1
|
Bianco A, Contoli M, Di Marco F, Saverio Mennini F, Papi A. As-needed anti-inflammatory reliever therapy for asthma management: evidence and practical considerations. Clin Exp Allergy 2020; 51:873-882. [PMID: 33247470 DOI: 10.1111/cea.13795] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/18/2020] [Accepted: 11/22/2020] [Indexed: 01/31/2023]
Abstract
Asthma is a chronic respiratory disease in which airway inflammation is a key feature, even in the milder expressions of the disease. The conventional pharmacological approach to mild asthma has long relied on reliever therapy with as-needed short-acting beta-agonists (SABAs), while anti-inflammatory maintenance with inhaled corticosteroids (ICSs) has been reserved for patients with more persistent asthma. Poor adherence to maintenance treatment is an important issue in asthma management, and can partly explain suboptimal symptom control. Over-reliance on SABA bronchodilators for rapid symptom relief is common in real life and potentially leads to an increased risk of asthma morbidity and mortality. Combined anti-inflammatory and reliever medications in a single inhaler have the potential to overcome these limitations. Recent studies in patients with mild asthma have shown that anti-inflammatory reliever therapy with budesonide-formoterol, given on an as-needed basis, is superior to SABA in ensuring asthma control and non-inferior to budesonide maintenance therapy in preventing exacerbations. To address the implications of these important findings for the management of patients with asthma, Italian specialists convened at a series of meetings held during the second half of 2018 across Italy. This article presents their position on these topics and includes a review of the evidence supporting the use of anti-inflammatory reliever therapy in mild asthma and the implementation of this novel approach in clinical practice.
Collapse
Affiliation(s)
- Andrea Bianco
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marco Contoli
- Respiratory Medicine, CEMICEF, University of Ferrara, Ferrara, Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università degli Studi di Milano, Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Saverio Mennini
- CEIS-Economic Evaluation and HTA (EEHTA), Faculty of Economics, University of Rome "Tor Vergata", Rome, Italy.,Institute for Leadership and Management in Health, Kingston University London, London, UK
| | - Alberto Papi
- Respiratory Medicine, CEMICEF, University of Ferrara, Ferrara, Italy
| | | |
Collapse
|
2
|
Szefler SJ, Chipps B. Challenges in the treatment of asthma in children and adolescents. Ann Allergy Asthma Immunol 2018; 120:382-388. [PMID: 29625664 DOI: 10.1016/j.anai.2018.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/20/2017] [Accepted: 01/04/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Despite the availability of effective treatments, asthma control in children and adolescents remains inadequate and rates of health care use are high. This follow-up to a recent review (O'Byrne et al, Eur Respir J. 2017;50[3]) examines a number of challenges in current pediatric asthma management compared with that of an adult perspective and discusses possible alternative strategies that might improve pediatric asthma management and control. DATA SOURCES The evidence base for this review is limited because, historically, much of the research has been performed in adults. STUDY SELECTIONS Not applicable. RESULTS Pediatric asthma management is complicated by variability in asthma severity and control and difficulty in measuring pulmonary function and airway inflammation. Current challenges in pediatric asthma management include the recommended initial therapy treating only the symptoms rather than the underlying inflammation and switching to controller therapy only when asthma subsequently worsens. CONCLUSION Alternative strategies that might improve pediatric asthma management and control include replacement of short-acting β2-agonist relievers by an inhaled corticosteroid plus a fast-acting β2-agonist (short-acting β2-agonist or fast- and long-acting β2-agonist) combination at Global Initiative for Asthma step 1 or 2 to ensure that patients receive an inhaled corticosteroid whenever they feel the need for symptomatic relief. Such an approach could eliminate the problem of learned overuse or over-reliance on short-acting β2-agonist reliever medication and address the other challenges in current pediatric asthma management. Clinical studies in pediatric patients or large studies involving a proportion of pediatric patients are required to provide the supporting evidence needed to help advance such new approaches and improve asthma control from a pediatric perspective.
Collapse
Affiliation(s)
- Stanley J Szefler
- Pediatric Asthma Research Program and The Breathing Institute, Children's Hospital Colorado, University Colorado School of Medicine, Aurora, Colorado
| | - Bradley Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
| |
Collapse
|
3
|
Tsang MSM, Cheng SW, Zhu J, Atli K, Chan BCL, Liu D, Chan HYT, Sun X, Chu IMT, Hon KL, Lam CWK, Shaw PC, Leung PC, Wong CK. Anti-Inflammatory Activities of Pentaherbs formula and Its Influence on Gut Microbiota in Allergic Asthma. Molecules 2018; 23:molecules23112776. [PMID: 30373169 PMCID: PMC6278535 DOI: 10.3390/molecules23112776] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/23/2018] [Accepted: 10/25/2018] [Indexed: 01/01/2023] Open
Abstract
Allergic asthma is a highly prevalent airway inflammatory disease, which involves the interaction between the immune system, environmental and genetic factors. Co-relation between allergic asthma and gut microbiota upon the change of diet have been widely reported, implicating that oral intake of alternative medicines possess a potential in the management of allergic asthma. Previous clinical, in vivo, and in vitro studies have shown that the Pentaherbs formula (PHF) comprising five traditional Chinese herbal medicines Lonicerae Flos, Menthae Herba, Phellodendri Cortex, Moutan Cortex, and Atractylodis Rhizoma possesses an anti-allergic and anti-inflammatory potential through suppressing various immune effector cells. In the present study, to further investigate the anti-inflammatory activities of PHF in allergic asthma, intragastrical administration of PHF was found to reduce airway hyperresponsiveness, airway wall remodeling and goblet cells hyperplasia in an ovalbumin (OVA)-induced allergic asthma mice model. PHF also significantly suppressed pulmonary eosinophilia and asthma-related cytokines IL-4 and IL-33 in bronchoalveolar lavage (BAL) fluid. In addition, PHF modulated the splenic regulatory T cells population, up-regulated regulatory interleukin (IL)-10 in serum, altered the microbial community structure and the short chain fatty acids content in the gut of the asthmatic mice. This study sheds light on the anti-inflammatory activities of PHF on allergic asthma. It also provides novel in vivo evidence that herbal medicines can ameliorate symptoms of allergic diseases may potentially prevent the development of subsequent atopic disorder such as allergic asthma through the influence of the gut microbiota.
Collapse
Affiliation(s)
- Miranda Sin-Man Tsang
- Institute of Chinese Medicine and State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Hong Kong, China.
| | - Sau-Wan Cheng
- Institute of Chinese Medicine and State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Hong Kong, China.
| | - Jing Zhu
- Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Karam Atli
- Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Ben Chung-Lap Chan
- Institute of Chinese Medicine and State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Hong Kong, China.
| | - Dehua Liu
- Institute of Chinese Medicine and State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Hong Kong, China.
| | - Helen Yau-Tsz Chan
- Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Xiaoyu Sun
- Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Ida Miu-Ting Chu
- Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Kam-Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Christopher Wai-Kei Lam
- State Key Laboratory of Quality Research in Chinese Medicines, Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau, China.
| | - Pang-Chui Shaw
- Institute of Chinese Medicine and State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Hong Kong, China.
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong, China.
- Li Dak Sum Yip Yio Chin R & D Centre for Chinese Medicine, The Chinese University of Hong Kong, Hong Kong, China.
| | - Ping-Chung Leung
- Institute of Chinese Medicine and State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Hong Kong, China.
| | - Chun-Kwok Wong
- Institute of Chinese Medicine and State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Hong Kong, China.
- Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
- Li Dak Sum Yip Yio Chin R & D Centre for Chinese Medicine, The Chinese University of Hong Kong, Hong Kong, China.
| |
Collapse
|
4
|
Płoszczuk A, Bosheva M, Spooner K, McIver T, Dissanayake S. Efficacy and safety of fluticasone propionate/formoterol fumarate in pediatric asthma patients: a randomized controlled trial. Ther Adv Respir Dis 2018; 12:1753466618777924. [PMID: 29857783 PMCID: PMC5985608 DOI: 10.1177/1753466618777924] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 04/11/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The efficacy and safety of fluticasone propionate/formoterol fumarate pressurized metered-dose inhaler (pMDI) (fluticasone/formoterol; Flutiform®; 100/10 µg b.i.d.) was compared with fluticasone propionate (Flixotide® Evohaler® pMDI; 100 µg b.i.d.) and fluticasone/salmeterol (Seretide® Evohaler® pMDI; 100/50 µg b.i.d.) in a pediatric asthma population (EudraCT number: 2010-024635-16). METHODS A double-blind, double-dummy, parallel group, multicenter study. Patients, aged 5-<12 years with persistent asthma ⩾ 6 months and forced expiratory volume in 1 s (FEV1) ⩽ 90% predicted were randomized 1:1:1 to 12 weeks' treatment. The study objectives were to demonstrate superiority of fluticasone/formoterol to fluticasone and non-inferiority to fluticasone/salmeterol. RESULTS A total of 512 patients were randomized: fluticasone/formoterol, 169; fluticasone, 173; fluticasone/salmeterol, 170. Fluticasone/formoterol was superior to fluticasone for the primary endpoint: change from predose FEV1 at baseline to 2 h postdose FEV1 over 12 weeks [least squares (LS) mean difference 0.07 l; 95% confidence interval (CI) 0.03, 0.11; p < 0.001] and the first key secondary endpoint, FEV1 area under the curve over 4 hours (AUC0-4 h) at week 12 (LS mean difference 0.09 l; 95% CI: 0.04, 0.13; p < 0.001). Per a prespecified non-inferiority margin of -0.1 l, fluticasone/formoterol was non-inferior to fluticasone/salmeterol for the primary endpoint (LS mean difference 0.00 l; 95% CI -0.04, 0.04; p < 0.001) and first key secondary endpoint (LS mean difference 0.01; 95% CI -0.03, 0.06; p < 0.001). Fluticasone/formoterol was non-inferior to fluticasone/salmeterol for the second key secondary endpoint, change from predose FEV1 over 12 weeks (treatment difference -0.02 l; 95% CI -0.06, 0.02; p < 0.001), but was not superior to fluticasone for this endpoint (LS mean difference 0.03 l; 95% CI -0.01, 0.07; p = 0.091). All treatments elicited large improvements from baseline to week 12 for the Pediatric Asthma Quality of Life Questionnaire (LS mean change 0.76 to 0.85 units) and Asthma Control Questionnaire (LS mean change -1.03 to -1.13 units). Few severe exacerbations were seen (fluticasone/formoterol: two; fluticasone/salmeterol: two). All treatments were well tolerated. CONCLUSIONS This study supports the efficacy and safety of fluticasone/formoterol in a pediatric asthma population and its superiority to fluticasone.
Collapse
Affiliation(s)
- Anna Płoszczuk
- Prywatna Praktyka Lekarska, Gabinet Pediatryczno-Alergologiczny, Ul. Przejazd 2A, Białystok, Poland
| | - Miroslava Bosheva
- University Hospital Plovdiv, Medical University of Plovdiv, Bulgaria
| | | | | | | |
Collapse
|
5
|
Hochhaus G, Davis-Cutting C, Oliver M, Lee SL, Lyapustina S. Current Scientific and Regulatory Approaches for Development of Orally Inhaled and Nasal Drug Products: Overview of the IPAC-RS/University of Florida Orlando Inhalation Conference. AAPS JOURNAL 2015; 17:1305-11. [PMID: 26033698 DOI: 10.1208/s12248-015-9791-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 05/26/2015] [Indexed: 11/30/2022]
Abstract
This article summarizes discussions at the March 2014 conference organized by the University of Florida (UF) and International Pharmaceutical Aerosol Consortium on Regulation and Science (IPAC-RS), entitled "Orlando Inhalation Conference: Approaches in International Regulation." The special focus of the conference was on global scientific and regulatory issues associated with the testing and demonstration of equivalence for the registration of orally inhaled drug products (OIDPs) in the United States, Europe, Brazil, China, and India. The scope included all types of OIDPs throughout their lifecycle, e.g., innovator/brand-name products, generics, modifications due to lifecycle management, device changes, etc. Details were presented for the U.S. "weight of evidence approach" for registration of generic products (which includes demonstration of in vitro and in vivo equivalence, as well as quantitative and qualitative sameness, and device similarity). The European "stepwise" approach was elucidated, and the thinking of regulatory agencies in the major emerging markets was clarified. The conference also highlighted a number of areas that would benefit from further research and discussion, especially around patient/device interface and human factor studies, statistical methods and criteria for demonstrating equivalence, the relative roles of in vivo and in vitro tests, and appropriate designs and metrics for in vivo studies of inhaled drugs.
Collapse
Affiliation(s)
- Guenther Hochhaus
- Department of Pharmaceutics College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | | | | | | | | |
Collapse
|