Current recommendations for the treatment of mild asthma

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Study on Allopathic and Alternative Treatments of Asthma and Factors Influencing Treatment Choices

Materials and Methods

The cross-sectional survey was conducted; primary data were collected from asthmatic patients in different hospitals and clinics of allopathic, homeopathic, and herbal practitioners in Karachi, Pakistan. The study duration was from January 2020 to December 2020. Asthmatic patients aged over 13 years were selected for the study. A written informed consent was taken from the patients before the interview. Collected data were analyzed by the Statistical Package of Social Sciences (SPSS) 22.

Result

Among 255 asthmatic patients; 51.4% (n = 131) were male and 48.6% (n = 124) were female. For control of acute attacks of asthma 88.2% (p = 0.0001) of patients significantly preferred allopathic treatment while 6.3% (p = 0.008) used homeopathic treatment and 5.5% chose herbal treatment. For maintenance of asthma, 78.8% (p = 0.0001) patients used allopathic treatment while 12.4% (p = 0.0001) homeopathic and 8.8% (p = 0.0001) patients used herbal treatment. About 63.4% (p = 0.0001) of the asthmatic patients used short-acting β-2 agonists for managing acute asthmatic episodes while long-acting β-2 agonists (p = 0.0001) and inhaled corticosteroids (p = 0.0001) were found to be the preferred medicines for maintenance therapy. Effectiveness of treatment (p = 0.004) and cost effectiveness (p = 0.0001) significantly act as contributing factors for the selection of the treatment. The majority of the patients were satisfied with their chosen treatments for control of asthmatic symptoms.

Conclusion

Most asthmatic patients preferred allopathic treatment for the management of acute episodes and control of asthmatic symptoms. It was found that the major factors for selecting a specific treatment include effectiveness, cost, and minimal side effects.

SMART in treatment of asthma exacerbations

OBJECTIVE

The objective of this review is to evaluate the effectiveness and practicality of SMART (single maintenance and reliever therapy) in the treatment of asthma exacerbation.

DATA SOURCES

PubMed, MEDLINE, Cochrane, and Clinical Trial databases using the keywords SMART therapy, maintenance and reliever therapy, and budesonide and formoterol.

STUDY SELECTION

Articles were selected based on their relevance and applicability to this topic.

RESULTS

Multiple studies have evaluated the efficacy of SMART in reducing asthma exacerbations in comparison to standard inhaled corticosteroid (ICS) maintenance and short-acting beta-agonist (SABA) rescue therapy. Most of the randomized trials demonstrated a reduction in asthma exacerbation with open-label studies revealing similar effectiveness in reducing asthma exacerbation. Previously, concerns have been raised regarding the administration of increased doses of long-acting beta-agonist that may potentially mask symptoms and delay appropriate medical attention. However, studies have not demonstrated an increase in morbidity or mortality. The primary concern regarding many of these trials is that they have been sponsored by pharmaceutical companies.

CONCLUSION

Although not all studies demonstrated the effectiveness of SMART, the majority revealed a significant reduction in asthma exacerbation frequency and severity.

The safety of long-term use of inhaled corticosteroids in patients with asthma: A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was performed to determine the safety of long-term use of ICS in patients with asthma.

METHODS

A systematic search was made of PubMed, Embase, Web of Science, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of asthma with ICS, compared with non-ICS treatment (placebo or other active drugs), were reviewed.

RESULTS

Eighty-six RCTs (enrolling 51,538 participants) met the inclusion criteria. Oral or oropharyngeal candidiasis (RR 2.58, 95% CI 2.00 to 3.33), and dysphonia/hoarseness (RR 1.56, 95% CI 1.31 to 1.85) were less frequent in the control group. There was no statistically significant difference in the risk of upper respiratory tract infection, lower respiratory tract infection, influenza, decline in bone mineral density, and fractures between the two groups.

CONCLUSION

In addition to the mild local adverse events, the long-term use of ICS was safe in patients with asthma.

Positioning As-needed Budesonide-Formoterol for Mild Asthma: Effect of Pre-study Treatment in Pooled Analysis of SYGMA 1 and 2

Rationale: The SYGMA (Symbicort Given as Needed in Mild Asthma) studies evaluated the efficacy and safety of as-needed budesonide (BUD)–formoterol (FORM) in patients whose asthma was uncontrolled on as-needed inhaled short-acting bronchodilators (subgroup 1) or controlled on inhaled corticosteroids (ICS) or leukotriene receptor antagonists (subgroup 2).

Objectives: To assess the influence of prestudy treatment in a post hoc analysis of the SYGMA studies.

Methods: In the SYGMA 1 (NCT022149199) and SYGMA 2 (NCT02224157) 52-week, double-blind, randomized, parallel-group studies, 6,735 patients with mild asthma were randomized to as-needed BUD–FORM, low-dose BUD + as-needed terbutaline (BUD maintenance), or as-needed terbutaline (SYGMA 1 only). Exacerbation rates and changes in symptom control and lung function were compared among treatments for both subgroups.

Results: In a pooled analysis of SYGMA 1 and 2, the annual severe exacerbation rate in subgroup 1 was significantly lower with as-needed BUD–FORM (0.08 [95% confidence interval (CI), 0.06–0.10]) than with BUD maintenance (0.10 [95% CI, 0.09–0.13]) (rate ratio [RR], 0.74 [95% CI, 0.56–0.98]; P = 0.03), and similar results were shown in subgroup 2 with BUD–FORM (0.12 [95% CI, 0.10–0.14]) and BUD maintenance (0.10 [95% CI, 0.09–0.13]) (RR, 1.10 [95% CI, 0.86–1.41]; P = 0.44). In SYGMA 1, the annual severe exacerbation rate in both subgroups was significantly lower with as-needed BUD–FORM than with as-needed terbutaline (subgroup 1: RR, 0.34 [95% CI, 0.20–0.58]; P < 0.001; subgroup 2: RR, 0.37 [95% CI, 0.25–0.54]; P < 0.001). The number needed to treat to prevent one severe exacerbation with as-needed BUD–FORM and BUD maintenance versus as-needed terbutaline were 20 and 34 in subgroup 1 and 13 and 12 in subgroup 2, respectively.

Conclusions: These findings suggest that, for patients with mild asthma currently receiving short-acting β₂-agonists alone, as-needed low-dose ICS–FORM should be preferred over maintenance ICS as initial controller treatment. For patients whose asthma is controlled on maintenance low-dose ICS, as-needed BUD–FORM is an alternative to maintenance ICS without the need for daily treatment, and both of these options are safer than switching to short-acting β₂-agonist–only treatment.

Efficacy and Safety of As-Needed Budesonide-Formoterol in Adolescents with Mild Asthma

BACKGROUND

Medication adherence is challenging for adolescents. In mild asthma, as-needed budesonide-formoterol (BUD-FORM) reduces severe exacerbations compared with as-needed short-acting beta₂-agonists, similar to the reduction with maintenance budesonide.

OBJECTIVE

This post hoc pooled analysis of Symbicort Given as-needed in Mild Asthma (SYGMA) 1 and 2 assessed the efficacy and safety of as-needed BUD-FORM in adolescents.

METHODS

SYGMA 1 and 2 were 52-week, double-blind studies (NCT022149199; NCT02224157) in patients 12 years or older with mild asthma. Patients were randomized to twice-daily placebo + as-needed BUD-FORM 200/6 μg, twice-daily BUD 200 μg + as-needed terbutaline (BUD maintenance), or twice-daily placebo + as-needed terbutaline 0.5 mg (SYGMA 1 only). Annualized severe exacerbation rates, maintenance treatment adherence, and safety (including change in height) were compared between treatment groups in adolescents (aged ≥12 to <18 years).

RESULTS

Severe exacerbation rate was similar with as-needed BUD-FORM and BUD maintenance (pooled analysis: 0.08 vs 0.07/y; P = .634), and was significantly lower with as-needed BUD-FORM versus as-needed terbutaline (SYGMA 1: 0.04 vs 0.17/y; P = .005). Median adherence was 73% in SYGMA 1 and 51% in SYGMA 2. Change in height from baseline in adolescents aged ≥12 years to <14 years was significantly greater with as-needed BUD-FORM (4.8 cm) versus BUD maintenance (3.9 cm) (pooled: P < .046), and was similar between as-needed BUD-FORM (4.5 cm) and as-needed terbutaline (4.1 cm) (SYGMA 1: P = .500). No new or unexpected safety concerns were identified.

CONCLUSIONS

In adolescents with mild asthma, as-needed BUD-FORM was superior to as-needed terbutaline for severe exacerbation reduction, with similar efficacy to BUD maintenance. As-needed BUD-FORM provides an alternative treatment option for adolescents with mild asthma, without needing daily treatment.

GINA 2020: Potential Impacts, Opportunities, and Challenges for Primary Care

In 2019, it was reported that changes to asthma management reported in the Global Initiative for Asthma (GINA) "…might be considered the most fundamental changes in asthma management in 30 years." These changes refer to the recommendation that the treatment of asthma in adolescents and adults would no longer include short-acting ß₂-agonist (SABA) only, but that people with asthma should receive either symptom-driven inhaled corticosteroids (ICS)-containing treatment (mild asthma) or daily ICS-containing treatment. The fundamental reason for this shift was driven by concerns about the risks and consequences associated with SABA-only treatment, the need to improve the day-to-day management of asthma symptoms to prevent exacerbations and emergent evidence. These recommendations have subsequently been reinforced and characterized in GINA 2020, and it is reasonable to say that they are significant, not only in terms of an asthma management framework but also as a management approach in practice. This opinion article specifically focuses on opportunities and challenges associated with the implementation of GINA 2020 in primary care practice that need to be recognized and addressed if the shift in asthma treatment paradigm is to be successfully implemented into day-to-day practice.

The Projected Economic and Health Burden of Uncontrolled Asthma in the United States

Rationale: Despite effective treatments, a large proportion of patients with asthma do not achieve sustained asthma control. The "preventable" burden associated with lack of proper control is likely taking a high toll at the personal and population level.Objectives: We predicted the future excess health and economic burden associated with uncontrolled asthma among American adolescents and adults for the next 20 years.Methods: We built a probabilistic model that linked state-specific estimates of population growth, aging, asthma prevalence, and asthma control levels. We conducted several meta-analyses to estimate the adjusted differences in healthcare resource use, quality-adjusted life years (QALYs), and productivity loss across control levels. We projected, nationally and at the state level, total direct and indirect (due to productivity loss) costs (in 2018 dollars) and QALYs lost because of uncontrolled asthma from 2019 to 2038.Measurements and Main Results: Total 20-year direct costs associated with uncontrolled asthma are estimated to be $300.6 billion (95% confidence interval [CI], $190.1 billion-411.1 billion). When indirect costs are added, total economic burden will be $963.5 billion (95% CI, $664.1 billion-1,262.9 billion). American adolescents and adults will lose an estimated 15.46 million (95% CI, 12.77 million-18.14 million) QALYs over this period because of uncontrolled asthma. Across states, the average 20-year per capita costs due to uncontrolled asthma ranged from $2,209 (Arkansas) to $6,132 (Connecticut).Conclusions: The burden of uncontrolled asthma is substantial and will continue to grow. Given that a substantial fraction of this burden is preventable, better adherence to evidence-informed asthma management strategies by care providers and patients has the potential to substantially reduce costs and improve quality of life.

Theory-Based Digital Interventions to Improve Asthma Self-Management Outcomes: Systematic Review

BACKGROUND

Asthma is a chronic disease requiring effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how and to what extent psychological theory has been applied to the development of digital interventions, or how using theory impacts outcomes.

OBJECTIVE

The study aimed to examine the use and application of theory in the development of digital interventions to enhance asthma self-management and to evaluate the effectiveness of theory-based interventions in improving adherence, self-management, and clinical outcomes.

METHODS

Electronic databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched systematically using predetermined terms. Additional studies were identified by scanning references within relevant studies. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Full-text review was undertaken for relevant studies. Those meeting inclusion criteria were assessed for risk of bias using the Cochrane Collaboration tool. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study outcomes were classified as medication adherence, self-management, asthma control, clinical markers of health, quality of life, other quality of life outcomes, and health care utilization. Effectiveness was calculated as an average outcome score based on the study's reported significance. The Theory Coding Scheme (TCS) was used to establish the extent to which each intervention had applied theory and which theoretical constructs or behavioral determinants were addressed. Associations between TCS scores and asthma outcomes were described within a narrative synthesis.

RESULTS

Fourteen studies evaluating 14 different digital interventions were included in this review. The most commonly cited theories were Social Cognitive Theory, Health Belief Model, and Self-Efficacy Theory. A greater use of theory in the development of interventions was correlated with effective outcomes (r=.657; P=.01): only the 3 studies that met >60% of the different uses of theory assessed by the TCS were effective on all behavioral and clinical outcomes measured. None of the 11 studies that met ≤60% of the TCS criteria were fully effective; however, 3 interventions were partially effective (ie, the intervention had a significant impact on some, but not all, of the outcomes measured). Most studies lacked detail on the theoretical constructs and how they were applied to the development and application of the intervention.

CONCLUSIONS

These findings suggest that greater use of theory in the development and application of digital self-management interventions for asthma may increase their effectiveness. The application of theory alone may not be enough to yield a successful intervention, and other factors (eg, the context in which the intervention is used) should be considered. A systematic approach to the use of theory to guide the design, selection, and application of intervention techniques is needed.

Inhaled Combined Budesonide-Formoterol as Needed in Mild Asthma

BACKGROUND

In patients with mild asthma, as-needed use of an inhaled glucocorticoid plus a fast-acting β₂-agonist may be an alternative to conventional treatment strategies.

METHODS

We conducted a 52-week, double-blind trial involving patients 12 years of age or older with mild asthma. Patients were randomly assigned to one of three regimens: twice-daily placebo plus terbutaline (0.5 mg) used as needed (terbutaline group), twice-daily placebo plus budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol) used as needed (budesonide-formoterol group), or twice-daily budesonide (200 μg) plus terbutaline used as needed (budesonide maintenance group). The primary objective was to investigate the superiority of as-needed budesonide-formoterol to as-needed terbutaline with regard to electronically recorded weeks with well-controlled asthma.

RESULTS

A total of 3849 patients underwent randomization, and 3836 (1277 in the terbutaline group, 1277 in the budesonide-formoterol group, and 1282 in the budesonide maintenance group) were included in the full analysis and safety data sets. With respect to the mean percentage of weeks with well-controlled asthma per patient, budesonide-formoterol was superior to terbutaline (34.4% vs. 31.1% of weeks; odds ratio, 1.14; 95% confidence interval [CI], 1.00 to 1.30; P=0.046) but inferior to budesonide maintenance therapy (34.4% and 44.4%, respectively; odds ratio, 0.64; 95% CI, 0.57 to 0.73). The annual rate of severe exacerbations was 0.20 with terbutaline, 0.07 with budesonide-formoterol, and 0.09 with budesonide maintenance therapy; the rate ratio was 0.36 (95% CI, 0.27 to 0.49) for budesonide-formoterol versus terbutaline and 0.83 (95% CI, 0.59 to 1.16) for budesonide-formoterol versus budesonide maintenance therapy. The rate of adherence in the budesonide maintenance group was 78.9%. The median metered daily dose of inhaled glucocorticoid in the budesonide-formoterol group (57 μg) was 17% of the dose in the budesonide maintenance group (340 μg).

CONCLUSIONS

In patients with mild asthma, as-needed budesonide-formoterol provided superior asthma-symptom control to as-needed terbutaline, assessed according to electronically recorded weeks with well-controlled asthma, but was inferior to budesonide maintenance therapy. Exacerbation rates with the two budesonide-containing regimens were similar and were lower than the rate with terbutaline. Budesonide-formoterol used as needed resulted in substantially lower glucocorticoid exposure than budesonide maintenance therapy. (Funded by AstraZeneca; SYGMA 1 ClinicalTrials.gov number, NCT02149199 .).

Long-Term Trajectories of Mild Asthma in Adulthood and Risk Factors of Progression

BACKGROUND

Most patients with asthma have mild disease. However, the clinical course of mild asthma and risk factors for progression are not well studied.

OBJECTIVE

To examine the long-term trajectories of mild asthma and the effects of early-stage risk factors on the subsequent disease course.

METHODS

From the administrative health data of British Columbia, Canada, we identified patients aged 14 to 45 years with newly diagnosed mild asthma between January 1997 and December 2012. For each follow-up year, we categorized a patient's asthma severity into mild/dormant, moderate, or severe on the basis of the intensity of asthma medications and occurrence of exacerbations. Ordinal logistic regression was used to estimate the probability of severity or all-cause death in the next year as a function of a patient's severity history in the past 3 years and selected baseline risk factors.

RESULTS

The study included 70,829 patients with incident mild asthma (62% women; mean age, 31 years). Over 10 years, 8% of these patients transitioned to moderate or severe asthma. Inappropriate use of rescue medications and older age were the most influential determinants for progression from mild asthma (odds ratios, 1.79; 95% CI, 1.68-1.90; P < .001; 1.24 per 10-year increase in age; 95% CI, 1.22-1.27; P < .001), whereas the presence of allergic rhinitis had no significant effects (odds ratio, 0.95; 95% CI, 0.91-1.00; P = .063).

CONCLUSIONS

Mild asthma remains largely stable over time. However, potentially modifiable factors such as inappropriate use of rescue medications are associated with a worsened prognosis.

Disease burden of mild asthma in China

BACKGROUND AND OBJECTIVE

The impact, treatment patterns and control of mild asthma are poorly understood for Chinese patients. This study describes the characteristics, therapeutic interventions and burden of mild asthma on patients residing in major cities of China.

METHODS

The Respiratory Disease Specific Program 2015, a cross-sectional survey, was conducted with Chinese physicians and their patients. The survey assessed clinical characteristics, asthma symptoms, exacerbations, rescue inhaler usage, treatment adherence, asthma control, work and activity impairments and healthcare utilization for patients prescribed Global Initiative for Asthma (GINA) Step 1 or 2 treatment defined mild asthma.

RESULTS

From a total sample of 988 patients, 229 patients met the criteria for mild asthma, with 25.3% classified as Step 1 and 74.7% as Step 2. Overall, 12.6% of patients were considered of high adherence to prescribed treatment. Physicians reported that 75% of patients overall were well controlled, although well-controlled asthma as defined by GINA was achieved in only 14.2% of patients. 26.5% of patients indicated daily use of as-needed rescue medication in the last 4 weeks. 17.8% of patients experienced ≥1 exacerbations in the last 12 months and impaired work productivity was 27.2% overall.

CONCLUSION

Less than 15% of patients were well controlled according to GINA criteria despite physicians reporting the majority of patients were well controlled. Over one-fourth of patients relied on daily rescue inhaler medication, while exacerbation frequency and work and activity impairment were higher than might reasonably be expected in a mild asthmatic population.

Disease Burden of Mild Asthma: Findings from a Cross-Sectional Real-World Survey

INTRODUCTION

Most asthma patients have mild disease, although the burden of mild asthma is not well understood nor studied. Some evidence suggests that many patients with mild asthma experience suboptimal symptom control and exacerbations. This study characterizes the burden of illness and treatment patterns among patients with a confirmed diagnosis of mild asthma, defined as GINA Step 1 or Step 2, and residing in China, France, Germany, Italy, Japan, Spain, the United Kingdom, or the United States.

METHODS

The Respiratory Disease-Specific Programme prospective cross-sectional survey was conducted with primary care and specialty physicians in each of the eight countries. Physician and patient surveys assessed demographic and clinical characteristics, frequency and timing of asthma symptoms, exacerbations, and rescue inhaler usage, the most recent FEV1% predicted, and healthcare utilization. GINA Step was determined by prescribed treatment regimen. GINA Step 1 patients were prescribed as-needed reliever medication and Step 2 required treatment with a low-dose inhaled corticosteroid, leukotriene receptor antagonist, or theophylline. Treatment adherence was assessed with the Morisky Medication Adherence scale, disease control with the Asthma Control Test, and work and activity impairments with the Work Productivity and Activity Impairment scale.

RESULTS

The sample included 1115 GINA Step 1 and 2 patients, with 53% classified as Step 2. Overall asthma control was suboptimal, with reports of nocturnal symptoms (40.6%), symptom worsening (10.5%), and rescue inhaler usage in the last 4 weeks (33.6%). 25% of patients were uncontrolled. The overall mean number of exacerbations in the last 12 months was 0.4, with a higher frequency of exacerbations in Step 2 patients who also experienced more exacerbations requiring treatment intensification, an emergency department visit, or hospitalization.

CONCLUSION

Mild asthma imposes a substantial burden on patients, establishing the need for comprehensive management plans and ongoing support for treatment adherence.

FUNDING

AstraZeneca.

Inflammasomes in the lung

Innate immune responses act as first line defences upon exposure to potentially noxious stimuli. The innate immune system has evolved numerous intracellular and extracellular receptors that undertake surveillance for potentially damaging particulates. Inflammasomes are intracellular innate immune multiprotein complexes that form and are activated following interaction with these stimuli. Inflammasome activation leads to the cleavage of pro-IL-1β and release of the pro-inflammatory cytokine, IL-1β, which initiates acute phase pro-inflammatory responses, and other responses are also involved (IL-18, pyroptosis). However, excessive activation of inflammasomes can result in chronic inflammation, which has been implicated in a range of chronic inflammatory diseases. The airways are constantly exposed to a wide variety of stimuli. Inflammasome activation and downstream responses clears these stimuli. However, excessive activation may drive the pathogenesis of chronic respiratory diseases such as severe asthma and chronic obstructive pulmonary disease. Thus, there is currently intense interest in the role of inflammasomes in chronic inflammatory lung diseases and in their potential for therapeutic targeting. Here we review the known associations between inflammasome-mediated responses and the development and exacerbation of chronic lung diseases.

The SYGMA programme of phase 3 trials to evaluate the efficacy and safety of budesonide/formoterol given 'as needed' in mild asthma: study protocols for two randomised controlled trials

Background

In many patients with mild asthma, the low frequency of symptoms and the episodic nature of exacerbations make adherence to regular maintenance treatment difficult. This often leads to over-reliance on short-acting β₂-agonist (SABA) reliever medication and under-treatment of the underlying inflammation, with poor control of asthma symptoms and increased risk of exacerbations. The use of budesonide/formoterol ‘as needed’ in response to symptoms may represent an alternative treatment option for patients with mild asthma.

Methods/design

The SYmbicort Given as needed in Mild Asthma (SYGMA) programme consists of two 52-week, double-blind, randomised, multicentre, parallel-group, phase 3 trials of patients aged 12 years and older with a clinical diagnosis of asthma for at least 6 months, who would qualify for treatment with regular inhaled corticosteroids (ICS). SYGMA1 aims to recruit 3750 patients who will be randomised to placebo twice daily (bid) plus as-needed budesonide/formoterol 160/4.5 μg, placebo bid plus as-needed terbutaline 0.4 mg, or budesonide 200 μg bid plus as-needed terbutaline 0.4 mg. The primary objective is to demonstrate the superiority of as-needed budesonide/formoterol over as-needed terbutaline for asthma control, as measured by well-controlled asthma weeks; a secondary objective is to establish the noninferiority of as-needed budesonide/formoterol versus maintenance budesonide plus as-needed terbutaline using the same outcome measure. SYGMA2 aims to recruit 4114 patients who will be randomised to placebo bid plus as-needed budesonide/formoterol 160/4.5 μg, or budesonide 200 μg bid plus as-needed terbutaline 0.4 mg. The primary objective is to demonstrate the noninferiority of as-needed budesonide/formoterol over budesonide bid plus as-needed terbutaline as measured by the annualised severe exacerbation rate. In both studies, use of all blinded study inhalers will be recorded electronically using Turbuhaler® Usage Monitors.

Discussion

Given the known risks of mild asthma, and known poor adherence with regular inhaled corticosteroids, the results of the SYGMA programme will help to determine the efficacy and safety of as-needed budesonide/formoterol therapy in mild asthma. Patient recruitment is complete, and completion of the phase 3 studies is planned in 2017.

Trial registration

ClinicalTrials.gov identifiers: NCT02149199 SYGMA1 and NCT02224157 SYGMA2. Registered on 16 May 2014 and 19 August 2014, respectively.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1731-4) contains supplementary material, which is available to authorized users.

Impact of adherence to treatment with fluticasone propionate/salmeterol in asthma patients

OBJECTIVE

Low adherence with asthma treatment may be associated with suboptimal outcomes and hence create a treatment gap in the real-life setting. The objective of this study was to assess the long-term association between adherence to treatment with fixed-dose fluticasone propionate/salmeterol (FSC) and the risk of exacerbations and health care utilization in patients with asthma.

RESEARCH DESIGN AND METHODS

Observational single cohort study utilizing the Quebec Health Insurance databases. All patients (age >12 years) with a diagnosis of asthma (ICD9-CM 493.xx) between 2001 and 2010 were entered into the study cohort at the time of their first prescription for FSC at any dose. Follow-up continued to the last known claim or death. Adherence to treatment was ascertained as compliance (medication possession ratio ≥80%) and persistence (absence of treatment gap ≥30 days).

MAIN OUTCOME MEASURES

Outcomes assessed were exacerbations defined as one of the following: use of oral corticosteroid (OCS), emergency room (ER) visit for asthma or hospitalization for asthma. Asthma related health care resource utilizations ascertained were number of prescription claims for rescue medications, ER visits, hospitalizations, intensive care unit (ICU) stay, intubations, and general practitioner (GP) and respirologist visits.

RESULTS

A total of 19,126 patients were included in the study. The proportion of compliant and persistent patients were 42.7% and 29.3% respectively. Multivariate logistic regression analyses showed a significantly reduced adjusted odds of exacerbations for compliant (OR = 0.48; 95% CI: 0.44-0.54) and persistent patients (OR = 0.42; 95% CI: 0.38-0.48). Similarly, significantly lower rates of health care utilization were observed for compliant and persistent patients.

CONCLUSIONS

The results of this large population-based study have shown that increased adherence to treatment with FSC is associated with lower risk for exacerbations, lower rescue medication use and lower health care utilization in asthma patients. Despite the typical limitations of an administrative database study including validity of the diagnosis, the fact that compliance and persistence are calculated based on filled claims which does not guarantee that the patients actually took their medications, and the absence of clinical and laboratory data, the findings have implications for physician and patient awareness of the importance of adherence in the management of asthma.

Airway inflammation and bronchial hyperreactivity in steroid naive children with intermittent and mild persistent asthma

BACKGROUND

Intermittent and mild persistent asthma are defined according to symptom frequency and spirometry and treated differently. To our knowledge, there is no study comparing airway inflammation between intermittent and mild persistent asthmatic children.

MATERIALS AND METHODS

Children aged 7-16 years, referred to our pediatric allergy clinic for recurrent respiratory complaints underwent a detailed clinical history and spirometry with reversibility. None of the subjects had been using regular anti-inflammatory treatment. After a 2-week run-in period during which asthma symptoms were recorded, exhaled NO measurement, bronchial provocation test with adenosine monophosphate and methacholine and sputum induction were performed. Data of patients with intermittent and mild persistent asthma and a control group were compared.

RESULTS

Thirty intermittent, 26 mild persistent asthmatic children, and 21 control subjects were studied. Sputum was obtained from 19 of intermittent asthmatics (63.3%), 18 of mild persistent asthmatics (69.2%), and 13 of control subjects (61.9%). Eosinophil count and exhaled nitric oxide were not different between asthmatic groups. Neutrophil count of children with mild persistent asthma was higher than the intermittent asthmatic group (P = 0.003). Geometric mean of PC20 methacoline values were not different between groups (P = 0.058). Geometric mean of PC20 AMP was lower among patients with mild persistent asthma (P = 0.102).

CONCLUSION

Eosinophilic airway inflammation and direct BHR may not be significantly different in intermittent asthmatic children from their peers with mild persistent disease. Neutrophilic airway inflammation and BHR to an indirect stimuli are more pronounced in the mild persistent group.

Mobile health applications for the most prevalent conditions by the World Health Organization: review and analysis

BACKGROUND

New possibilities for mHealth have arisen by means of the latest advances in mobile communications and technologies. With more than 1 billion smartphones and 100 million tablets around the world, these devices can be a valuable tool in health care management. Every aid for health care is welcome and necessary as shown by the more than 50 million estimated deaths caused by illnesses or health conditions in 2008. Some of these conditions have additional importance depending on their prevalence.

OBJECTIVE

To study the existing applications for mobile devices exclusively dedicated to the eight most prevalent health conditions by the latest update (2004) of the Global Burden of Disease (GBD) of the World Health Organization (WHO): iron-deficiency anemia, hearing loss, migraine, low vision, asthma, diabetes mellitus, osteoarthritis (OA), and unipolar depressive disorders.

METHODS

Two reviews have been carried out. The first one is a review of mobile applications in published articles retrieved from the following systems: IEEE Xplore, Scopus, ScienceDirect, Web of Knowledge, and PubMed. The second review is carried out by searching the most important commercial app stores: Google play, iTunes, BlackBerry World, Windows Phone Apps+Games, and Nokia's Ovi store. Finally, two applications for each condition, one for each review, were selected for an in-depth analysis.

RESULTS

Search queries up to April 2013 located 247 papers and more than 3673 apps related to the most prevalent conditions. The conditions in descending order by the number of applications found in literature are diabetes, asthma, depression, hearing loss, low vision, OA, anemia, and migraine. However when ordered by the number of commercial apps found, the list is diabetes, depression, migraine, asthma, low vision, hearing loss, OA, and anemia. Excluding OA from the former list, the four most prevalent conditions have fewer apps and research than the final four. Several results are extracted from the in-depth analysis: most of the apps are designed for monitoring, assisting, or informing about the condition. Typically an Internet connection is not required, and most of the apps are aimed for the general public and for nonclinical use. The preferred type of data visualization is text followed by charts and pictures. Assistive and monitoring apps are shown to be frequently used, whereas informative and educational apps are only occasionally used.

CONCLUSIONS

Distribution of work on mobile applications is not equal for the eight most prevalent conditions. Whereas some conditions such as diabetes and depression have an overwhelming number of apps and research, there is a lack of apps related to other conditions, such as anemia, hearing loss, or low vision, which must be filled.