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Pitrez PM, Nanthapisal S, Castro APBM, Teli C, P G A. Managing moderate-to-severe paediatric asthma: a scoping review of the efficacy and safety of fluticasone propionate/salmeterol. BMJ Open Respir Res 2023; 10:e001706. [PMID: 37620110 PMCID: PMC10450074 DOI: 10.1136/bmjresp-2023-001706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Fluticasone propionate/salmeterol xinafoate (FP/SAL) is an inhaled corticosteroid (ICS) and long-acting β2-agonist (LABA) combination, indicated for the regular treatment of children (aged >4 years) with asthma that is inadequately controlled with ICS monotherapy plus as-needed short-acting β2-agonists, or already adequately controlled with ICS/LABA. OBJECTIVE Compared with the adult population, fewer clinical studies have investigated the efficacy of FP/SAL in paediatric patients with moderate and moderate-to-severe asthma. In this review, we synthesise the available evidence for the efficacy and safety of FP/SAL in the paediatric population, compared with other available therapies indicated for asthma in children. ELIGIBILITY CRITERIA A literature review identified randomised controlled trials and observational studies of FP/SAL in the paediatric population with moderate-to-severe asthma. SOURCES OF EVIDENCE The Medline database was searched using PubMed (https://pubmed.ncbi.nlm.nih.gov/), with no publication date restrictions. Search strategies were developed and refined by authors. CHARTING METHODS Selected articles were screened for clinical outcome data (exacerbation reduction, nocturnal awakenings, lung function, symptom control, rescue medication use and safety) and a table of key parameters developed. RESULTS Improvements in asthma outcomes with FP/SAL include reduced risk of asthma-related emergency department visits and hospitalisations, protection against exercise-induced asthma and improvements in measures of lung function. Compared with FP monotherapy, greater improvements in measures of lung function and asthma control are reported. In addition, reduced incidence of exacerbations, hospitalisations and rescue medication use is observed with FP/SAL compared with ICS and leukotriene receptor antagonist therapy. Furthermore, FP/SAL therapy can reduce exposure to both inhaled and oral corticosteroids. CONCLUSIONS FP/SAL is a reliable treatment option in patients not achieving control with ICS monotherapy or a different ICS/LABA combination. Evidence shows that FP/SAL is well tolerated and has a similar safety profile to FP monotherapy. Thus, FP/SAL provides an effective option for the management of moderate-to-severe asthma in the paediatric population.
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Affiliation(s)
- Paulo Marcio Pitrez
- Pediatric Pulmonology Division, Hospital Santa Casa de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Sira Nanthapisal
- Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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2
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Hoggins R, Velpula M, Woodward S, Tighe MP. How to use the fractional exhaled nitric oxide test. Arch Dis Child Educ Pract Ed 2022; 107:133-140. [PMID: 34344763 PMCID: PMC8938658 DOI: 10.1136/archdischild-2019-318326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
Measurement of fractional exhaled nitric oxide (FeNO) has become a mainstream, NICE-recommended, objective test of asthma severity. We explore the uses and practical issues with the FeNO test using clinically relevant questions for general paediatricians.
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Affiliation(s)
- Rhiannon Hoggins
- Paediatrics, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Madhavi Velpula
- Paediatrics, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Susan Woodward
- Paediatrics, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Mark Peter Tighe
- Paediatrics, University Hospitals Dorset NHS Foundation Trust, Poole, UK
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Hon KL, Bao YM, Chan KC, Chau KW, Chen RS, Cheok KTG, Chiu WK, Deng L, He CH, Ieong KM, Kung JSC, Lam P, Lam SYD, Lee QU, Lee SL, Leung TF, Leung TNH, Shi L, Siu KK, Tan WP, Wang MH, Wong TW, Wu BJ, Yip AYF, Zheng YJ, Ng DK. Determinants for asthma control, quality of life and use of complementary and alternative medicine in asthmatic pediatric patients in four cities. World J Pediatr 2018; 14:482-491. [PMID: 30047047 DOI: 10.1007/s12519-018-0167-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 05/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Asthma is a significant chronic health problem worldwide. Management aims at disease control by reducing functional impairment and exacerbations and improving quality of life (QoL). We report a multi-center study to survey asthma control and QoL in four cities in the Pearl River Delta. METHODS The conjoint survey involved ten Hong Kong pediatric hospitals/units, two Shenzhen hospitals, two Macau hospitals, and two Guangzhou hospitals on asthma control (using Asthma Control Test) and QoL (Pediatric Allergic Disease Quality of Life Questionnaire, PADQLQ). Acceptability of a treatment is graded as very good/good/fair/poor. RESULTS Good asthma control was only reported in 80% subjects in Hong Kong, but higher in sister cities (85-94%, P < 0.001). Allergic rhinitis, "incense burning", and "smoker in family" were prevalent among the four cities. Logistic regression showed better control of asthma was associated with better PADQLQ (B = - 0.029, P < 0.001), better acceptability of bronchodilator (B = - 1.488, P = 0.025), negatively with "smoker in family" (B = - 0.83, P = 0.015) and various PADQLQ domains. Conversely, worse PADQLQ was associated with allergic rhinitis severity (B = 4.77, P < 0.001), poor control of asthma (B = 7.56, P < 0.001), increased frequency of traditional Chinese medicine use (B = 1.7, P < 0.05), increased frequency of bronchodilator usage (B = 1.05, P < 0.05), "smoker in family" (B = 4.05, P < 0.05), and incense burning at home (B = 3.9, P < 0.05). CONCLUSIONS There are some clinical and cultural differences among the four southern Chinese cities within the Guangdong province. This study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and QoL for health-care interventions. Having a smoker in the family is independently associated with poor asthma control and QoL.
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Affiliation(s)
- Kam Lun Hon
- Department of Pediatrics, The Chinese University of Hong Kong 6/F Prince of Wales Hospital, Room 84042, Shatin, N.T, Hong Kong SAR, China.
| | - Yan Min Bao
- Department of Respiratory Diseases, Shenzhen Children's Hospital, Shenzhen, 518026, China
| | - Kate C Chan
- Department of Pediatrics, The Chinese University of Hong Kong 6/F Prince of Wales Hospital, Room 84042, Shatin, N.T, Hong Kong SAR, China
| | - Kin Wai Chau
- Hong Kong Society of Pediatric Respirology and Allergy, Hong Kong SAR, China.,Pediatric Respiratory and Sleep Disorders Center, Room 1315D, Argyle Centre Phase 1, 688 Nathan Road, Mongkok, Kowloon, Hong Kong SAR, China
| | - Rong-Shan Chen
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China
| | | | - Wa Keung Chiu
- Department of Pediatrics and Adolescent Medicine, United Christian Hospital, 130, Hip Wo Street, Kwun Tong, Hong Kong SAR, China
| | - Li Deng
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China
| | - Chun-Hui He
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China
| | - Kin Mui Ieong
- Department of Pediatrics, Central Hospital Conde S. Januario, Macau, China
| | - Jeng Sum C Kung
- Department of Pediatrics, The Chinese University of Hong Kong 6/F Prince of Wales Hospital, Room 84042, Shatin, N.T, Hong Kong SAR, China
| | - Ping Lam
- Department of Pediatrics and Adolescent Medicine, Caritas Medical Center, 111, Wing Hong Street, Sham Shui Po, Hong Kong SAR, China
| | - Shu Yan David Lam
- Department of Pediatrics and Adolescent Medicine, Tuen Mun Hospital, 23 Tsing Chung Koon Road,Tuen Mun, New Territories, Hong Kong SAR, China
| | - Qun Ui Lee
- Department of Pediatrics and Adolescent Medicine, Princess Margaret Hospital, 2-10 Princess Margaret Hospital Road, Lai Chi Kok, Kowloon, Hong Kong SAR, China
| | - So Lun Lee
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, 102, Pokfulam Road, Hong Kong SAR, China.,Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ting Fan Leung
- Department of Pediatrics, The Chinese University of Hong Kong 6/F Prince of Wales Hospital, Room 84042, Shatin, N.T, Hong Kong SAR, China
| | - Theresa N H Leung
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong SAR, China.,Department of Pediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, 3, Lok Man Road, Chaiwan, Hong Kong SAR, China.,Department of Pediatrics, The University of Hong Kong-Shenzhen Hospital, 1, Haiyuan 1st Road, Futian, Shenzhen, China
| | - Lei Shi
- Department of Pediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, 3, Lok Man Road, Chaiwan, Hong Kong SAR, China
| | - Ka Ka Siu
- Department of Pediatrics, The University of Hong Kong-Shenzhen Hospital, 1, Haiyuan 1st Road, Futian, Shenzhen, China
| | - Wei-Ping Tan
- Department of Pediatrics and Adolescent Medicine, Kwong Wah Hospital, 25 Waterloo Road, KLN Hong Kong SAR, China
| | - Maggie Haitian Wang
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China.,JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Tak Wai Wong
- Department of Pediatrics and Adolescent Medicine, Alice Ho Miu Ling Nethersole Hospital, 11, Chuen On Road, Tai Po, Hong Kong SAR, China
| | - Bao-Jing Wu
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Ada Y F Yip
- Department of Pediatrics and Adolescent Medicine, Kwong Wah Hospital, 25 Waterloo Road, KLN Hong Kong SAR, China
| | - Yue-Jie Zheng
- Department of Respiratory Diseases, Shenzhen Children's Hospital, Shenzhen, 518026, China
| | - Daniel K Ng
- Department of Pediatrics and Adolescent Medicine, Kwong Wah Hospital, 25 Waterloo Road, KLN Hong Kong SAR, China
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Abstract
Abstract
Background: The prevalence of asthma has increased significantly in Thailand. Budesonide/formoterol maintenance and reliever therapy has been available for several years. However, cost-effectiveness of such treatment has never been examined in Thailand. Objective: Design a cost-effectiveness (CE) analysis conducted from a Thai healthcare perspective as a piggyback study accompanying a recent clinical trial. Methods: The CE analysis was conducted from the healthcare provider’s perspective. Data were collected from a six-month, double-blind, multi-national study involving 3321 symptomatic asthma patients randomized to either: bud/form maintenance and reliever therapy, bud/form 320/9 μg bid plus terbutaline as needed, or salmeterol/ fluticasone (salm/flut) 25/125 μg two inhalations bid plus terbutaline as needed. Efficacy was determined as the number of exacerbations per patient during a six-month period. Thai unit costs were collected from the national sources and expert opinions, and applied to the resource use data for a deterministic economic evaluation. Results: There were significantly fewer exacerbations in the bud/form maintenance and reliever therapy (0.12 events/patient/6 months) group vs. the bud/form (0.16 events/patient/6 months, p <0.01), or salm/flut groups (0.19 events/patient/6 months, p <0.001). Total direct costs (healthcare visits and drug costs) were 27.0% and 5.9% lower in the bud/form maintenance and reliever therapy group than in the bud/form and salm/flut groups, respectively. Conclusion: Bud/form maintenance and reliever therapy was associated with significantly fewer exacerbations, compared to other fixed combination treatments in a recent multi-national clinical trial. This might result in lower direct costs if applied to the Thai healthcare system.
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Harnan SE, Tappenden P, Essat M, Gomersall T, Minton J, Wong R, Pavord I, Everard M, Lawson R. Measurement of exhaled nitric oxide concentration in asthma: a systematic review and economic evaluation of NIOX MINO, NIOX VERO and NObreath. Health Technol Assess 2016; 19:1-330. [PMID: 26484874 DOI: 10.3310/hta19820] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND High fractions of exhaled nitric oxide (FeNO) in the breath of patients with symptoms of asthma are correlated with high levels of eosinophils and indicate that a patient is likely to respond to inhaled corticosteroids. This may have a role in the diagnosis and management of asthma. OBJECTIVE To assess the diagnostic accuracy, clinical effectiveness and cost-effectiveness of the hand-held electrochemical devices NIOX MINO(®) (Aerocrine, Solna, Sweden), NIOX VERO(®) (Aerocrine) and NObreath(®) (Bedfont Scientific, Maidstone, UK) for the diagnosis and management of asthma. DATA SOURCES Systematic searches were carried out between March 2013 and April 2013 from database inception. Databases searched included MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, Science Citation Index Expanded and Conference Proceedings Citation Index - Science. Trial registers such as ClinicalTrials.gov and the metaRegister of Controlled Trials were also searched in March 2013. All searches were updated in September 2013. REVIEW METHODS A rapid review was conducted to assess the equivalence of hand-held and chemiluminescent FeNO monitors. Systematic reviews of diagnostic accuracy and management efficacy were conducted. A systematic review of economic analyses was also conducted and two de novo health economic models were developed. All three reviews were undertaken according to robust high-quality methodology. RESULTS The rapid review (27 studies) found varying levels of agreement between monitors (Bland-Altman 95% limits of agreement up to ±10 parts per billion), with better agreement at lower FeNO values. Correlation was good (generally r > 0.9). The diagnostic accuracy review identified 22 studies in adults (all ages) and four in children. No studies used NObreath or NIOX VERO and seven used NIOX MINO. Estimates of diagnostic accuracy varied widely. FeNO used in combination with another test altered diagnostic accuracy only slightly. High levels of heterogeneity precluded meta-analysis. Limited observations included that FeNO may be more reliable and useful as a rule-in than as a rule-out test; lower cut-off values in children and in smokers may be appropriate; and FeNO may be less reliable in the elderly. The management review identified five randomised controlled trials in adults, one in pregnant asthmatics and seven in children. Despite clinical heterogeneity, exacerbation rates were lower in all studies but not generally statistically significantly so. Effects on inhaled corticosteroid (ICS) use were inconsistent, possibly because of differences in management protocols, differential effectiveness in adults and children and differences in population severity. One UK diagnostic model and one management model were identified. Aerocrine also submitted diagnostic and management models. All had significant limitations including short time horizons and the selective use of efficacy evidence. The de novo diagnostic model suggested that the expected difference in quality-adjusted life-year (QALY) gains between diagnostic options is likely to be very small. Airway hyper-responsiveness by methacholine challenge test is expected to produce the greatest QALY gain but with an expected incremental cost-effectiveness ratio (ICER) compared with FeNO (NObreath) in combination with bronchodilator reversibility of £1.125M per QALY gained. All remaining options are expected to be dominated. The de novo management model indicates that the ICER of guidelines plus FeNO monitoring using NObreath compared with guidelines alone in children is expected to be approximately £45,200 per QALY gained. Within the adult subgroup, FeNO monitoring using NObreath compared with guidelines alone is expected to have an ICER of approximately £2100 per QALY gained. The results are particularly sensitive to assumptions regarding changes in ICS use over time, the number of nurse visits for FeNO monitoring and duration of effect. CONCLUSIONS Limitations of the evidence base impose considerable uncertainty on all analyses. Equivalence of devices was assumed but not assured. Evidence for diagnosis is difficult to interpret in the context of inserting FeNO monitoring into a diagnostic pathway. Evidence for management is also inconclusive, but largely consistent with FeNO monitoring resulting in fewer exacerbations, with a small or zero reduction in ICS use in adults and a possible increased ICS use in children or patients with more severe asthma. It is unclear which specific management protocol is likely to be most effective. The economic analysis indicates that FeNO monitoring could have value in diagnostic and management settings. The diagnostic model indicates that FeNO monitoring plus bronchodilator reversibility dominates many other diagnostic tests. FeNO-guided management has the potential to be cost-effective, although this is largely dependent on the duration of effect. The conclusions drawn from both models require strong technical value judgements with respect to several aspects of the decision problem in which little or no empirical evidence exists. There are many potential directions for further work, including investigations into which management protocol is best and long-term follow-up in both diagnosis and management studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013004149. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Sue E Harnan
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Munira Essat
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tim Gomersall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jon Minton
- Advanced Quantitative Methods Network (AQMEN), University of Glasgow, Glasgow, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ian Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mark Everard
- School of Paediatrics and Child Health, University of Western Australia, Princess Margaret Hospital, WA, Australia
| | - Rod Lawson
- Department of Respiratory Medicine, Royal Hallamshire Hospital, Sheffield, UK
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Price DB, Colice G, Israel E, Roche N, Postma DS, Guilbert TW, van Aalderen WM, Grigg J, Hillyer EV, Thomas V, Martin RJ. Add-on LABA in a separate inhaler as asthma step-up therapy versus increased dose of ICS or ICS/LABA combination inhaler. ERJ Open Res 2016; 2:00106-2015. [PMID: 27730200 PMCID: PMC5005184 DOI: 10.1183/23120541.00106-2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/09/2016] [Indexed: 01/01/2023] Open
Abstract
Asthma management guidelines recommend adding a long-acting β2-agonist (LABA) or increasing the dose of inhaled corticosteroid (ICS) as step-up therapy for patients with uncontrolled asthma on ICS monotherapy. However, it is uncertain which option works best, which ICS particle size is most effective, and whether LABA should be administered by separate or combination inhalers. This historical, matched cohort study compared asthma-related outcomes for patients (aged 12-80 years) prescribed step-up therapy as a ≥50% extrafine ICS dose increase or add-on LABA, via either a separate inhaler or a fine-particle ICS/LABA fixed-dose combination (FDC) inhaler. Risk-domain asthma control was the primary end-point in comparisons of cohorts matched for asthma severity and control during the baseline year. After 1:2 cohort matching, the increased extrafine ICS versus separate ICS+LABA cohorts included 3232 and 6464 patients, respectively, and the fine-particle ICS/LABA FDC versus separate ICS+LABA cohorts included 7529 and 15 058 patients, respectively (overall mean age 42 years; 61-62% females). Over one outcome year, adjusted OR (95% CI) for achieving asthma control were 1.25 (1.13-1.38) for increased ICS versus separate ICS+LABA and 1.06 (1.05-1.09) for ICS/LABA FDC versus separate ICS+LABA. For patients with asthma, increased dose of extrafine-particle ICS, or add-on LABA via ICS/LABA combination inhaler, is associated with significantly better outcomes than ICS+LABA via separate inhalers.
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Affiliation(s)
- David B. Price
- Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Gene Colice
- Washington Hospital Center and George Washington University School of Medicine, Washington, DC, USA
| | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicolas Roche
- University Paris Descartes (EA2511), Cochin Hospital Group (AP-HP), Paris, France
| | - Dirkje S. Postma
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Jonathan Grigg
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Victoria Thomas
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Richard J. Martin
- National Jewish Health and the University of Colorado Denver, Denver, CO, USA
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Takeuchi M, Kano H, Takahashi K, Iwata T. Comparative effectiveness of inhaled corticosteroids for paediatric asthma: protocol for a systematic review and Bayesian network meta-analysis. BMJ Open 2015; 5:e008501. [PMID: 26493456 PMCID: PMC4620167 DOI: 10.1136/bmjopen-2015-008501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Use of inhaled corticosteroid (ICS) is the mainstream maintenance therapy for paediatric asthma. Several forms of ICS are available, but the relative effectiveness among ICS has not been well investigated in published, randomised, controlled trials. The paucity of direct comparisons between ICS may have resulted in insufficient estimation in former systematic reviews/meta-analyses. To supplement the information on the comparative effectiveness of ICS for paediatric asthma, we plan to conduct a network meta-analysis that will enable summary of direct and indirect evidence. METHODS AND ANALYSIS We will retrieve randomised, controlled trials that examined the effectiveness of ICS for paediatric asthma from the PubMed and Cochrane Central Register of Controlled Trials. After one author scans the title and abstract for eligible studies, two authors will independently review study data and assess the quality of the study. Studies of children (≤18 years old) with chronic asthma or recurrent wheezing episodes will be included if they used ICS for ≥4 weeks. We will define a priori core outcomes and supplemental outcomes of paediatric asthma, including exacerbation, healthcare use and pulmonary function. Studies reporting a minimum of one core outcome will be entered into the systematic review. After the systematic review is performed, extracted data of relevant studies will be synthesised in the Bayesian framework using a random-effects model. ETHICS AND DISSEMINATION The results will be disseminated through peer-reviewed publications and conference presentations. PROTOCOL REGISTRATION NUMBER UMIN (000016724) and PROSPERO (CRD42015025889).
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Affiliation(s)
- Masato Takeuchi
- Department of Pediatrics, Kikkoman General Hospital, Noda, Chiba, Japan
| | - Hirotsugu Kano
- Department of Pediatrics, Teikyo University School of Medicine University Hospital-Mizonokuchi, Kawasaki, Kanagawa, Japan
| | - Kenzo Takahashi
- Graduate School of Public Health, Teikyo University, Itabashi, Tokyo, Japan
| | - Tsutomu Iwata
- Faculty of Child Studies, Department of Education for Childcare, Tokyo Kasei University, Sayama, Saitama, Japan
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Martin RJ, Price D, Roche N, Israel E, van Aalderen WMC, Grigg J, Postma DS, Guilbert TW, Hillyer EV, Burden A, von Ziegenweidt J, Colice G. Cost-effectiveness of initiating extrafine- or standard size-particle inhaled corticosteroid for asthma in two health-care systems: a retrospective matched cohort study. NPJ Prim Care Respir Med 2014; 24:14081. [PMID: 25297072 PMCID: PMC4373495 DOI: 10.1038/npjpcrm.2014.81] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/13/2014] [Accepted: 08/30/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Real-life studies are needed to determine the cost-effectiveness of asthma therapies in clinical practice. AIM To compare the cost-effectiveness of extrafine-particle inhaled corticosteroid (ICS) with standard size-particle ICS in the United Kingdom (UK) and United States (US). METHODS These retrospective matched cohort analyses used large electronic databases to study asthma-related outcomes for patients in the UK (12-60 years old; n=1730) and US (12-80 years; n=10,312) prescribed extrafine beclomethasone or fluticasone as their first ICS therapy for asthma. Patients were matched on demographic characteristics and asthma severity during 1 baseline year, and asthma control and asthma-related costs were compared during 1 outcome year. RESULTS In both the UK and US, adjusted odds of risk-domain asthma control were similar, whereas the odds of overall control (no hospitalisation or oral steroids for asthma, no antibiotics for lower respiratory infection, limited reliever use) were greater for extrafine ICS in both countries (UK odds ratio, 1.23; 95% confidence interval (CI), 1.01-1.50). Asthma-related annual costs, adjusted for baseline, were significantly lower for extrafine-particle ICS cohorts in both countries (UK difference, -£66 (95% CI,-93 to -37)). Cost-effectiveness analyses using the two measures of asthma control found 92 and 98% probabilities of extrafine-particle ICS being the preferred treatment strategy (less costly and more effective than standard size-particle ICS) in the UK, and 84 and 100% probabilities in the US. CONCLUSIONS Initiating ICS therapy for asthma as extrafine-particle ICS seems the dominant treatment option (less costly and more effective) compared with standard size-particle ICS in both the UK and the US.
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Affiliation(s)
| | - David Price
- Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Research in Real Life, Ltd, Cambridge, UK
| | - Nicolas Roche
- Cochin Hospital Group, AP-HP, University of Paris Descartes, Paris, France
| | - Elliot Israel
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Jonathan Grigg
- Blizard Institute, Queen Mary University of London, London, UK
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | - Gene Colice
- Washington Hospital Center and George Washington University School of Medicine, Washington, DC, USA
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9
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Molinari G, Colombo G, Celenza C. Respiratory allergies: a general overview of remedies, delivery systems, and the need to progress. ISRN ALLERGY 2014; 2014:326980. [PMID: 25006500 PMCID: PMC3972928 DOI: 10.1155/2014/326980] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 12/24/2013] [Indexed: 01/10/2023]
Abstract
The spread of respiratory allergies is increasing in parallel with the alarm of the scientific community. Evidently, our knowledge of the onset mechanisms of these diseases and, as a consequence, of the available remedies is inadequate. This review provides a brief, general description of current therapeutic resources and the state of research with regard to both drugs and medical devices in order to highlight their limits and the urgent need for progress. Increasing the amount of basic biochemical research will improve our knowledge of such onset mechanisms and the potential efficacy of therapeutic preparations.
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Affiliation(s)
- Giuliano Molinari
- Biochemistry Consulting Service, Giuliano Molinari, 20017 Rho, Milan, Italy
| | - Giselda Colombo
- Allergy and Immunology Unit, San Raffaele Hospital, 20132 Milan, Italy
| | - Cinzia Celenza
- Quality Assurance Service, Sandoz S.P.A., 21040 Origgio, Varese, Italy
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Abstract
Glucocorticoids modulate the secretion of growth hormone (GH) by various and competing effects on the hypothalamus and pituitary gland. The final effects of this modulation depend on hormone concentrations and the duration of exposure. The traditional hypothesis is that chronically raised levels of glucocorticoids suppress the secretion of GH. However, a functional impairment of the GH reserve might also be observed in patients with low levels of glucocorticoids, such as those with secondary hypoadrenalism, which is consistent with the model of biphasic dose-dependent effects of glucocorticoids on the somatotropic axis. This Review updates our current understanding of the mechanisms underlying the effects of glucocorticoids on the secretion of GH and the clinical implications of the dual action of glucocorticoids on the GH reserve in humans. This Review will also address the potential diagnostic and therapeutic implications of GH for patients with a deficiency or excess of glucocorticoids.
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Affiliation(s)
- Gherardo Mazziotti
- Department of Medicine, Endocrine and Bone Unit, Azienda Ospedaliera Carlo Poma of Mantua, 46100 Mantua, Italy
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Abstract
Asthma is a prevalent health condition in children, with economic implications for the individual and their family, as well as for societies with nationalized healthcare. Pharmaceutical cost is the main driver of healthcare expenditure in asthma. Existent explicit guidelines are meant to guide asthma management across all age groups, but they are failing. Pharmacologic management of asthma consists of a stepwise treatment approach to achieve symptom control. Various studies suggest a significant number of medical practitioners are prescribing inhaled corticosteroids (ICS) and ICS/long-acting beta agonist (LABA) combination inhalers inappropriately, including prescribing high doses of ICS without specialist consultation. ICS/LABA combination inhalers should only be used in persistent asthmatics, which account for approximately 5% of all children with asthma. Despite this, there is an increase in prescribing rates of ICS/LABA combination inhalers in the context of a decrease in the prevalence of asthma. Furthermore, there is inappropriate prescribing of ICS/LABA combination inhalers in children under 5 years of age, and initiation of relatively more expensive ICS/LABA combination inhalers in patients who have not previously been prescribed ICS. There is evidence to suggest that cost is a significant barrier to asthma management, especially for the more expensive ICS/LABA combination inhalers. Hence, prescribing cost-effective asthma medications appropriately is one of the most important strategies in reducing the morbidity and mortality associated with asthma. It is incumbent on every medical practitioner to not prescribe expensive medications if not indicated, both for the sake of the patient and for society.
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Affiliation(s)
- Sandra Chuang
- Respiratory Department, Sydney Childrens Hospital, Randwick, Sydney, NSW, Australia.
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12
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Papadopoulos NG, Arakawa H, Carlsen KH, Custovic A, Gern J, Lemanske R, Le Souef P, Mäkelä M, Roberts G, Wong G, Zar H, Akdis CA, Bacharier LB, Baraldi E, van Bever HP, de Blic J, Boner A, Burks W, Casale TB, Castro-Rodriguez JA, Chen YZ, El-Gamal YM, Everard ML, Frischer T, Geller M, Gereda J, Goh DY, Guilbert TW, Hedlin G, Heymann PW, Hong SJ, Hossny EM, Huang JL, Jackson DJ, de Jongste JC, Kalayci O, Aït-Khaled N, Kling S, Kuna P, Lau S, Ledford DK, Lee SI, Liu AH, Lockey RF, Lødrup-Carlsen K, Lötvall J, Morikawa A, Nieto A, Paramesh H, Pawankar R, Pohunek P, Pongracic J, Price D, Robertson C, Rosario N, Rossenwasser LJ, Sly PD, Stein R, Stick S, Szefler S, Taussig LM, Valovirta E, Vichyanond P, Wallace D, Weinberg E, Wennergren G, Wildhaber J, Zeiger RS. International consensus on (ICON) pediatric asthma. Allergy 2012; 67:976-97. [PMID: 22702533 PMCID: PMC4442800 DOI: 10.1111/j.1398-9995.2012.02865.x] [Citation(s) in RCA: 259] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2012] [Indexed: 01/08/2023]
Abstract
Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.
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Affiliation(s)
- N G Papadopoulos
- Department of Allergy, 2nd Pediatric Clinic, University of Athens, Athens, Greece.
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13
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Dani C, Corsini I, Burchielli S, Cangiamila V, Romagnoli R, Jayonta B, Longini M, Paternostro F, Buonocore G. Natural Surfactant Combined with Beclomethasone Decreases Lung Inflammation in the Preterm Lamb. Respiration 2011; 82:369-76. [DOI: 10.1159/000328928] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 04/29/2011] [Indexed: 11/19/2022] Open
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Patient-reported outcomes in clinical trials of inhaled asthma medications: systematic review and research needs. Qual Life Res 2010; 20:343-57. [PMID: 20945162 DOI: 10.1007/s11136-010-9750-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To assess the diversity, application, analysis and interpretation of patient-reported outcomes (PROs) in asthma clinical trials. METHODS We critically appraised the use of asthma-specific PROs in 87 randomised controlled trials (RCTs) of inhaled asthma medications published during 1985-2006. RESULTS A total of 79 RCTs reported PROs, of which 78 (99%) assessed symptom scores and seven (9%) assessed asthma quality of life scores. Only eight (10%) used validated instruments and five (6%) provided clinical interpretation of scores. Due to heterogeneity in the reporting of symptom measures, it is not possible to determine how many discrete symptom assessment instruments have been used. Only 26 (33%) of the RCTs that measured symptom scores reported the scores for follow-up. Limited improvement occurred over time: fewer than 30% of the RCTs used validated PRO measures in any individual year. CONCLUSION Numerous validated PRO instruments are available but it is unclear why few are used in asthma clinical trials. Problems include poor reporting, and uncritical analysis and interpretation of PRO scores. Research needs include identifying and recommending a set of PROs for use in asthma clinical research and providing guidance for researchers on the application, analysis and interpretation of PRO measures in clinical trials.
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Innes AL, McGrath KW, Dougherty RH, McCulloch CE, Woodruff PG, Seibold MA, Okamoto KS, Ingmundson KJ, Solon MC, Carrington SD, Fahy JV. The H antigen at epithelial surfaces is associated with susceptibility to asthma exacerbation. Am J Respir Crit Care Med 2010; 183:189-94. [PMID: 20732988 DOI: 10.1164/rccm.201003-0488oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Acute asthma exacerbations, precipitated by viral infections, are a significant cause of morbidity, but not all patients with asthma are equally susceptible. OBJECTIVES To explore susceptibility factors for asthma exacerbations, we considered a role for histoblood group antigens because they are implicated in mechanisms of gastrointestinal viral infection, specifically the O-secretor mucin glycan phenotype. We investigated if this phenotype is associated with susceptibility to asthma exacerbation. METHODS We performed two consecutive case-control studies in subjects with asthma who were either prone or resistant to asthma exacerbations. Exacerbation-prone cases had frequent use of prednisone for an asthma exacerbation and frequent asthma-related healthcare utilization, whereas exacerbation-resistant control subjects had rarely reported asthma exacerbations. The frequency of different mucin glycan phenotypes, defined by the presence or absence of H (O), A, B, or AB antigens, was compared in cases and control subjects. MEASUREMENTS AND MAIN RESULTS In an initial study consisting of 49 subjects with asthma (23 cases and 26 control subjects), we found that having the O-secretor phenotype was associated with a 5.8-fold increase in the odds of being a case (95% confidence interval, 1.7-21.0; P = 0.006). In a replication study consisting of 204 subjects with asthma (101 cases and 103 control subjects), we found that having the O-secretor phenotype was associated with a 2.3-fold increased odds of being a case (95% confidence interval, 1.2-4.4; P = 0.02). CONCLUSIONS The O-secretor mucin glycan phenotype is associated with susceptibility to asthma exacerbation. Clinical trial registered at www.clinicaltrials.gov (NCT00201266).
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Affiliation(s)
- Anh L Innes
- The Cardiovascular Research Institute, University of California, San Francisco, California, USA
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Aalbers R. Fixed or adjustable maintenance-dose budesonide/formoterol compared with fixed maintenance-dose salmeterol/fluticasone propionate in asthma patients aged >or=16 years: post hoc analysis of a randomized, double-blind/open-label extension, parallel-group study. Clin Drug Investig 2010; 30:439-51. [PMID: 20528000 DOI: 10.2165/11533420-000000000-00000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Inhaled corticosteroid (ICS)/long-acting beta(2)-agonist (LABA) combinations are the preferred maintenance therapy for adult asthma patients uncontrolled by ICS alone. Supporting data are largely from mixed populations of adolescents and adults, although ICS/LABA combinations are not approved for adolescents in all countries. This analysis evaluates overall asthma control in asthma patients aged >or=16 years receiving ICS/LABA combinations. METHODS This was a post hoc analysis of asthma patients aged >or=16 years in a randomized, double-blind/open-label extension, parallel-group study. Patients received fixed maintenance-dose budesonide/formoterol (Symbicort Turbuhaler), fixed maintenance-dose salmeterol/fluticasone propionate (Seretide/Advair/Adoair Diskus) or adjustable maintenance-dose budesonide/formoterol. Patients used terbutaline or salbutamol for as-needed reliever medication. The primary efficacy variable was the odds of having a well controlled asthma week during the randomized treatment period. RESULTS ICS/LABA regimens were well tolerated and efficacious, and the odds for achieving a well controlled asthma week did not differ between groups in this sub-analysis. The number of exacerbations was similar between fixed-dose regimens; however, there were trends toward fewer exacerbations requiring hospitalization/emergency room treatment in the fixed- and adjustable maintenance-dose budesonide/formoterol groups (three and two events, respectively) than in the fixed-dose salmeterol/fluticasone propionate group (eight events). Improvements in forced expiratory volume in 1 second (FEV(1)) were small but significantly greater with fixed-dose budesonide/formoterol versus fixed-dose salmeterol/fluticasone propionate. CONCLUSIONS This post hoc analysis supports the use of ICS/LABA combinations in adults aged >or=16 years.
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Affiliation(s)
- René Aalbers
- Department of Pulmonology, Martini Hospital, Groningen, the Netherlands.
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Bahadori K, Quon BS, Doyle-Waters MM, Marra C, Fitzgerald JM. A systematic review of economic evaluations of therapy in asthma. J Asthma Allergy 2010; 3:33-42. [PMID: 21437038 PMCID: PMC3047905 DOI: 10.2147/jaa.s11038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Indexed: 11/23/2022] Open
Abstract
Background: Asthma’s cost-effectiveness is a major consideration in the evaluation of its treatment options. Our objective was to perform a systematic review of the cost-effectiveness of asthma medications. Methods: We performed a systematic search of MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, OHE-HEED, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessments Database, NHS Economic Evaluation Database, and Web of Science and reviewed references from key articles between 1990 and Jan 2008. Results: A total of 49 RCTs met the inclusion criteria. Maintenance therapy with inhaled corticosteroids was found to be very cost-effective and in uncontrolled asthmatics patients currently being treated with ICS, the combination of an ICS/LABA represents a safe, cost-effective treatment. The simplified strategy using budesonide and formoterol for maintenance and reliever therapy was also found to be as cost-effective as salmeterol/fluticasone plus salbutamol. Omalizumab was found to be cost-effective. An important caveat with regard to the published literature is the relatively high proportion of economic evaluations which are funded by the manufacturers of specific drug treatments. Conclusion: Future studies should be completed independent of industry support and ensure that the comparator arms within studies should include dosages of drugs that are equivalent.
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Kulus M, Hébert J, Garcia E, Fowler Taylor A, Fernandez Vidaurre C, Blogg M. Omalizumab in children with inadequately controlled severe allergic (IgE-mediated) asthma. Curr Med Res Opin 2010; 26:1285-93. [PMID: 20377320 DOI: 10.1185/03007991003771338] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many children with severe persistent allergic (IgE-mediated) asthma remain inadequately controlled despite treatment with high-dose inhaled corticosteroids (ICS) plus a long-acting beta(2)-agonist (LABA). RESEARCH AND DESIGN METHODS This pre-specified analysis of a randomized, double-blind, placebo-controlled trial evaluated the efficacy and safety of omalizumab in children (6-<12 years) with perennial allergen sensitivity, and history of asthma exacerbations and symptoms despite treatment with ICS (fluticasone >or=500 microg x day(-1) or equivalent) plus a LABA. Patients received omalizumab (75-375 mg once or twice a month by subcutaneous injection, as determined from dosing tables) or placebo over 52 weeks (24-week fixed-steroid then 28-week adjustable-steroid phases). RESULTS Out of 246 randomized patients (omalizumab, n = 166; placebo, n = 80), efficacy was analysed in 235 (omalizumab, n = 159; placebo, n = 76). Over the 24-week fixed-steroid phase, omalizumab reduced the rate of clinically significant asthma exacerbations (worsening symptoms requiring doubling of baseline ICS dose and/or systemic steroids) by 34% versus placebo (0.42 vs 0.63, rate ratio 0.662; P = 0.047). Over 52 weeks, the exacerbation rate was reduced by 50% (P < 0.001). Omalizumab had an acceptable safety profile, with no statistically significant (P < 0.05) differences in adverse events observed between omalizumab and placebo. CONCLUSION Add-on omalizumab is well-tolerated and reduces exacerbations in children (6-<12 years) with severe persistent allergic asthma, inadequately controlled despite high-dose ICS plus a LABA. It should be noted that the sample size was not based on providing statistical power in the severe subgroup, and no corrections were made for multiple comparisons; however, outcomes consistently favoured omalizumab.
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Affiliation(s)
- M Kulus
- Medical University of Warsaw, Warsaw, Poland.
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Dani C, Corsini I, Burchielli S, Cangiamila V, Longini M, Paternostro F, Buonocore G, Rubaltelli FF. Natural surfactant combined with beclomethasone decreases oxidative lung injury in the preterm lamb. Pediatr Pulmonol 2009; 44:1159-67. [PMID: 19911365 DOI: 10.1002/ppul.21145] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We performed a randomized study in preterm lambs to assess the hypothesis that the treatment with natural surfactant combined with beclomethasone might decrease pulmonary oxidative stress in an animal model of respiratory distress syndrome (RDS). Animals received 200 mg/kg of porcine natural surfactant or 200 mg/kg of natural surfactant combined with 400 or 800 microg/kg of beclomethasone. Lung tissue oxidation was studied by measuring total hydroperoxide (TH), advanced oxidation protein products (AOPP), and non-protein bound iron (NPBI) in bronchial aspirate samples. In addition, lung mechanics was evaluated. TH was lower in the groups treated with surfactant plus 400 or 800 microg/kg of beclomethasone than in the surfactant group; AOPP was lower in the group treated with surfactant plus 800 microg/kg of beclomethasone than in the other groups; NPBI was similar in all groups. Surfactant treatment was followed by a sustained improvement of tidal volume (TV) and airway resistance, while dynamic compliance did not vary. However, the mean airway pressure needed to obtain similar values of TV was lower in the group treated with surfactant plus 800 microg/kg of beclomethasone than in other groups. We concluded that natural surfactant combined with beclomethasone at 800 microg/kg is effective in reducing the oxidative lung stress and improving the respiratory function in an animal model of RDS.
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Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, Careggi University Hospital of Florence, Florence, Italy.
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