVE

Our study aimed to detail medical resource utilization (MRU) and related direct cost for PAR, with or without concomitant AA, in France.

METHODS

Using Electronic Health Records (EHRs), we identified in 2010 two cohorts of PAR patients, based on General Practitioners' diagnoses and prescribing data, with and without concomitant AA. For each patient, the EHRs were linked to corresponding claims data with MRU and costs during years 2011 to 2013. Predefined subgroup analyses were performed according to severity of PAR and level of AA control.

RESULTS

The median annual cost reimbursed by social security system for a patient with PAR, and no AA was 159€ in 2013. This varied from 111€ to 188€ depending on PAR severity. For patients with PAR and concomitant AA, the median annual cost varied between 266€ and 375€, and drug treatment accounted for 42-55% of the costs, depending on asthma control.

CONCLUSION

This study linking diagnoses from EHRs to claims data collected valid information on PAR management, with or without concomitant AA, and on related costs. There was a clear increase in costs with severity of PAR and control of AA.

Severe and non-severe asthma in the community: A large electronic database analysis

BACKGROUND

A large electronic database analysis was conducted in a community of 351,799 people, ages 20-70 years to determine the prevalence and clinical characteristics of severe asthma, according to 2014 international guidelines and healthcare utilization.

METHODS

Severe asthmatics were grouped into controlled severe-asthma and uncontrolled severe-asthma and additional subgroups of uncontrolled severe asthma on the basis of medications dispensed. Non-asthmatic population at the same ages served as controls.

RESULTS

A total of 19,991 (5.68%) were diagnosed as asthmatic, of which 4.65% had severe asthma. Of these, one-third was uncontrolled severe-asthma. Controlled severe-asthma group was similar to non-severe asthma and non-asthmatics in the rate of emergency room visits (21.5%, 22%, and 20%, respectively) and to all cause hospitalizations (7.4%, 7.4%, and 6.4%, respectively). Uncontrolled severe-asthmatics had significantly more hospitalizations (RR = 2.9) than controlled severe-asthmatics. Only 19.2% of uncontrolled-severe asthmatics had IgE testing and 3.6% were dispensed omalizumab.

CONCLUSIONS

The prevalence of severe asthma is slightly less than 5% of all asthmatics. Controlling severe asthma is crucial to reducing healthcare utilization. A simple electronic database analysis, based on dispensed medications, can help healthcare providers identify subgroups of uncontrolled severe asthmatics that require focused efforts.

CLINICAL TRIAL REGISTRATION

NCT01961258. Ethics Committee approval: 032/2013C.

Level of Asthma Controller Therapy Before Admission to the Hospital

BACKGROUND

In asthma, choice of controller therapy and adherence to treatment can affect the risk of future severe exacerbations leading to hospitalization.

OBJECTIVE

Our objective was to characterize treatment dispensation profiles before hospital admission for asthma.

METHODS

Using a 1/97th random sample of the national French claims data, patients with asthma aged 6 to 40 years were identified between 2006 and 2014. Patients with subsequent asthma-related hospitalization were selected. On the basis of controller therapy dispensed in the 12 months before admission, treatment profiles were categorized into clusters, using Ward's minimum-variance hierarchical clustering method.

RESULTS

Of 17,846 patients with asthma, we identified 275 patients (1.5%) with an asthma-related hospitalization. Three distinct clusters were identified. The first cluster (63.6%) included patients with few dispensations of any controller medication (<1 unit). The second cluster (32.4%) consisted of patients with frequent dispensations of long-acting beta agonists (LABAs)/inhaled corticosteroids (ICS) in fixed-dose combinations. The third cluster (4%) comprised patients receiving free combinations of ICS and LABAs, with more dispensations of LABAs than of ICS.

CONCLUSIONS

In France, before an asthma-related hospitalization, more than 60% of patients received little controller therapy and 4% were exposed to higher dispensation of LABAs than of ICS. These results indicate that a large fraction of asthma-related hospitalizations can potentially be prevented with better pharmacotherapy.

'Real-life' effectiveness studies of omalizumab in adult patients with severe allergic asthma: systematic review

We reviewed 24 'real-life' effectiveness studies of omalizumab in the treatment of severe allergic asthma that included 4117 unique patients from 32 countries with significant heterogeneity in patients, clinicians and settings. The evidence underscores the short- and long-term benefit of anti-IgE therapy in terms of the following: improving lung function; achieving asthma control and reducing symptomatology, severe exacerbations and associated work/school days lost; reducing healthcare resource utilizations, in particular hospitalizations, hospital lengths of stay and accident specialist or emergency department visits; reducing or discontinuing other asthma medications; and improving quality of life - thus confirming, complementing and extending evidence from randomized trials. Thus, omalizumab therapy is associated with signal improvements across the full objective and subjective burden of illness chain of severe allergic asthma. Benefits of omalizumab may extend up to 2-4 years, and the majority of omalizumab-treated patients may benefit for many years. Omalizumab has positive short- and long-term safety profiles similar to what is known from randomized clinical trials. Initiated patients should be monitored for treatment response at 16 weeks. Those showing positive response at that time are highly likely to show sustained treatment response and benefit in terms of clinical, quality of life and health resource utilization outcomes.

Treating Moderate-to-Severe Allergic Asthma with a Recombinant Humanized Anti-IgE Monoclonal Antibody (Omalizumab)

Bronchial asthma is a chronic inflammatory disease of the airways which is recognized as a highly prevalent health problem in both the developed and the developing world, with significant human and economic consequences.Allergy is acknowledged as a major risk factor for asthma. The pathogenetic aspects of allergic asthma are characterized by airway inflammation with infiltration of mast cells, basophils, eosinophils, monocytes and T helper type 2 lymphocytes, along with the isotype switching of B cells to generate immunoglobulins of the immunoglobulin E (IgE) class. Increased asthma severity is not only associated with recurrent hospitalization and increased mortality but also with higher social costs.Inhaled corticosteroids are the standard anti-inflammatory medication and are effective for most asthma patients, but there is a substantial number of asthmatics who remain symptomatic even after receiving treatment with inhaled corticosteroids and long-acting beta(2)-adrenoceptor agonists (beta(2)-agonists), and sometimes are in need of systemic corticosteroids to control the disease. These patients account for about 50% of the healthcare costs of asthma.New treatment options more specifically targeting the pathophysiologic events causing development of asthma are therefore required in these patients.A novel therapeutic approach to asthma and other allergic respiratory diseases involves interference with the action of IgE and prevention of subsequent IgE-mediated responses.Omalizumab is a humanized recombinant monoclonal anti-IgE antibody developed for the treatment of allergic diseases, with clear efficacy in adolescent and adult patients with moderate-to-severe allergic asthma. This non-anaphylactogenic anti-IgE antibody inhibits IgE functions by blocking free serum IgE and inhibiting their binding to cellular receptors. Omalizumab therapy is well tolerated and significantly improves symptoms and disease control, and reduces asthma exacerbations and the need to use high dosages of inhaled corticosteroids. Moreover, omalizumab improves quality of life of patients with severe persistent allergic asthma that is inadequately controlled by currently available asthma medications. In conclusion, omalizumab may fulfill an important need in patients with moderate-to-severe asthma inadequately controlled with inhaled corticosteroids +beta(2)-agonists.

Clinically relevant outcome measures for new therapies of asthma using pharmaceutical and biologic agents

PURPOSE OF REVIEW

To determine the benefits of new asthma drugs or therapies, they should be assessed with regard to their effects on relevant clinical outcomes.

RECENT FINDINGS

The most frequently used outcomes have been symptoms, rescue medication needs and pulmonary function tests, although others such as quality of life, exacerbations and impairment of activities have also been identified as important ones. Improvements in our understanding of basic mechanisms of asthma have led to the development of new sets of outcomes including inflammatory markers and a rapidly increasing number of biomarkers, which however require validation, and assessment of their clinical usefulness. Many studies have not only looked at induced sputum cell differentials or FENO to phenotype asthma but also as treatment efficacy markers. Periostin is considered a marker of TH2-induced airway inflammation and a predictor of response to drugs such as anti-IL13 and omalizumab, although at the individual level, such prediction remains imperfect.

SUMMARY

There is a need to develop new markers of activity of the disease, with a prognostic value with regard to the benefits of new treatments.

Saving in medical costs by achieving guideline-based asthma symptom control: a population-based study

BACKGROUND

Asthma control is increasingly used as an outcome measure in asthma trials. Economic evaluations of asthma interventions require converting the impact of interventions on control to impact on resource use. The purpose of this study was to estimate the savings in direct costs by achieving asthma symptom control as defined in the Global Initiative for Asthma (GINA) 2014 management strategy.

METHODS

Adolescents and adults with asthma were recruited through random digit dialing. Asthma control per GINA and the use of healthcare resources were assessed at baseline and three-monthly visits up to 1 year. We used regression models to associate costs, measured in 2012 Canadian dollars ($), with symptom control, adjusting for potential confounding variables.

RESULTS

The final sample included 517 individuals (average age 48.9, 65.8% female) with mostly mild-moderate asthma contributing 2033 follow-up visits. In 598 (29.4%), 809 (39.8%), and 626 (30.8%) of visits, asthma was symptomatically controlled, partially controlled, or uncontrolled, respectively. The average 3-month costs of asthma were $134.5. Of these, 20.5% were attributable to inpatient care, 47.8% to outpatient care, and 31.5% to medication. Compared to controlled asthma, partially controlled asthma was associated with a nonsignificant increase of $9.5 (95% CI -$13.6 - $32.6) in adjusted 3-month costs and uncontrolled asthma with a statistically significant increase of $81.7 (95% CI $48.5 - $114.9).

CONCLUSION

A substantial fraction of this population-based sample of largely mild-moderate asthmatics was symptomatically uncontrolled. Achieving symptom control was associated with a reduction in direct costs. The adjusted values from this study can be used to inform cost-effectiveness analyses of asthma treatments.

Systemic Exposures of Fluticasone Propionate and Salmeterol Following Inhalation via Metered Dose Inhaler with the Mini Spacer Compared with the Aerochamber Plus Spacer

BACKGROUND

The Mini Spacer has been developed for use with Ventolin(®) metered dose inhalers (MDIs) to improve accessibility to affordable spacers in developing countries. To ensure patient safety is not compromised if the Mini Spacer is used off-label with fluticasone propionate (FP) or salmeterol/FP combination (SFC) MDIs (currently not recommended), this study compared the systemic exposure of FP and salmeterol following delivery of FP and SFC MDIs with the Mini Spacer and the Aerochamber Plus(®) spacer (Aerochamber).

METHODS

This was an open-label, randomized, single dose, crossover study in healthy subjects that evaluated four treatments: i) FP 250 μg MDI with Mini Spacer; ii) FP 250 μg MDI with Aerochamber; iii) SFC 25/250 μg with Mini Spacer; iv) SFC 25/250 μg with Aerochamber. There was a minimum 7 day washout between treatments. Pharmacokinetic samples were collected over 24 hours post-dose. The co-primary endpoints were FP area under the concentration-time curve from time zero to 24 h [FP AUC(0-24)] and salmeterol maximum plasma concentration [Cmax].

RESULTS

FP systemic exposure in terms of AUC(0-24) was lower following inhalation with the Mini Spacer compared with the Aerochamber for both FP 250 μg (Mini Spacer/Aerochamber Ratio 0.76 [90% CI: 0.57-1.01]) and SFC 25/250 μg (Ratio 0.74 [90% CI: 0.56-0.99]). Salmeterol systemic exposure was also lower following SFC 25/250 μg with Mini Spacer compared with Aerochamber (Cmax Ratio 0.90 [90% CI 0.48-1.66]). The incidence of adverse events was low and similar with each treatment.

CONCLUSIONS

In the event of use of the Mini Spacer with FP and SFC MDIs, which is not recommended, FP and salmeterol systemic exposure is unlikely to be higher than if MDIs were to be used with the Aerochamber. However, these data do not indicate that the Mini Spacer and Aerochamber are interchangeable.

Small airway dysfunction and bronchial asthma control : the state of the art

According to national and international guidelines, achieving and maintaining asthma control is a major goal of disease management. In closely controlled clinical trials, good asthma control can be achieved , with the medical treatments currently available, in the majority of patients , but large population-based studies suggest that a significant proportion of patients in real-life setting experience suboptimal levels of asthma control and report lifestyle limitations with a considerable burden on quality of life. Poor treatment adherence and persistence, failure to use inhalers correctly, heterogeneity of asthma phenotypes and associated co-morbidities are the main contributing factors to poor disease control. Now, it is widely accepted that peripheral airway dysfunction , already present in patients with mild asthma, is a key contributor of worse control. The aim of this paper is to investigate the association between small-airways dysfunction and asthma symptoms/control. We therefore performed a PubMed search using keywords : small airways; asthma (limits applied: Humans, English language) and selected papers with a study population of asthmatic patients, reporting measurement of small-airways parameters and clinical symptoms/control.

Utilization and Costs of Severe Uncontrolled Asthma in a Managed-Care Setting

BACKGROUND

Clinical and economic burden of patients with severe uncontrolled asthma (SUA) in a real-world managed-care setting required further documentation.

OBJECTIVE

The objective of this study was to determine the characteristics, clinical, and economic burden of SUA in a managed-care setting.

METHODS

This observational study identified patients with persistent asthma aged 12 years or more (N = 25,935) using the International Classification of Diseases, 9th Revision asthma codes and Healthcare Effectiveness Data and Information Set administrative criteria. An SUA subgroup was identified when all of the following 3 criteria were met in 2012: (1) 2 or more asthma exacerbations; (2) 6 or more medium- or high-dose dispensed canisters of inhaled corticosteroid (ICS) as monotherapy or with long-acting β2-agonist; and (3) 3 or more dispensed non-ICS controllers. Health care utilization and direct costs (all-cause and asthma-related) in 2013 were compared between SUA and non-SUA subgroups using multivariable regression.

RESULTS

Compared with the non-SUA subgroup (N = 25,350, 97.7%), the SUA subgroup (N = 585, 2.3%) at baseline was significantly older and had more comorbidities, asthma specialist care, controller medication dispensed, and asthma exacerbations. During follow-up, patients with SUA exhibited significantly more asthma exacerbations and short-acting β2-agonist use, and higher all-cause and asthma-related costs than patients with non-SUA. The adjusted asthma-related average direct cost per patient at follow-up was significantly higher for SUA (mean ± SE) ($2325 ± $75) than non-SUA ($1261 ± $9) with an incremental cost of $1056 (95% CI, $907-$1205). Asthma drugs accounted for the major difference (incremental cost of $848/patient; 95% CI, $737-$959).

CONCLUSION

Increases and disparities in health care utilization and direct cost by SUA status suggest that patients with SUA require more intensive therapy, greater attention to adherence and comorbidities, more specialist care, and, possibly, personalized treatment approaches including novel biologic treatments.

Improved asthma control in patients with severe, persistent allergic asthma after 12 months of nightly temperature-controlled laminar airflow: an observational study with retrospective comparisons

Introduction

Continuous or episodic allergen exposure is a major risk factor of frequent symptoms and exacerbations for patients with allergic asthma. It has been shown that temperature-controlled laminar airflow (TLA) significantly reduced allergen exposure and airway inflammation and improved quality of life of patients with poorly controlled allergic asthma.

Objective

The objective was to evaluate the effects of nighttime TLA when used during real-life conditions for 12 consecutive months in addition to the patients’ regular medication.

Methods

This multicenter, pre- and postretrospective observational study included patients with inadequately controlled moderate-to-severe allergic asthma who received add-on treatment with TLA for 12 consecutive months. Data on medication use, asthma control, asthma symptoms, lung function, use of hospital resources, and exacerbations were collected after 4 and 12 months and compared with corresponding data collected retrospectively from medical records during the year prior to inclusion in the study.

Results

Data from 30 patients (mean age 28; range 8–70) completing 4 months and 27 patients completing 12 months of TLA use are presented. The mean number of exacerbations was reduced from 3.6 to 1.3 (p<0.0001), and the ratio of asthma-related emergency room visits or hospitalizations diminished from 72.4 to 23.3% (p=0.001) or from 44.8 to 20.0% (p<0.05), respectively, after 12 months of TLA use. The Asthma Control Test index increased from 14.1 to 18.5 (p<0.0001). After 4 months of TLA use, clear improvements can be shown for most variables in line with the data collected after 12 months.

Conclusions

The addition of TLA to the patients’ regular medication significantly reduced exacerbations, asthma symptoms, and the utilization of hospital resources. The data support that TLA may be an important new non-pharmacological approach in the management of poorly controlled allergic asthma.

Cost effectiveness of tiotropium in patients with asthma poorly controlled on inhaled glucocorticosteroids and long-acting β-agonists

BACKGROUND

A considerable proportion of patients with asthma remain uncontrolled or symptomatic despite treatment with a high dose of inhaled glucocorticosteroids (ICSs) and long-acting β2-agonists (LABAs). Tiotropium Respimat(®) added to usual care improves lung function, asthma control, and the frequency of non-severe and severe exacerbations, in a population of adult asthma patients who are uncontrolled despite treatment with ICS/LABA.

OBJECTIVE

This study estimated the cost effectiveness of tiotropium therapy as add-on to usual care in asthma patients that are uncontrolled despite treatment with ICS/LABA combination from the perspective of the UK National Health Service (NHS).

METHODS

A Markov model was developed which considers levels of asthma control and exacerbations. The model analysed cost and quality-adjusted life-years (QALYs); sensitivity and scenario analyses were also conducted to test the robustness of the base case outcomes. All costs are given at 2012 prices.

RESULTS

The model found that in this category of asthma with unmet need, add-on tiotropium therapy generated an incremental 0.24 QALYs and £5,238 costs over a lifetime horizon, resulting in an incremental cost-effectiveness ratio of £21,906 per QALY gained. Sensitivity analysis suggested that findings were most dependent on the costs of managing uncontrolled asthma and the cost of treatment with tiotropium.

CONCLUSION

In this modelled analysis of two clinical trials, tiotropium was found to be cost effective when added to usual care in patients who remain uncontrolled despite treatment with high-dose ICS/LABA. Further research should investigate the long-term treatment effectiveness of tiotropium.

Pharmacokinetics of fluticasone propionate and salmeterol delivered as a combination dry powder via a capsule-based inhaler and a multi-dose inhaler

AIM

To compare salmeterol (SALM) and fluticasone propionate (FP) systemic exposure following inhaled salmeterol/fluticasone propionate combination (SFC) from a unit-dose capsule-based inhaler (Rotacaps(®)/Rotahaler(®)) and a multi-dose dry powder inhaler (Diskus(®)) in healthy volunteers.

METHODS

An open-label, randomised, repeat-dose, cross-over, adaptive design study (n = 36 in each part) evaluated SFC 50/250 μg and SFC 50/100 μg in Rotacaps used with two types of Rotahaler inhalers (airflow resistance similar to (S) and lower than (L) Diskus) versus the Diskus. Primary endpoints were area under the concentration-time curve over the dosing interval [AUC0-τ] and maximum plasma concentration [Cmax].

RESULTS

SFC 50/250 μg Rotacaps/Rotahaler (S) showed 1.2-1.9-fold greater FP and SALM systemic exposure compared with Diskus. FP and SALM systemic exposure were comparable to DISKUS following SFC 50/250 μg Rotacaps/Rotahaler (L) (90% CI of ratio of Rotahaler to DISKUS within 0.8-1.25) for salmeterol (AUC0-τ and Cmax) and FP (AUC0-τ). Following SFC 50/100 μg Rotacaps/Rotahaler (L), FP and SALM systemic exposures were 1.2-1.4 fold higher in terms of FP (AUC0-τ and Cmax) and salmeterol (Cmax) compared with Diskus. SFC at both doses and via both inhalers was well tolerated.

CONCLUSIONS

SFC 50/250 μg Rotacaps/Rotahaler (L) showed comparable systemic exposure to Diskus in terms of FP AUC and SALM AUC and Cmax. These results merit further progression of SFC 50/250 μg Rotacaps/Rotahaler (L) to phase 3 clinical evaluation in asthma and COPD patients. The lack of pharmacokinetic comparability between the inhalers for SFC 50/100 μg requires further evaluation.

[A new fixed dose combination of fluticasone and formoterol in a pressurised metered-dose inhaler for the treatment of asthma]

The combination of an inhaled corticosteroid and a long acting beta-2 agonist is indicated for the regular treatment of persistent moderate-to-severe asthmatics whose asthma is not controlled by inhaled corticosteroids and the occasional use of a short acting beta-2 agonist. The aim of this review is to give an overview of the rationale of combining formoterol and fluticasone and to analyze the clinical data concerning a new fixed combination of fluticasone and formoterol in a pressurised metered-dose inhaler with a dose counter (Flutiform(®)) that was approved for the treatment of asthma in France in 2013. The clinical studies provide evidence that combined fluticasone/formoterol is more efficacious than fluticasone or formoterol given alone, and provides similar improvements in lung function to fluticasone (Flixotide(®)) and formoterol (Foradil(®)) administered concurrently. The combination of fluticasone/formoterol gave a more rapid bronchodilatation than the combination fluticasone/salmeterol. As a whole, the combination of fluticasone/formoterol had similar efficacy and tolerability profiles to the combinations of either budesonide/formoterol or fluticasone/salmeterol.

Treating severe allergic asthma with anti-IgE monoclonal antibody (omalizumab): a review

Increased asthma severity is not only associated with enhanced recurrent hospitalization and mortality but also with higher social costs. Several cases of asthma are atopic in nature, with the trigger for acute asthma attacks and chronic worsening of inflammation being allergens inducing an immune, IgE mediated response. Anti-inflammatory treatments are effective for most of asthma patients, but there are subjects whose disease is incompletely controlled by inhaled or systemic corticosteroids and these patients account for about 50% of the healthcare costs of asthma. Omalizumab is a biological engineered, humanized recombinant monoclonal anti-IgE antibody developed for the treatment of allergic diseases and with clear efficacy in adolescent and adult patients with severe allergic asthma. The anti-IgE antibody inhibits IgE functions blocking free serum IgE and inhibiting their binding to cellular receptors. By reducing serum IgE levels and IgE receptor expression on inflammatory cells in the context of allergic cascade, omalizumab has demonstrated to be a very useful treatment of atopic asthma, improving quality of life of patients with severe persistent allergic asthma that is inadequately controlled by currently available asthma medications. Several trials have demonstrated that this therapy is well tolerated and significantly improves symptoms and disease control, reducing asthma exacerbations and the need to use high dosage of inhaled corticosteroids.

Why do patients with long-term conditions use unscheduled care? A qualitative literature review

Unscheduled care (UC) refers to non-routine face-to-face care, such as accident and emergency care, out-of-hours care, or walk-in centres. Current health service policy aims to reduce its use. Unscheduled care is common in people with long-term conditions such as diabetes, asthma, chronic obstructive pulmonary disease and coronary heart disease. By reviewing qualitative research literature, we aimed to understand the breadth of psychosocial and other influences on UC use in people with long-term conditions. Few qualitative papers specifically address UC in patients in these disease groups. Therefore, our literature search also included qualitative research that explored factors potentially relevant to UC use, including attitudes to healthcare use in general. By searching Medline, Embase, Psycinfo and Cinahl from inception to 2011, we identified 42 papers, published since 1984, describing relevant original research and took a meta-ethnographic approach in reviewing them. The review was conducted between Spring 2009 and April 2011, with a further search in December 2011. Most papers reported on asthma (n = 13) or on multiple or unspecified conditions (n = 12). The most common methods reported were interviews (n = 33) and focus groups (n = 13), and analyses were generally descriptive. Theoretical and ethical background was rarely explicit, but the implicit starting point was generally the 'problem' of UC, and health-care, use in general, decontextualised from the lives of the patients using it. Patients' use of UC emerged as understandable, rational responses to pressing clinical need in situations in which patients thought it the only option. This belief reflected the value that they had learned to attach to UC versus routine care through previous experiences. For socially or economically marginalised patients, UC offered access to clinical or social care that was otherwise unavailable to them.

Implementation of GINA guidelines in Ho Chi Minh City: a model for Viet Nam

SETTING

The Global Initiative for Asthma (GINA) guidelines have not been implemented effectively in primary care settings in Viet Nam.

OBJECTIVES

To estimate the proportion of patients with controlled asthma and the direct health care costs of managing asthma according to GINA guidelines at four out-patient clinics in Ho Chi Minh City (HCMC), Viet Nam.

METHODS

One hundred and six patients with asthma were treated and followed up according to GINA guidelines for 12 months. Clinical and pulmonary function responses and direct health care costs were evaluated every 3 months during the study.

RESULTS

The proportion of patients with controlled asthma rose from 1.0% at the start of the study to 36.8% by the end of the study (P < 0.0001). The proportion of patients who had at least one hospitalisation per year decreased significantly, from 32.1% to 5.7% (P < 0.0001). The annual per patient median direct health care cost was US$169. Using asthma controllers continuously gave better asthma control than using them intermittently (OR 12.9, 95%CI 4.7-35.7).

CONCLUSIONS

The implementation of GINA guidelines at out-patient clinics in HCMC, Viet Nam, improved asthma control with modest direct health care costs.

The nature and influence of pharmaceutical industry involvement in asthma trials

BACKGROUND

Pharmaceutical industry-sponsored research has been shown to be biased toward reporting positive results. Frequent industry participation in trials assessing the efficacy of inhaled corticosteroid (ICS) and long-acting beta2<⁄span>-agonist (LABA) combination treatment makes assessing industry influence difficult and warrants an assessment of specific potential publication bias in this area.

OBJECTIVE

To describe the frequency of industry involvement in ICS⁄LABA trials and explore associations among significant outcomes, type of industry involvement and type of primary outcome.

METHODS

A systematic review of trials comparing ICS⁄LABA combination therapy with ICS monotherapy for asthma was conducted. Data concerning the type of industry sponsorship, primary outcome and statistical results were collected. Comparisons between type of sponsorship and significant results were analyzed using Pearson's chi squared test and relative risk.

RESULTS

Of 91 included studies (median year of publication 2005 [interquartile range 1994 to 2008]), 86 (95%) reported pharmaceutical involvement. Author affiliation was reported in 49 of 86 (57%), and 19 of 86 (22%) were industry-reported trials without full publications. The remainder were published journal articles. Studies with a first or senior author affiliated with industry were 1.5 times more likely to report statistically significant results for the primary outcome compared with studies with other types of industry involvement. Pulmonary measures were 1.5 times more likely to be statistically significant than were measures of asthma control.

CONCLUSIONS

The potential biases identified were consistent with other research focused on author role and industry involvement, and suggest that degree of bias may vary with type of affiliation.

Economic costs for adult asthmatics according to severity and control status in Korean tertiary hospitals

OBJECTIVE

The prevalence of asthma is increasing, and asthma causes considerable socioeconomic burden worldwide. Few studies have been conducted to evaluate the risk factors associated with economic cost of asthma in Korea. This study evaluated asthma cost according to severity, control, and patient factors in Korean tertiary hospitals.

METHODS

Direct and indirect costs were assessed in physician-diagnosed adult asthmatics recruited from eight tertiary hospitals in Korea. Official direct medical costs were derived from the analysis of 1-year expenditures related to hospital care utilization and asthma medication. Nonofficial medical costs, nonmedical direct costs, and indirect costs were investigated using a questionnaire designed specifically for the study.

RESULTS

A total of 314 patients with persistent asthma were recruited. Both direct and indirect costs were significantly higher for patients with severe persistent asthma than for those with mild and moderate persistent asthma ($2214 vs. $871 and $978, p < .001; $2927 vs. $490 and $443, p < .001, respectively). Costs of asthma increased significantly in poorly controlled compared with somewhat controlled and well-controlled asthma ($7009.8 vs. $2725.3 vs. $1517.3, respectively; p < .001). After stratification for severity, a significant cost increase in the poorly controlled asthma group was observed only for indirect costs and not for direct costs. A multivariate analysis showed that female gender was a risk factor for increased indirect costs.

CONCLUSION

The burden of asthma was higher both for patients with severe persistent asthma and for patients with poorly controlled asthma. More effective strategies are needed to improve control status, particularly targeting patients with severe asthma.

[The costs of asthma in France and the economic implications of its level of control]

INTRODUCTION

The prevalence of asthma is increasing in France and the proportion of patients with poorly controlled or uncontrolled asthma remains significant. The economic impact of this public health issue is still poorly documented and this is addressed in the present literature review.

STATE OF THE ART

Older identified studies aimed to estimate the use of asthma-related health care resources according to the asthma severity. Only more recent studies have taken into account the level of control of the disease as well. A consistent finding was that asthma-related medical costs were highly dependent both on the degree of severity and level of control.

PERSPECTIVES

Studies identified in this review used the recommendations current at the time of their publication to define severity or levels of control in connection to asthma-related medical consumption, which leads to important methodological variation among them. Economic evaluation which is generally based on annual consumption estimates is hampered by the fact that the level of control reflects only a short-term situation.

CONCLUSIONS

Although data in the literature are consistent in showing that improved control of the disease significantly reduces the costs of its management, there is a need for economic studies based on recent definitions of control and using appropriate methodology.

[Cost of childhood asthma in Spain: a cost evaluation model based on the prevalence]

INTRODUCTION

Asthma is the most common chronic disease in childhood, reduces the quality of life of children and their families, and produces high social and health care costs. In Spain, the cost of managing paediatric asthma is unknown.

OBJECTIVE

To estimate the cost of managing paediatric asthma in Spain and to examine its variability depending on asthma severity.

PATIENTS AND METHODS

The cost of asthma in children under 16 years in 2008 was estimated by building a costs assessment model including the factors that influence the cost of asthma in children: prevalence, distribution of disease severity, age, frequency of resources use depending on severity, and the cost of each resource. A sensitivity analysis was conducted to evaluate the underlying uncertainty depending on the variability of the estimators of resource use, the unit cost of each resource, and the prevalence.

RESULTS

According to the model, the total cost of paediatric asthma in Spain is around 532 million euros, with a range of 392 to 693 million euros. Direct costs (health care costs) represent 60% of the total costs, and indirect costs (carer time), 40%. The mean annual cost per child with asthma is 1,149 euros, ranging from 403 euros for the mildest category of the disease to 5,380 euros for the most severe.

CONCLUSIONS

The cost of paediatric asthma in Spain is very high and depends on disease severity. Although the most important costs are for the health care system, indirect costs are not negligible.

Recommendation for optimal management of severe refractory asthma

Patients whose asthma is not adequately controlled despite treatment with a combination of high dose inhaled corticosteroids and long-acting bronchodilators pose a major clinical challenge and an important health care problem. Patients with severe refractory disease often require regular oral corticosteroid use with an increased risk of steroid-related adverse events. Alternatively, immunomodulatory and biologic therapies may be considered, but they show wide variation in efficacy across studies thus limiting their generalizability. Managing asthma that is refractory to standard treatment requires a systematic approach to evaluate adherence, ensure a correct diagnosis, and identify coexisting disorders and trigger factors. In future, phenotyping of patients with severe refractory asthma will also become an important element of this systematic approach, because it could be of help in guiding and tailoring treatments. Here, we propose a pragmatic management approach in diagnosing and treating this challenging subset of asthmatic patients.

Italian real-life experience of omalizumab

Omalizumab is a humanized murine monoclonal antibody directed toward a portion of the IgE indicated in Europe for the treatment of severe persistent allergic asthma, inadequately controlled despite high-dose of ICS (mean BDP equivalent dose of inhaled corticosteroid 2224.68microg/die) in association with long-acting beta(2) agonists. Our aim was to describe the experience, efficacy and safety in a cohort of Italian patients treated with omalizumab in a real-life clinical setting. One hundred and forty two patients from 13 Italian Centers were observed and analysed. The dosage of omalizumab was established according to the labelling indication, with a median dose of IgE of 297.38IU/ml or kU/l. During the previous year, all patients experienced frequent exacerbations (mean=4.87), emergency visits (mean=4.45) and hospitalisation (mean=1.53). Following treatment with omalizumab, the annual rate of exacerbations, emergency visits and hospitalisation decreased by 79%, 88% and 95%, respectively. The proportion of patients without exacerbation, not needing emergency visits and hospitalization increased by 610%, 154% and 28%, respectively. The response to omalizumab measured with the GETE (global evaluation of treatment effectiveness) scale rated as good to excellent in 77% of patients. Overall, 9.6% (n=9) of the patients experienced one single adverse effect. Only one patient reported a serious adverse event (local reaction at the site of injection) leading to interruption of treatment. The observed reduction of asthma-related events in particularly poorly controlled patients in this Italian real-life setting is consistent with the results of other observational studies.

Comparison of physicians' compliance, clinical efficacy, and drug cost before and after introduction of Asthma Prevention and Management Guidelines in Japan (JGL2003)

BACKGROUND

This study investigated the variations in the clinical efficacy and drug cost following the introduction of the Asthma Prevention and Management Guidelines in Japan (JGL2003).

METHODS

The medical charts of fifty outpatients treated continuously for asthma, aged 16-50 years, from October 2002 to October 2004 at Showa University Hospital were analyzed for physicians' compliance with asthma guidelines, symptom severity, episodes in various occasions, prescriptions and drug costs.

RESULTS

Physicians' compliance with the guidelines, which were defined as the number of patient visits treated in conformity with the JGL over the total number of patient visits, was found to be high before (89.4%) and after (90.3%) the introduction of JGL2003, without a statistical difference. On the other hand, the distribution of asthma symptom severity varied significantly (P<0.0001). Fewer patients were recognized as having more severe asthma symptoms after the introduction of JGL2003. Significantly more patients with severe asthma symptoms were detected in the physicians' noncompliant group than in the compliant group (P<0.0001). The number of patients prescribed with oral corticosteroids, long-acting beta2-agonists containing patches, long-acting oral beta2-agonists, short-acting inhaled beta2-agonists, sustained-released theophylline and leukotriene receptor antagonists decreased after the introduction of JGL2003. Furthermore, the total annual drug cost per patient decreased significantly by an average of 16,259 yen (P=0.006).

CONCLUSIONS

The JGL2003 was judged to have improved criteria, which thus resulted in the high compliance of physicians with the guidelines, in the remission of asthma symptoms and in the reduction in the total annual drug cost per patient.

Cost effectiveness of leukotriene receptor antagonists versus long-acting beta-2 agonists as add-on therapy to inhaled corticosteroids for asthma: a pragmatic trial

BACKGROUND

Information is lacking on the relative effectiveness and cost effectiveness--in a real-life primary-care setting--of leukotriene receptor antagonists (LTRAs) and long-acting beta2 adrenergic receptor agonists (beta2 agonists) as add-on therapy for patients whose asthma symptoms are not controlled on low-dose inhaled corticosteroids (ICS).

OBJECTIVE

To estimate the cost effectiveness of LTRAs compared with long-acting beta2 agonists as add-on therapy for patients whose asthma symptoms are not controlled on low-dose ICS.

METHODS

An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma insufficiently controlled with ICS (n = 361) were randomly assigned to add-on LTRAs (n = 176) or long-acting beta2 agonists (n = 185). The main outcome measures were the incremental cost per point improvement in the Mini Asthma Quality of Life Questionnaire (MiniAQLQ), per point improvement in the Asthma Control Questionnaire (ACQ) and per QALY gained from perspectives of the UK NHS and society.

RESULTS

Over 2 years, the societal cost per patient receiving LTRAs was pounds sterling 1157 versus pounds sterling 952 for long-acting beta2 agonists, a (significant, adjusted) increase of pounds sterling 214 (95% CI 2, 411) [year 2005 values]. Patients receiving LTRAs experienced a non-significant incremental gain of 0.009 QALYs (95% CI -0.077, 0.103). The incremental cost per QALY gained from the societal (NHS) perspective was pounds sterling 22,589 (pounds sterling 11,919). Uncertainty around this point estimate suggested that, given a maximum willingness to pay of pounds sterling 30,000 per QALY gained, the probability that LTRAs are a cost-effective alternative to long-acting beta2 agonists as add-on therapy was approximately 52% from both societal and NHS perspectives.

CONCLUSIONS

On balance, these results marginally favour the repositioning of LTRAs as a cost-effective alternative to long-acting beta2 agonists as add-on therapy to ICS for asthma. However, there is much uncertainty surrounding the incremental cost effectiveness because of similarity of clinical benefit and broad confidence intervals for differences in healthcare costs.

TRIAL REGISTRATION

UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811.

Cost effectiveness of leukotriene receptor antagonists versus inhaled corticosteroids for initial asthma controller therapy: a pragmatic trial

BACKGROUND

Information is lacking on the relative effectiveness and cost effectiveness--in a primary-care setting--of leukotriene receptor antagonists (LTRAs) as an alternative to inhaled corticosteroids (ICS) for initial asthma controller therapy.

OBJECTIVE

To compare the cost effectiveness of LTRAs versus ICS for patients initiating asthma controller therapy.

METHODS

An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma and symptoms requiring regular anti-inflammatory therapy (n = 326) were randomly assigned to LTRAs (n = 162) or ICS (n = 164). The main outcome measures were the incremental costs per point improvement in the Mini Asthma Quality of Life Questionnaire, per point improvement in the Asthma Control Questionnaire and per QALY gained from the UK NHS and societal perspectives.

RESULTS

Over 2 years, resource use was similar between the two treatment groups, but the cost to society per patient was significantly higher for the LTRA group, at pounds sterling 711 versus pounds sterling 433 for the ICS group (adjusted difference pounds sterling 204; 95% CI 74, 308) [year 2005 values]. Cost differences were driven primarily by differences in prescription drug costs, particularly study drug costs. There was a nonsignificant (imputed, adjusted) difference between treatment groups, favouring ICS, in QALYs gained at 2 years of -0.073 (95% CI -0.143, 0.010). Therapy with LTRAs was, on average, a dominated strategy, and, at a threshold for willingness to pay of pounds sterling 30,000 per QALY gained, the probability of LTRAs being cost effective compared with ICS was approximately 3% from both societal and NHS perspectives.

CONCLUSIONS

There is a very low probability of LTRAs being cost effective in the UK, at 2005 values, compared with ICS for initial asthma controller therapy.

TRIAL REGISTRATION

UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811.

Impact of patient characteristics, education and knowledge on emergency room visits in patients with asthma and COPD: a descriptive and correlative study

Background

Asthma and COPD are major health problems and an extensive burden for the patient and the health care system. Patient education has been recommended, but the influence on knowledge and health outcomes is not fully examined. Our aims were to compare patient characteristics, education and knowledge in patients who had an emergency room (ER) visit, to explore factors related to disease knowledge, and to investigate patient characteristics, patient education and knowledge in relation to further ER visits over a 12 month period.

Methods

Eighty-four patients with asthma and 52 with COPD, who had had an ER visit, were included. They were interviewed by telephone 4 to 6 weeks after the ER visit and followed for a year.

Results

Patients with COPD were older, more sedentary, had had more ER visits the previous year, and had more co morbidity than patients with asthma. About 80% of the patients had received information from health professionals or participated in education/rehabilitation, but a minority (< 20%) reported that their knowledge about how to handle the disease was good. Patients with "good knowledge" were younger, were more likely to have asthma diagnose, and had a higher educational background (p < 0.05). Sixty-seven percent of the patients with COPD had repeated ER visits during the following year versus 42% in asthma (p < 0.05) (adjusted HRR: 1.73 (1.03-2.90)). Patients who had had ER visits the year before inclusion had a higher risk of ER visits the following year (adjusted HRR: 3.83 (1.99-7.38)). There were no significant differences regarding patient education and knowledge between the group with and without further ER visits after adjusting for sex, diagnose, age, and educational background.

Conclusion

Patients with asthma had a better self reported knowledge of disease management and were less likely to have new exacerbations than patients with COPD. Reported level of knowledge was, however, in it self not a predictor of exacerbations. This indicates that information is not sufficient to reduce the burden of disease. Patient education focused on self-management and behavioral change should be emphasized.

Phenotypic determinants of uncontrolled asthma

BACKGROUND

Although uncontrolled asthma remains frequent, determinants of asthma control are poorly studied.

OBJECTIVES

The aim was to estimate the distribution and the phenotypic characteristics of asthma control in 2 groups of subjects defined by the use of inhaled corticosteroids (ICS) in the past 12 months, in the Epidemiological study on the Genetics and Environment of Asthma, bronchial hyperresponsiveness and atopy (EGEA).

METHODS

Five hundred one adult current patients with asthma who participated in the follow-up of the EGEA study were included. Asthma control was assessed from survey questions reflecting asthma control, as defined in the 2006 Global Initiative for Asthma guidelines. The factors analyzed were age, sex, educational level, body mass index, active and passive smoking, sensitization to aeroallergens, total IgE, rhinitis, chronic cough/phlegm, and age at asthma onset. Analyses were stratified according to ICS use.

RESULTS

Uncontrolled asthma was more frequent in ICS users (27.6%, 35.0%, and 37.4% with controlled, partly-controlled, and uncontrolled asthma respectively) compared with non-ICS users (60.0%, 23.9%, and 16.1%, respectively). In ICS users, chronic cough or phlegm and female sex were independently and significantly related to uncontrolled asthma. In non-ICS users, high total IgE and sensitization to molds were associated with uncontrolled asthma. Smoking and rhinitis were not associated with asthma control.

CONCLUSION

Optimal asthma control remained unachieved in the majority of patients with asthma in this study. Factors associated with uncontrolled asthma were different in ICS users (chronic cough/phlegm, female sex) and non-ICS users (high total IgE and sensitization to molds).

ADAM8: a new therapeutic target for asthma

BACKGROUND

A proteinase with a disintegrin and a metalloproteinase domain-8 (ADAM8) has been linked to asthma.

OBJECTIVE

To explore whether ADAM8 is a therapeutic target for asthma.

METHODS

We reviewed literature on ADAM8's function and expression and activities in lungs of humans and mice with allergic airway inflammation (AAI). We used these data to generate hypotheses about the contributions of ADAM8 to asthma pathogenesis.

CONCLUSIONS

ADAM8 levels are increased in airway epithelium and airway inflammatory cells in mice with AAI and human asthma patients. Data from murine models of AAI indicate that ADAM8 dampens airway inflammation. It is not clear whether ADAM8 contributes directly to structural remodeling in asthmatic airways. Additional studies are required to validate ADAM8 as a therapeutic target for asthma.

Economic burden of asthma: a systematic review

BACKGROUND

Asthma is associated with enormous healthcare expenditures that include both direct and indirect costs. It is also associated with the loss of future potential earnings related to both morbidity and mortality. The objective of the study is to determine the burden of disease costs associated with asthma.

METHODS

We performed a systematic search of MEDLINE, EMBASE, CINAHL, CDSR, OHE-HEED, and Web of Science Databases between 1966 and 2008.

RESULTS

Sixty-eight studies met the inclusion criteria. Hospitalization and medications were found to be the most important cost driver of direct costs. Work and school loss accounted for the greatest percentage of indirect costs. The cost of asthma was correlated with comorbidities, age, and disease severity.

CONCLUSION

Despite the availability of effective preventive therapy, costs associated with asthma are increasing. Strategies including education of patients and physicians, and regular follow-up are required to reduce the economic burden of asthma.

Asthma patients' self-reported behaviours toward inhaled corticosteroids

BACKGROUND

Patient adherence to recommended use of ICS is questionable in asthma, with irregular use or interruptions occurring frequently. Factors explaining discontinuation of controller therapy could orientate interventions. The characteristics of patients with interruptions of inhaled corticosteroids (ICSs), intentional or accidental, were investigated.

METHODS

Asthma patients regularly prescribed ICS by GPs (Cegedim network) were included. Patients' characteristics and behaviours toward ICS (accidental/intentional interruptions, less frequent use of ICS and change in dosing) were identified from self-report questionnaires, and linked to data prescription database. Interrelations between declared behaviours toward ICS were studied with a Multiple Component Analysis (MCA) and the correlates of ICS interruptions were identified.

RESULTS

During the past 3 months, 31.6% of 204 patients (mean age: 53.8 years, females: 59.3%) intentionally interrupted ICS when feeling better, 25.4% forgot ICS and 18.3% deliberately changed the doses. A quarter of patients considered constant use of respiratory medicines as unhealthy. MCA revealed that intentional, accidental interruptions and less frequent use of ICS were closely correlated. Risk of intentional interruption was increased when patients considered constant use of respiratory therapy to be unhealthy (OR=3.36, 95%CI=[1.47-7.66]). Conversely, risk was significantly lower when ICS was associated or combined with another controller (OR=0.24, 95%CI=[0.08-0.73]), compared to ICS in monotherapy. Less frequent interruptions were observed in patients older than 65 (OR=0.35, 95%CI=[0.13-0.89]).

CONCLUSIONS

Our study suggests that discontinuation of use of controllers is associated with other inadequate behaviours or beliefs about inhaled controllers. Efforts should be targeted at patients' perceptions and behaviours toward controller therapy.

Asthma control score based on filled medication prescriptions: a validation study

BACKGROUND

Periodic measurement of disease control is recommended to characterize asthma and monitor treatment.

OBJECTIVE

To elaborate and validate an asthma control score (ACS) for use in studies based on administrative health databases.

METHODS

Adult patients with asthma were recruited from a clinic. The ACS is based on the average number of doses of short-acting inhaled beta(2)-agonists taken per week and short courses of oral corticosteroids dispensed over a three-month period. Data were obtained from the Régie de l'assurance maladie du Québec database in Canada. The ACS was compared with the asthma control questionnaire and the use of health care services for asthma over a 12-month period.

RESULTS

A total of 60 patients were enrolled. They had a mean (+/- SD) age of 50.4+/-13.9 years, and 43.3% were male. Patients had had asthma for 20.8+/-15.1 years on average and had a mean prebronchodilator forced expiratory volume in 1 s of 77.0% of the predicted value. The mean ACS was 8.3+/-11.6, with a range of 0 to 60. The ACS was not found to be correlated with the asthma control questionnaire, but it was significantly associated with health care services used. For each additional point in the ACS, patients were 2% more likely to need acute care for asthma (rate ratio 1.02; P=0.02).

CONCLUSIONS

Further studies including patients followed by general practitioners are required before the general use of this score. This innovative score is useful to rapidly assess the control of asthma over long periods of time and at a low cost in studies using administrative drug databases.

Asthma worsenings: approaches to prevention and management from the Asthma Worsenings Working Group

Most asthma patients prescribed maintenance asthma therapies still experience periods of asthma worsenings characterized by daytime or night-time symptoms, or an increased need for rescue medication. In fact, these episodes are highly prevalent even in patients with well-controlled disease. Published literature suggests that asthma worsenings likely represent a window of opportunity during which patients could intervene early to prevent exacerbations or further deterioration of asthma symptoms. However, current evidence suggests that most patients fail to respond or to self-manage appropriately during these periods.To address the issue of asthma worsenings, an interdisciplinary committee of respirologists, allergists, family physicians, pharmacists and certified asthma educators from across Canada developed a practical definition of asthma worsenings and provided approaches to the prevention and management of these episodes based on current literature. To date, combination inhaled corticosteroid/long-acting beta-agonist therapy, particularly single inhaler maintenance and reliever therapy, appears to be an effective strategy for preventing asthma worsenings and exacerbations. Addressing the potential barriers to appropriate patient self-management of asthma worsenings, such as failure to adequately identify and respond to worsenings, low expectations for controlling asthma, low health literacy and poor patient-health care professional communication, are also critical to the successful prevention and management of these episodes. Finally, an interdisciplinary team approach involving patients and their families, certified asthma educators, primary care physicians, pharmacists and specialists is likely to have the greatest impact on the identification, prevention and management of asthma worsenings.

An evaluation of the cost-effectiveness of omalizumab for the treatment of severe allergic asthma

Omalizumab is the first licensed anti-immunoglobulin (Ig) E antibody shown to be effective for treatment of allergic (IgE-mediated) asthma. Recent international guidelines recommend omalizumab as add-on treatment to fixed dose inhaled corticosteroid (ICS) and long-acting beta(2)-agonist (LABA) combination therapy. However, omalizumab is more expensive than other current asthma treatments and health and reimbursement authorities are increasingly demanding evidence of economic benefit to support pricing and formulary listing. The aims of this article are to (i) summarize data on the human and economic burden of severe asthma, (ii) summarize the efficacy data obtained for omalizumab in clinical trials in patients with inadequately controlled severe persistent allergic asthma despite high-dose ICS plus a LABA, and (iii) discuss the cost-effectiveness evidence published for omalizumab in this patient population. A wealth of evidence exists highlighting that the health, economic and societal burden of asthma is considerable and is highly skewed towards patients with severe asthma, particularly when asthma is inadequately controlled. Omalizumab is clinically beneficial in patients with severe persistent allergic asthma despite high-dose ICS plus a LABA, particularly in a subgroup of patients who respond to therapy. In patients who respond to therapy, the cost-effectiveness of omalizumab compares well with other biologic treatments for chronic illness.

Impact of patient-related factors on asthma control

BACKGROUND

Patient-related factors are a significant component in the serious public health problem of poor asthma control, yet they have not been extensively studied.

AIMS

To gauge the impact of baseline patient characteristics, compliance and inhaler device manipulation on Asthma Control Score (ACS).

METHODS

ACS (between 0 and 9) was calculated from data recorded in a routine consultation in 4,362 patients with persistent asthma using a maintenance treatment with only inhaled corticosteroid and correlated with patient characteristics, compliance (using 2 methods) and critical errors in inhaler handling.

RESULTS

Mean ASC was 2.95 (95%CI: 2.88-3.02) and asthma control was unsatisfactory (i.e., ACS > or = 4) in 41.1% of subjects, with higher proportions in smokers, non-compliant patients, and those misusing their device. Mean ACS tended to rise with age, and was higher in smokers than in non-smokers (+0.83 point) and ex-smokers (+0.49 point). More than 20% of all subjects were using their inhaler device incorrectly (Turbuhaler 37.1%; Metered-dose inhaler 28.1%; Diskus 21.3%; Aerolizer 7.4%) and this was associated with a 0.84-point increase in ACS. Mean ACS was lower in the most compliant patients (-0.74 points in the 13.4% with a perfect score on a compliance questionnaire) and much lower than in the least compliant (-1.84 points in the 6.6% who reported missing 4 or more doses per week).

CONCLUSION

Patient-related factors including smoking, poor compliance and critical errors in device manipulation, have significant negative impact on asthma control. This could be addressed by patient education.