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Maneechotesuwan K, Singh D, Fritscher LG, Dursunoglu N, Pg A, Phansalkar A, Aggarwal B, Pizzichini E, Chorazy J, Burnett H. Impact of inhaled fluticasone propionate/salmeterol on health-related quality of life in asthma: A network meta-analysis. Respir Med 2022; 203:106993. [DOI: 10.1016/j.rmed.2022.106993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 10/31/2022]
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Shang W, Wang G, Wang Y, Han D. The safety of long-term use of inhaled corticosteroids in patients with asthma: A systematic review and meta-analysis. Clin Immunol 2022; 236:108960. [PMID: 35218965 DOI: 10.1016/j.clim.2022.108960] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/19/2022] [Accepted: 02/19/2022] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Wenli Shang
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, China
| | - Guizuo Wang
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, China
| | - Yan Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Dong Han
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, China.
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Tabassum T, Rahman A, Araf Y, Ullah MA, Hosen MJ. Management of asthma patients during the COVID-19 pandemic: pathophysiological considerations to address the challenges. Beni-Suef Univ J Basic Appl Sci 2022; 11:20. [PMID: 35155689 PMCID: PMC8817645 DOI: 10.1186/s43088-022-00204-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 01/27/2022] [Indexed: 12/15/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) has become a serious global health issue, especially for people with pre-existing health conditions. Patients dealing with asthma are presumed to be at higher risk as COVID-19 may cause severe respiratory distress. Main body From the initial stage of the pandemic, several clinical trials and studies have assessed the association between COVID-19 and asthma; however, no significant association was reported. This may be due to the fact that most of the asthma cases remained undiagnosed and overlapping respiratory features make it difficult to differentiate between these two diseases. The pathomechanism of the conditions and the immune response generated in response to the conditions suggest that the presence of any of the conditions is very likely to influence the presence or severity of the other condition. So far, no specific treatments are known for COVID-19; however, the use of plasma therapy and broad-spectrum antiviral drugs during the initial phase of the pandemic and widespread vaccination during the latter phase has given positive outcomes in reducing COVID-19 cases as well as disease severity. Short conclusion Taking asthma as an increased risk factor for COVID-19 morbidity, this article aims to provide comprehensive insights into the risk and proper management of asthma patients during this COVID-19 pandemic. The common medications of asthma patients suppress their respiratory immune response that might facilitate cytokine storm in COVID-19 patients. Similarly, there are risks of viral-induced asthma exacerbations. Besides, different social issues such as shortage of medicines, SDOH, and delayed clinical trials put asthma patients through inconvenience. The primary focus at this point should be to reduce probable asthma attacks and severity to prevent hospitalization of asthma patients. Moreover, for better management of asthma patients maintaining an asthma action plan and healthy lifestyle, ensuring a nutritious diet, and developing self-management interventions can play a crucial role.
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Graff S, Brusselle G, Hanon S, Sohy C, Dupont L, Peche R, Michils A, Pilette C, Joos G, Lahousse L, Lapperre T, Louis R, Schleich F. Anti-Interleukin-5 Therapy Is Associated with Attenuated Lung Function Decline in Severe Eosinophilic Asthma Patients from the Belgian Severe Asthma Registry. J Allergy Clin Immunol Pract 2021; 10:467-477. [PMID: 34563736 DOI: 10.1016/j.jaip.2021.09.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Asthmatics have accelerated lung function decline over time compared with healthy individuals. OBJECTIVE To evaluate risk factors for accelerated lung function decline. METHODS In a longitudinal analysis on severe asthmatics enrolled in the Belgian Severe Asthma Registry with at least 2 visits a minimum of 12 months apart, we compared characteristics of patients with and without decline (loss of post-bronchodilation forced expiratory volume in 1 s [FEV1] (% predicted)/y greater than zero) over time. Multiple linear regression was applied to study the factors independently associated with FEV1 decline. RESULTS In the overall population (n = 318), median annual FEV1 decline was 0.27 (-4.22 to 3.80) % predicted/y over a period of 23 months (12-41 months). Asthma was less controlled at baseline in nondecliners than in decliners (53%). Lung function and residual volume at baseline were higher in the declining group. Decliners presented with increased bronchial reactivity (ie, a lower provocative concentration of methacholine causing a 20% fall in FEV1) at baseline. Twenty-five percent of nondecliners were started on anti-interleukin-5 (anti-IL-5) for severe eosinophilic asthma during the study compared with 10% of decliners. The multivariable model suggested that Asthma Control Questionnaire score at baseline, late-onset asthma, and addition of anti-IL-5 during follow-up were associated with lower FEV1 decline, independently from other variables such as evolution in exacerbations, smoking status, inhaled corticosteroids or oral corticosteroids dose, or add-on anti-immunoglobulin E over time, whereas reversibility to salbutamol and higher FEV1 were associated with accelerated FEV1 decline. CONCLUSIONS Add-on therapy with anti-IL-5 in severe eosinophilic asthma was associated with an attenuated FEV1 decline. The causality of this observation should, however, be confirmed in future prospective controlled studies.
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Affiliation(s)
- Sophie Graff
- Department of Respiratory Medicine, CHU Sart-Tilman, I(3)GIGA Research Group, University of Liège, Liège, Belgium.
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Shane Hanon
- Respiratory Division, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Carine Sohy
- Department of Respiratory Medicine, Centre Hospitalier Universitaire UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Lieven Dupont
- Department of Respiratory Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Rudy Peche
- Department of Respiratory Medicine, CHU-Charleroi, A. Vésale Hospital, Charleroi, Belgium
| | - Alain Michils
- Chest Department, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Charles Pilette
- Cliniques Universitaires St.-Luc and Institute of Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium
| | - Guy Joos
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Ghent University, Ghent, Belgium
| | - Therese Lapperre
- Department of Pulmonary Medicine, Antwerp University and University Hospital Antwerp, Antwerp, Belgium
| | - Renaud Louis
- Department of Respiratory Medicine, CHU Sart-Tilman, I(3)GIGA Research Group, University of Liège, Liège, Belgium
| | - Florence Schleich
- Department of Respiratory Medicine, CHU Sart-Tilman, I(3)GIGA Research Group, University of Liège, Liège, Belgium
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Chen H, Xu Z, Yang J, Huang L, Wang K. Inhaled corticosteroids and risk of influenza in patients with asthma: a meta-analysis of randomized controlled trials. Aging Clin Exp Res 2021; 33:1771-1782. [PMID: 33026595 DOI: 10.1007/s40520-020-01688-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND It was reported that inhaled corticosteroids (ICS) treatment may affect local immunity and microbial community of the airway. However, whether ICS treatment increases the risk of influenza in patients with asthma remains unclear. This meta-analysis aimed to compare the risk of influenza between ICS and non-ICS treatment in patients with asthma. METHODS PubMed, Embase, Cochrane Library and Clinical Trials.gov were searched from inception until November 2019. Randomized controlled trials (RCTs) were included that compared ICS treatment with non-ICS treatment on the risk of influenza in patients with asthma. Meta-analyses were conducted by the Peto approach and Mantel-Haenszel approach with corresponding 95% CIs. RESULTS Nine trials involving 6486 patients were included in this meta-analysis. The risk of influenza was not different between ICS treatment and the control groups (Peto OR: 1.01, 95% CI 0.74-1.37, P = 0.95). The results of subgroup analyses based on durations (long-term and short-term treatment), doses (high-, medium- and low-dose treatment) and types (fluticasone and budesonide treatment) of ICS were consistent with the above pooled results. Moreover, subgroup analysis based on patients' age also revealed that use of ICS did not increase the risk of influenza. Results of the two meta-analysis approaches were similar. CONCLUSIONS Use of ICS does not increase the risk of influenza in patients with asthma. This study adds to safety evidence of ICS as a regular controller treatment for patients with asthma.
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Affiliation(s)
- Hong Chen
- Respiratory Diseases Laboratory, Chengdu Second People's Hospital, No. 10 Qingyun South Street, Chengdu, 610017, China
| | - Zhibo Xu
- Respiratory Diseases Laboratory, Chengdu Second People's Hospital, No. 10 Qingyun South Street, Chengdu, 610017, China
| | - Jing Yang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Lan Huang
- Respiratory Diseases Laboratory, Chengdu Second People's Hospital, No. 10 Qingyun South Street, Chengdu, 610017, China
| | - Ke Wang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China.
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Nolte H, Bernstein DI, Nelson HS, Ellis AK, Kleine-Tebbe J, Lu S. Efficacy and Safety of Ragweed SLIT-Tablet in Children with Allergic Rhinoconjunctivitis in a Randomized, Placebo-Controlled Trial. J Allergy Clin Immunol Pract 2020; 8:2322-2331.e5. [PMID: 32304832 DOI: 10.1016/j.jaip.2020.03.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ragweed sublingual immunotherapy (SLIT) tablet reduces symptoms and symptom-relieving medication use in adults with allergic rhinitis with or without conjunctivitis (AR/C) but has not been evaluated in children. OBJECTIVE This international, multicenter, double-blind, placebo-controlled trial evaluated the efficacy and safety of ragweed SLIT-tablet in children with AR/C. METHODS Children (N = 1025; 77.7% polysensitized) aged 5 to 17 years with ragweed pollen-induced AR/C with or without asthma (FEV1 ≥80% predicted) were randomized 1:1 to daily ragweed SLIT-tablet (12 Amb a 1-Unit) or placebo for up to 28 weeks (NCT02478398). The primary end point was the average total combined score (TCS; sum of rhinoconjunctivitis daily symptom score [DSS] and daily medication score [DMS]) during peak ragweed pollen season (RPS). Key secondary end points were TCS during the entire RPS, and DSS and DMS during the peak RPS. RESULTS Relative TCS (95% CI) improvements with ragweed SLIT-tablet versus placebo were -38.3% (-46.0% to -29.7%; least square [LS] mean difference, -2.73; P < .001) during peak RPS and -32.4% (-40.7% to -23.3%; LS mean difference, -1.86; P < .001) during the entire RPS. DSS and DMS during peak RPS improved with SLIT-tablet versus placebo by -35.4% (-43.2% to -26.1%; LS mean difference, -1.40; P < .001) and -47.7% (-59.8% to -32.5%; LS mean difference, -1.84; P < .001), respectively. Asthma DSS, short-acting β-agonist use, and nocturnal awakenings during peak RPS improved with SLIT-tablet versus placebo by -30.7%, -68.1%, and -75.1%, respectively (all nominal P ≤ .02). No events of anaphylaxis, airway compromise, or severe treatment-related systemic allergic reactions were reported. CONCLUSIONS Ragweed SLIT-tablet significantly improved symptoms and decreased symptom-relieving medication use in children with ragweed pollen-induced AR/C and was well tolerated.
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Affiliation(s)
| | - David I Bernstein
- Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Harold S Nelson
- Department of Medicine, Allergy/Immunology Service, National Jewish Health, Denver, Colo
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Susan Lu
- Merck & Co., Inc., Kenilworth, NJ
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Adeli M, El-Shareif T, Hendaus MA. Asthma exacerbation related to viral infections: An up to date summary. J Family Med Prim Care 2019; 8:2753-2759. [PMID: 31681638 PMCID: PMC6820381 DOI: 10.4103/jfmpc.jfmpc_86_19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 02/01/2019] [Accepted: 08/27/2019] [Indexed: 12/21/2022] Open
Abstract
Asthma exacerbation can be a major life threatening event. Viruses have been pinned as the cause behind the vast majority of these exacerbations. The purpose of this short review is to explore the mechanisms behind these exacerbations, focusing mostly on viral infections as triggers. We will also be discussing the phenotypes prone to asthma exacerbation, the pathophysiology of viral induced asthma and ventilation patterns of asthmatic lungs. This manuscript will assist primary care physicians in delineating the proper pathophysiology of the disease as well as the management.
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Affiliation(s)
- Mehdi Adeli
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar.,Department of Pediatrics, Hamad General Corporation, Doha, Qatar.,Department of Clinical Pediatrics, Weill- Cornell Medicine, Doha, Qatar
| | | | - Mohamed A Hendaus
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar.,Department of Pediatrics, Hamad General Corporation, Doha, Qatar.,Department of Clinical Pediatrics, Weill- Cornell Medicine, Doha, Qatar
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Abstract
BACKGROUND Epidemiological evidence has suggested a link between beta2-agonists and increases in asthma mortality. There has been much debate about whether regular (daily) long-acting beta2-agonists (LABA) are safe when used in combination with inhaled corticosteroids (ICS). This updated Cochrane Review includes results from two large trials that recruited 23,422 adolescents and adults mandated by the US Food and Drug Administration (FDA). OBJECTIVES To assess the risk of mortality and non-fatal serious adverse events (SAEs) in trials that randomly assign participants with chronic asthma to regular formoterol and inhaled corticosteroids versus the same dose of inhaled corticosteroid alone. SEARCH METHODS We identified randomised trials using the Cochrane Airways Group Specialised Register of trials. We checked websites of clinical trial registers for unpublished trial data as well as FDA submissions in relation to formoterol. The date of the most recent search was February 2019. SELECTION CRITERIA We included randomised clinical trials (RCTs) with a parallel design involving adults, children, or both with asthma of any severity who received regular formoterol and ICS (separate or combined) treatment versus the same dose of ICS for at least 12 weeks. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We obtained unpublished data on mortality and SAEs from the sponsors of the studies. We assessed our confidence in the evidence using GRADE recommendations. The primary outcomes were all-cause mortality and all-cause non-fatal serious adverse events. MAIN RESULTS We found 42 studies eligible for inclusion and included 39 studies in the analyses: 29 studies included 35,751 adults, and 10 studies included 4035 children and adolescents. Inhaled corticosteroids included beclomethasone (daily metered dosage 200 to 800 µg), budesonide (200 to 1600 µg), fluticasone (200 to 250 µg), and mometasone (200 to 800 µg). Formoterol metered dosage ranged from 12 to 48 µg daily. Fixed combination ICS was used in most of the studies. We judged the risk of selection bias, performance bias, and attrition bias as low, however most studies did not report independent assessment of causation of SAEs.DeathsSeventeen of 18,645 adults taking formoterol and ICS and 13 of 17,106 adults taking regular ICS died of any cause. The pooled Peto odds ratio (OR) was 1.25 (95% confidence interval (CI) 0.61 to 2.56, moderate-certainty evidence), which equated to one death occurring for every 1000 adults treated with ICS alone for 26 weeks; the corresponding risk amongst adults taking formoterol and ICS was also one death (95% CI 0 to 2 deaths). No deaths were reported in the trials on children and adolescents (4035 participants) (low-certainty evidence).In terms of asthma-related deaths, no children and adolescents died from asthma, but three of 12,777 adults in the formoterol and ICS treatment group died of asthma (both low-certainty evidence).Non-fatal serious adverse eventsA total of 401 adults experienced a non-fatal SAE of any cause on formoterol with ICS, compared to 369 adults who received regular ICS. The pooled Peto OR was 1.00 (95% CI 0.87 to 1.16, high-certainty evidence, 29 studies, 35,751 adults). For every 1000 adults treated with ICS alone for 26 weeks, 22 adults had an SAE; the corresponding risk for those on formoterol and ICS was also 22 adults (95% CI 19 to 25).Thirty of 2491 children and adolescents experienced an SAE of any cause when receiving formoterol with ICS, compared to 13 of 1544 children and adolescents receiving ICS alone. The pooled Peto OR was 1.33 (95% CI 0.71 to 2.49, moderate-certainty evidence, 10 studies, 4035 children and adolescents). For every 1000 children and adolescents treated with ICS alone for 12.5 weeks, 8 had an non-fatal SAE; the corresponding risk amongst those on formoterol and ICS was 11 children and adolescents (95% CI 6 to 21).Asthma-related serious adverse eventsNinety adults experienced an asthma-related non-fatal SAE with formoterol and ICS, compared to 102 with ICS alone. The pooled Peto OR was 0.86 (95% CI 0.64 to 1.14, moderate-certainty evidence, 28 studies, 35,158 adults). For every 1000 adults treated with ICS alone for 26 weeks, 6 adults had an asthma-related non-fatal SAE; the corresponding risk for those on formoterol and ICS was 5 adults (95% CI 4 to 7).Amongst children and adolescents, 9 experienced an asthma-related non-fatal SAE with formoterol and ICS, compared to 5 on ICS alone. The pooled Peto OR was 1.18 (95% CI 0.40 to 3.51, very low-certainty evidence, 10 studies, 4035 children and adolescents). For every 1000 children and adolescents treated with ICS alone for 12.5 weeks, 3 had an asthma-related non-fatal SAE; the corresponding risk on formoterol and ICS was 4 (95% CI 1 to 11). AUTHORS' CONCLUSIONS We did not find a difference in the risk of death (all-cause or asthma-related) in adults taking combined formoterol and ICS versus ICS alone (moderate- to low-certainty evidence). No deaths were reported in children and adolescents. The risk of dying when taking either treatment was very low, but we cannot be certain if there is a difference in mortality when taking additional formoterol to ICS (low-certainty evidence).We did not find a difference in the risk of non-fatal SAEs of any cause in adults (high-certainty evidence). A previous version of the review had shown a lower risk of asthma-related SAEs in adults taking combined formoterol and ICS; however, inclusion of new studies no longer shows a difference between treatments (moderate-certainty evidence).The reported number of children and adolescents with SAEs was small, so uncertainty remains in this age group.We included results from large studies mandated by the FDA. Clinical decisions and information provided to patients regarding regular use of formoterol and ICS need to take into account the balance between known symptomatic benefits of formoterol and ICS versus the remaining degree of uncertainty associated with its potential harmful effects.
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Affiliation(s)
- Sadia Janjua
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Stefanie Schmidt
- UroEvidence@Deutsche Gesellschaft für UrologieNestorstr. 8‐9 (1. Hof)BerlinGermany10709
| | - Montse Ferrer
- IMIM (Hospital del Mar Medical Research Institute)Health Services Research GroupC/ Doctor Aiguader, 88BarcelonaSpain08003
| | - Christopher J Cates
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
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Almeida PCA, Ponte EV, Souza-Machado A, Cruz AA. Longitudinal trends in clinical characteristics and lung function of patients with severe asthma under treatment in Brazil. BMC Pulm Med 2016; 16:141. [PMID: 27829403 PMCID: PMC5103442 DOI: 10.1186/s12890-016-0302-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 10/27/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The structural changes of the respiratory system related to ageing determine lung function decline in healthy subjects after 25 years of age. An annual reduction of 25 ml in Forced Expiratory Volume in 1 s (FEV1) is expected. We aimed to describe the longitudinal lung function variation of subjects with severe asthma receiving appropriate treatment. METHODS Consecutive patients enrolled in a Brazilian reference clinic between 2003 and 2006 were invited to participate. The study participants were followed up for a median of 8 years, and were evaluated with spirometry in three distinct occasions (V0, V1 and V8), at least. At V0, upon enrollment, subjects with previous severe untreated asthma were evaluated by a specialist, had their health resource utilization in the last 12 months recorded, and performed spirometry. In V1, 1 year after V0, under proper management, subjects repeated the procedures and answered the Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ). In the last study visit (V8), 7 years after V1, all patients underwent a pre and post-broncodilator (postBD) spirometry, skin prick test for aeroallergens, answered the ACQ and the AQLQ and had another interview with the specialist. RESULTS Two hundred thirty-four subjects were followed up between V0 and V8. A comparison between spirometries of V1 and V8, after the initial improvement has supposedly reached a plateau, shows that the FEV1 and FVC declined significantly both in absolute and percent of predicted values. FEV1postBD did not change significantly between V0 and V1, but declined by -27.1 (-51.1-1.4) ml/yr between V1 and V8. CONCLUSIONS Currently available treatment with a combination of inhaled corticosteroids and LABA may not be sufficient to prevent lung function decline in subjects with severe asthma.
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Affiliation(s)
- P C A Almeida
- ProAR - Center of Excellence for Asthma of Federal University of Bahia (UFBA), Salvador, Brazil.
| | - E V Ponte
- Faculdade de Medicina de Jundiaí, São Paulo, Brazil
| | - A Souza-Machado
- Institute for Health Sciences of UFBA and Coordinator of ProAR, Salvador, Brazil
| | - A A Cruz
- Center of Excellence for Asthma of UFBA, Salvador, Brazil
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Kerstjens HAM, Casale TB, Bleecker ER, Meltzer EO, Pizzichini E, Schmidt O, Engel M, Bour L, Verkleij CB, Moroni-Zentgraf P, Bateman ED. Tiotropium or salmeterol as add-on therapy to inhaled corticosteroids for patients with moderate symptomatic asthma: two replicate, double-blind, placebo-controlled, parallel-group, active-comparator, randomised trials. The Lancet Respiratory Medicine 2015; 3:367-76. [DOI: 10.1016/s2213-2600(15)00031-4] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/29/2014] [Indexed: 11/26/2022]
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Borghardt JM, Weber B, Staab A, Kloft C. Pharmacometric Models for Characterizing the Pharmacokinetics of Orally Inhaled Drugs. AAPS J 2015; 17:853-70. [PMID: 25845315 DOI: 10.1208/s12248-015-9760-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/25/2015] [Indexed: 12/12/2022]
Abstract
During the last decades, the importance of modeling and simulation in clinical drug development, with the goal to qualitatively and quantitatively assess and understand mechanisms of pharmacokinetic processes, has strongly increased. However, this increase could not equally be observed for orally inhaled drugs. The objectives of this review are to understand the reasons for this gap and to demonstrate the opportunities that mathematical modeling of pharmacokinetics of orally inhaled drugs offers. To achieve these objectives, this review (i) discusses pulmonary physiological processes and their impact on the pharmacokinetics after drug inhalation, (ii) provides a comprehensive overview of published pharmacokinetic models, (iii) categorizes these models into physiologically based pharmacokinetic (PBPK) and (clinical data-derived) empirical models, (iv) explores both their (mechanistic) plausibility, and (v) addresses critical aspects of different pharmacometric approaches pertinent for drug inhalation. In summary, pulmonary deposition, dissolution, and absorption are highly complex processes and may represent the major challenge for modeling and simulation of PK after oral drug inhalation. Challenges in relating systemic pharmacokinetics with pulmonary efficacy may be another factor contributing to the limited number of existing pharmacokinetic models for orally inhaled drugs. Investigations comprising in vitro experiments, clinical studies, and more sophisticated mathematical approaches are considered to be necessary for elucidating these highly complex pulmonary processes. With this additional knowledge, the PBPK approach might gain additional attractiveness. Currently, (semi-)mechanistic modeling offers an alternative to generate and investigate hypotheses and to more mechanistically understand the pulmonary and systemic pharmacokinetics after oral drug inhalation including the impact of pulmonary diseases.
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Affiliation(s)
- Jens Markus Borghardt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
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Virchow JC, Backer V, de Blay F, Kuna P, Ljørring C, Prieto JL, Villesen HH. Defining moderate asthma exacerbations in clinical trials based on ATS/ERS joint statement. Respir Med 2015; 109:547-56. [PMID: 25676887 DOI: 10.1016/j.rmed.2015.01.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/23/2015] [Accepted: 01/23/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Exacerbations are a key outcome in clinical research, providing patient-relevant information about symptomatic control, health state and disease progression. Generally considered as an episode of (sub)acute deterioration of respiratory symptoms, a precise, clinically useful definition is needed for use in clinical trials. AIM AND METHODS Focussing on moderate exacerbations, this opinion piece reviews landmark trials and current guidelines to provide a practical definition of a moderate exacerbation. Specifically, we adapt the ATS/ERS consensus statement of terminology Reddel et al. (2009) [1] which provides a conceptual (or 'theoretical') definition for moderate exacerbations, to an operational (or 'practical') criterion suitable for use in clinical research. RESULTS The proposed definition for a moderate exacerbation requires ≥1 of the following criteria combined with a change in treatment: a) nocturnal awakening(s) due to asthma requiring SABA for 2 consecutive nights or an increase of ≥0.75 from baseline in daily symptom scores on 2 consecutive days; b) increase from baseline in occasions of SABA use on 2 consecutive days (minimum increase: 4 puffs/day); c) ≥20% decrease in PEF from baseline on at least 2 consecutive mornings/evenings or ≥20% decrease in FEV1 from baseline and/or d) visit to the emergency room/trial site for asthma treatment not requiring systemic corticosteroids. CONCLUSION A clinically and patient-relevant, operational definition of moderate exacerbations is needed. The proposed definition has been endorsed by the EMA Scientific Advice Working Party in 2011and needs to be trialled in forthcoming clinical studies.
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Affiliation(s)
- J Christian Virchow
- Department of Pneumology/Intensive Care Medicine, Zentrum für Innere Medizin, Klinik I, Universitätsklinikum Rostock, Germany.
| | - Vibeke Backer
- Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen University, Denmark
| | - Frédéric de Blay
- Chest Diseases Department, University Hospital of Strasbourg, Federation of Translational Medicine of Strasbourg, Strasbourg University, Strasbourg, France
| | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Barlicki University Hospital, Lodz, Poland
| | - Christian Ljørring
- Global Clinical Development, ALK, Bøge Allé 1, DK 2970 Hørsholm, Denmark
| | - Jesus L Prieto
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Hanne H Villesen
- Global Clinical Development, ALK, Bøge Allé 1, DK 2970 Hørsholm, Denmark
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Loymans RJB, Gemperli A, Cohen J, Rubinstein SM, Sterk PJ, Reddel HK, Jüni P, ter Riet G. Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: network meta-analysis. BMJ 2014; 348:g3009. [PMID: 24919052 PMCID: PMC4019015 DOI: 10.1136/bmj.g3009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the comparative effectiveness and safety of current maintenance strategies in preventing exacerbations of asthma. DESIGN Systematic review and network meta-analysis using Bayesian statistics. DATA SOURCES Cochrane systematic reviews on chronic asthma, complemented by an updated search when appropriate. ELIGIBILITY CRITERIA TRIALS OF Adults with asthma randomised to maintenance treatments of at least 24 weeks duration and that reported on asthma exacerbations in full text. Low dose inhaled corticosteroid treatment was the comparator strategy. The primary effectiveness outcome was the rate of severe exacerbations. The secondary outcome was the composite of moderate or severe exacerbations. The rate of withdrawal was analysed as a safety outcome. RESULTS 64 trials with 59,622 patient years of follow-up comparing 15 strategies and placebo were included. For prevention of severe exacerbations, combined inhaled corticosteroids and long acting β agonists as maintenance and reliever treatment and combined inhaled corticosteroids and long acting β agonists in a fixed daily dose performed equally well and were ranked first for effectiveness. The rate ratios compared with low dose inhaled corticosteroids were 0.44 (95% credible interval 0.29 to 0.66) and 0.51 (0.35 to 0.77), respectively. Other combined strategies were not superior to inhaled corticosteroids and all single drug treatments were inferior to single low dose inhaled corticosteroids. Safety was best for conventional best (guideline based) practice and combined maintenance and reliever therapy. CONCLUSIONS Strategies with combined inhaled corticosteroids and long acting β agonists are most effective and safe in preventing severe exacerbations of asthma, although some heterogeneity was observed in this network meta-analysis of full text reports.
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Affiliation(s)
- Rik J B Loymans
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
| | - Armin Gemperli
- Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Berne, Switzerland Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland Swiss Paraplegic Research, Nottwil, Switzerland
| | - Judith Cohen
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
| | - Sidney M Rubinstein
- Department of Health Sciences, Section Health Economics and Health Technology Assessment, VU University Amsterdam, Amsterdam, Netherlands
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Peter Jüni
- Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Berne, Switzerland
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
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14
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Berger WE, Bensch GW, Weinstein SF, Skoner DP, Prenner BM, Shekar T, Nolte H, Teper AA. Bronchodilation with mometasone furoate/formoterol fumarate administered by metered-dose inhaler with and without a spacer in children with persistent asthma. Pediatr Pulmonol 2014; 49:441-50. [PMID: 24019197 DOI: 10.1002/ppul.22850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 05/20/2013] [Accepted: 05/20/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND The bronchodilatory effect of mometasone furoate/formoterol fumarate (MF/F) administered by metered-dose inhaler (MDI) with or without a spacer has not been evaluated previously in children aged 5-11 years. METHODS This was a randomized, multicenter, placebo-controlled, single-dose, four-period crossover study. Children with persistent asthma aged 5-11 years participated in this study. Subjects used inhaled corticosteroids with/without long-acting beta-2 agonists for 12 weeks before enrollment and at screening had forced expiratory volume in 1 sec (FEV1 ) ≥70% predicted. Subjects received MF/F MDI 100/10 µg with/without spacer (AeroChamber Plus® with Flow-Vu® Anti-Static Valved Holding Chamber), F-Dry Powder Inhaler (F-DPI) 10 µg, and placebo MDI with/without spacer in separate treatment periods. The primary endpoint was FEV1 area under the curve from 0 to 12 hr (AUC0-12hr ) for the comparison of MF/F with spacer versus placebo. Secondary measurements included MF/F without spacer versus placebo, as well as MF/F with spacer versus MF/F without spacer, and F-DPI versus placebo. Analysis was performed with an analysis of covariance model for a crossover study. RESULTS Data from 87 subjects were analyzed. MF/F with spacer demonstrated a larger change in mean FEV1 AUC0-12hr versus placebo (115 vs. -9 mL), with a treatment difference of 124 mL (95% CI 94-154, P < 0.001). Similarly, MF/F without spacer versus placebo resulted in a 102 mL difference in mean-adjusted FEV1 AUC0-12hr (95% CI 73-131, P < 0.001), whereas the difference between MF/F with spacer versus MF/F without spacer was 22 mL (95% CI -8 to 52, P = 0.144). The difference between F-DPI versus placebo was 106 mL (95% CI 77-135, P < 0.001). No unexpected adverse events were observed. CONCLUSIONS In this trial, MF/F MDI 100/10 µg demonstrated significant bronchodilation in children aged 5-11 years regardless of the use of a spacer. No difference in bronchodilation was observed between MF/F MDI and F-DPI.
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Affiliation(s)
- William E Berger
- Allergy & Asthma Associates of Southern California, Mission Viejo, California
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15
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Kosoglou T, Hubbell J, Cutler DL, Johnson-Levonas AO, Xu D, Kantesaria BS, Kim K, Miller SD. Hypothalamic-pituitary-adrenal axis effects of mometasone furoate/formoterol fumarate vs fluticasone propionate/salmeterol administered through metered-dose inhaler. Chest 2014; 144:1795-1802. [PMID: 24077095 DOI: 10.1378/chest.13-0505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The effects of mometasone furoate and fluticasone propionate on the hypothalamic-pituitary-adrenal axis were compared when administered from combination metered-dose inhaler (MDI) products. METHODS In a randomized, open-label, placebo-controlled, parallel group study, 66 patients with mild to moderate asthma received one of the following four treatments bid through an MDI for 42 days: mometasone furoate/formoterol (MF/F) 200 μg/10 μg, MF/F 400 μg/10 μg, fluticasone propionate/salmeterol (FP/S) 460 μg/42 μg, or placebo. Plasma cortisol concentrations were measured over 24 h on days -1 (baseline) and 42. Geometric mean ratio (GMR) and 90% CI for mean change from baseline to day 42 in 24-h plasma cortisol area under the curve (AUC) were calculated for each treatment. If the 90% CI for the GMRs fell within 70% to 143%, treatments were deemed comparable. RESULTS Mean baseline cortisol AUCs were similar across groups. Mean cortisol effects (change from baseline) were similar for MF/F 400 μg/10 μg and FP/S 460 μg/42 μg (GMR, 119%; 90% CI, 101%-140%). Effects of MF/F 200 μg/10 μg on cortisol AUC were similar to placebo (GMR, 92%; 90% CI, 78%-110%), whereas MF/F 400 μg/10 μg and FP/S 460 μg/42 μg lowered cortisol AUC vs placebo (GMR, 78% [90% CI, 66%-92%] and 66% [90% CI 56%-78%], respectively). All treatments were generally well tolerated. CONCLUSIONS MF/F 400 μg/10 μg or FP/S 460 μg/42 μg bid through an MDI led to similar reductions from baseline in mean cortisol AUC (22% and 34% lower than placebo, respectively), whereas the effect of MF/F 200 μg/10 μg was similar to placebo.
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Affiliation(s)
| | | | | | | | - Danlin Xu
- Merck & Co, Inc, Whitehouse Station, NJ
| | | | | | - S David Miller
- Northeast Medical Research Associates, North Dartmouth, MA
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16
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Abstract
BACKGROUND Epidemiological evidence has suggested a link between beta2-agonists and increases in asthma mortality. Much debate has surrounded possible causal links for this association and whether regular (daily) long-acting beta2-agonists are safe when used alone or in conjunction with inhaled corticosteroids. This is an updated Cochrane Review. OBJECTIVES To assess the risk of fatal and non-fatal serious adverse events in people with chronic asthma given regular formoterol with inhaled corticosteroids versus the same dose of inhaled corticosteroids alone. SEARCH METHODS Trials were identified using the Cochrane Airways Group Specialised Register of trials. Web sites of clinical trial registers were checked for unpublished trial data; Food and Drug Administration (FDA) submissions in relation to formoterol were also checked. The date of the most recent search was August 2012. SELECTION CRITERIA Controlled clinical trials with a parallel design were included if they randomly allocated people of any age and severity of asthma to treatment with regular formoterol and inhaled corticosteroids for at least 12 weeks. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. Unpublished data on mortality and serious adverse events were obtained from the sponsors. We assessed the quality of evidence using GRADE recommendations. MAIN RESULTS Following the 2012 update, we have included 20 studies on 10,578 adults and adolescents and seven studies on 2788 children and adolescents. We found data on all-cause fatal and non-fatal serious adverse events for all studies, and we judged the overall risk of bias to be low.Six deaths occurred in participants taking regular formoterol with inhaled corticosteroids, and one in a participant administered regular inhaled corticosteroids alone. The difference was not statistically significant (Peto odds ratio (OR) 3.56, 95% confidence interval (CI) 0.79 to 16.03, low-quality evidence). All deaths were reported in adults, and one was believed to be asthma-related.Non-fatal serious adverse events of any cause were very similar for each treatment in adults (Peto OR 0.98, 95% CI 0.76 to 1.27, moderate-quality evidence), and weak evidence suggested an increase in events in children on regular formoterol (Peto OR 1.62, 95% CI 0.80 to 3.28, moderate-quality evidence).In contrast with all-cause serious adverse events, the addition of new trial data means that asthma-related serious adverse events associated with formoterol are now significantly fewer in adults taking regular formoterol with inhaled corticosteroids (Peto OR 0.49, 95% CI 0.28 to 0.88, moderate-quality evidence). Although a greater number of asthma-related events were reported in children receiving regular formoterol, this finding was not statistically significant (Peto OR 1.49, 95% CI 0.48 to 4.61, low-quality evidence). AUTHORS' CONCLUSIONS From the evidence in this review, it is not possible to reassure people with asthma that regular use of inhaled corticosteroids with formoterol carries no risk of increasing mortality in comparison with use of inhaled corticosteroids alone. On the other hand, we have found no conclusive evidence of serious harm, and only one asthma-related death was registered during more than 4200 patient-years of observation with formoterol.In adults, no significant difference in all-cause non-fatal serious adverse events was noted with regular formoterol with inhaled corticosteroids, but a significant reduction in asthma-related serious adverse events was observed in comparison with inhaled corticosteroids alone.In children the number of events was too small, and consequently the results too imprecise, to allow determination of whether the increased risk of all-cause non-fatal serious adverse events found in a previous meta-analysis on regular formoterol alone is abolished by the additional use of inhaled corticosteroids.We await the results of large ongoing surveillance studies mandated by the Food and Drug Administration (FDA) for more information. Clinical decisions and information provided to patients regarding regular use of formoterol have to take into account the balance between known symptomatic benefits of formoterol and the degree of uncertainty associated with its potential harmful effects.
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Affiliation(s)
- Christopher J Cates
- Population Health Sciences and Education, St George's University of London, Cranmer Terrace, London, UK, SW17 0RE
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17
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Abstract
INTRODUCTION Asthma is a common chronic respiratory disease affecting the airways causing inflammation, airway hyperreactivity (AHR), and respiratory symptoms. Frequently, asthma can be effectively treated with inhaled corticosteroids (ICS) but in more severe cases additional drugs are required, such as long-acting β2-agonists (LABA). Mometasone furoate (MF) is a synthetic steroid exhibiting a strong affinity for the glucocorticoid receptor as well as a low bioavailability and a high plasma protein binding. In most cases, MF only requires once daily administration. Formoterol fumarate (F) is a full β2-agonist with a rapid onset and 12 h of duration. AREAS COVERED The present paper reviews the current knowledge of the novel combination of MF and F for the treatment of asthma. Furthermore, a description of the individual components is included. EXPERT OPINION At present, only few clinical studies of MF/F are available for review and more studies of MF/F efficacy are needed, especially comparative studies on other ICS/LABA drugs. However, it does not appear from the reviewed literature that MF/F or its individual components are inferior to other equivalent treatments.
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Affiliation(s)
- Christian Grabow Westergaard
- Bispebjerg Hospital, Department of Respiratory Medicine L, Respiratory Research Unit, Bispebjerg Bakke 23, DK-2400 Copenhagen NV, Denmark.
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18
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Abstract
The corticosteroid mometasone and the long-acting β(2)-selective adrenoreceptor agonist formoterol have been combined in a single pressurized metered-dose inhaler for use in patients aged ≥12 years with asthma. In a 26-week well designed trial in patients with persistent asthma uncontrolled on medium-dose inhaled corticosteroids (ICS), mometasone/formoterol 200 μg/10 μg twice daily (bid) was more effective than placebo or the same nominal dosage of formoterol alone in reducing the incidence of asthma deteriorations, as well as in improving lung function, asthma control, asthma symptoms and asthma-related quality-of-life outcomes. The combination was also more effective than the same nominal dosage of mometasone alone in improving lung function and asthma control. Similarly, in a 12-week well designed trial in patients with persistent asthma uncontrolled on high-dose ICS, mometasone/formoterol 400 μg/10 μg bid was more effective than the same nominal dosage of mometasone alone in improving lung function, asthma control and asthma symptoms. Treatment with a lower dosage of the combination (200 μg/10 μg bid) yielded similar results and, moreover, significantly reduced the incidence of asthma deteriorations compared with mometasone alone. Mometasone/formoterol was generally well tolerated in clinical trials of 12-52 weeks' duration. The adverse event profile of the combination was consistent with that of its individual components; no new or unexpected safety signals were detected.
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19
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Gaz C, Cremona G, Panunzi S, Patterson B, De Gaetano A. A geometrical approach to the PKPD modelling of inhaled bronchodilators. J Pharmacokinet Pharmacodyn 2012; 39:415-28. [PMID: 22801773 DOI: 10.1007/s10928-012-9259-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 06/20/2012] [Indexed: 11/29/2022]
Abstract
The present work introduces a new method to model the pharmacokinetics (PK) and pharmacodynamics (PD) of an inhaled dose of bronchodilator, alternative to classic compartmental representations or computational fluid dynamics. A five compartment PK model comprising alimentary tract absorption (gut), bronchial tree mucosa, bronchial muscles, plasma, and elimination/excretion pathways has been developed. Many anatomical and physiological features of the bronchial tree depend on bronchial generation or on mean distance from the larynx. Among these are diameters, resistances, and receptor density, which determine together the local response to the inhaled drug; integrating these local responses over the whole bronchial tree allows an approximation of total bronchodilator response and airflow resistance. While the PK part of the model reflects classical compartmental assumptions, the PD part adds a simplified geometrical and functional description of the bronchial tree to a typical empirical model of local effect on bronchial muscle, leading to the direct computation of the approximate forced expiratory volume in 1 s (FEV(1)). In the present work the construction of the model is detailed, with reference to literature data. Simulation of a hypothetical asthmatic subject is employed to illustrate the behaviour of the model in representing the evolution over time of the distribution and pharmacological effect of an inhaled dose of a bronchodilator. The relevance of particle size and drug formulation diffusivity on therapeutic efficacy is discussed.
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Affiliation(s)
- Claudio Gaz
- Consiglio Nazionale Delle Ricerche, Istituto di Analisi Dei Sistemi ed Informatica A. Ruberti, Viale Manzoni, 30, 00185, Rome, Italy
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Adcock IM, Caramori G, Kirkham PA. Strategies for improving the efficacy and therapeutic ratio of glucocorticoids. Curr Opin Pharmacol 2012; 12:246-51. [PMID: 22445282 DOI: 10.1016/j.coph.2012.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 02/13/2012] [Indexed: 01/11/2023]
Abstract
Although glucocorticoids are very effective in suppressing inflammation there is a clear clinical unmet need for new or improved glucocorticoids in patients with severe asthma and COPD. Recent developments include the targeted deposition of ultrafine glucocorticoid particles to treat small airways and the potential of novel agents that have a reduced side effect profile. Understanding the drivers of relative glucocorticoid resistance in these patients may lead to the development of newer drugs aimed at subsets of patients, for example asthmatics with high periostin levels. Alternatively, inhibitors of kinase pathways that are associated with inflammatory responses may be able to modulate glucocorticoid function and combinations of these inhibitors along with novel glucocorticoids may provide the combination therapy of the future.
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Affiliation(s)
- Ian M Adcock
- Airways Disease, National Heart & Lung Institute, Imperial College London, SW3 6LY, UK.
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Tashkin DP, Doherty DE, Kerwin E, Matiz-Bueno CE, Knorr B, Shekar T, Banerjee S, Staudinger H. Efficacy and safety of a fixed-dose combination of mometasone furoate and formoterol fumarate in subjects with moderate to very severe COPD: results from a 52-week Phase III trial. Int J Chron Obstruct Pulmon Dis 2012; 7:43-55. [PMID: 22334768 PMCID: PMC3276256 DOI: 10.2147/copd.s27319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND A clinical trial of mometasone furoate/formoterol fumarate (MF/F) administered via a metered-dose inhaler in subjects with moderate to very severe chronic obstructive pulmonary disease (COPD) investigated the efficacy and safety of a fixed-dose combination of MF/F. METHODS This multicenter, double-blind, placebo-controlled trial had a 26-week treatment period and a 26-week safety extension. Subjects (n = 1055; ≥40 years) were current or ex- smokers randomized to twice-daily treatment with inhaled MF/F 400/10 μg, MF/F 200/10 μg, MF 400 μg, F 10 μg, or placebo. The coprimary endpoints of the trial were mean changes from baseline in forced expiratory volume in 1 second (FEV(1)) over 0-12 hours (AUC(0-12) FEV(1)) with MF/F versus MF, and in morning predose FEV(1) with MF/F versus F. Key secondary endpoints were quality of life (Saint George's Respiratory Questionnaire [SGRQ]), symptom-free nights, and partly stable COPD at 26 weeks, as well as time to first COPD exacerbation. RESULTS Significant improvements in FEV(1) AUC(0-12) occurred at endpoint with MF/F 400/10 and MF/F 200/10 versus MF 400 (P ≤ 0.007). Significant bronchodilation occurred in 5 minutes with MF/F, and serial spirometry demonstrated sustained FEV(1) improvements with MF/F over the treatment period. Significant improvements in morning predose FEV(1) occurred with both MF/F doses, and these effects were further investigated by excluding results for subjects whose morning FEV(1) data were collected >2 days after the last dose of study treatment. Improvements in SGRQ total scores surpassed the minimum clinically important difference of at least 4 units with MF/F 400/10. MF/F 400/10 significantly reduced the time-to-first COPD exacerbation. Similar proportions of subjects in all five treatment groups reported treatment-emergent adverse events. Rates of pneumonia were low (≤1.0%) across treatment groups. CONCLUSION MF/F 400/10 μg twice daily was shown to be an effective therapy for patients with moderate to very severe COPD, and both MF/F 400/10 μg twice daily and MF/F 200/10 μg twice daily were well tolerated.
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Affiliation(s)
- Donald P Tashkin
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
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23
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Doherty DE, Tashkin DP, Kerwin E, Knorr BA, Shekar T, Banerjee S, Staudinger H. Effects of mometasone furoate/formoterol fumarate fixed-dose combination formulation on chronic obstructive pulmonary disease (COPD): results from a 52-week Phase III trial in subjects with moderate-to-very severe COPD. Int J Chron Obstruct Pulmon Dis 2012; 7:57-71. [PMID: 22334769 PMCID: PMC3276257 DOI: 10.2147/copd.s27320] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rationale The purpose of this study was to investigate the clinical efficacy and safety of a fixed-dose combination of mometasone furoate/formoterol fumarate (MF/F) administered via a metered-dose inhaler in subjects with moderate-to-very severe chronic obstructive pulmonary disease (COPD). Methods This multicenter, double-blind, placebo-controlled trial had a 26-week treatment period and a 26-week safety extension. Subjects (n = 1196), at least 40 years old, were current or ex-smokers randomized to twice-daily inhaled MF/F 400/10 μg, MF/F 200/10 μg, MF 400 μg, F 10 μg, or placebo. The trial’s co-primary endpoints were mean changes from baseline, as area under the curve (AUC), in forced expiratory volume (FEV1) over 0–12 hours (AUC0–12 h FEV1) with MF/F versus MF, and in morning (AM) pre-dose (trough) FEV1 with MF/F versus F after 13 weeks of treatment. Key secondary endpoints were the effects of MF/F on respiratory health status using the Saint George’s Respiratory Questionnaire (SGRQ), symptom-free nights, partly stable COPD at 26 weeks, and time to first COPD exacerbation. Results The largest improvements in AUC0–12 h FEV1 were observed with MF/F 400/10 μg and MF/F 200/10 μg. Serial spirometry results demonstrated that bronchodilator effects with MF/F occurred rapidly (within 5 minutes), persisted for 12 hours after dosing, and were sustained over the 26-week treatment period. Similar findings were observed for AM pre-dose FEV1, for which effects were further investigated, excluding subjects whose AM FEV1 data were incorrectly collected after 2 days from the last dose of study treatment. Improvements in SGRQ scores surpassed the minimum clinically important difference of more than four units with both MF/F treatments. At 26 weeks, no notable between-treatment differences in the occurrence and nature of adverse events (AEs) were reported. No unexpected AEs were observed. Overall, 90 subjects reported AEs considered to be treatment-related, the most common of which were lenticular opacities, dysphonia, and oral candidiasis. Discussion In conclusion, MF/F treatments improved lung function and respiratory health status, reduced exacerbations, and were well tolerated in subjects with moderate-to-very severe COPD.
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Affiliation(s)
- Dennis E Doherty
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY 40536, USA.
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Bernstein DI, Hébert J, Cheema A, Murphy KR, Chérrez-Ojeda I, Matiz-Bueno CE, Kuo WL, Nolte H. Efficacy and onset of action of mometasone furoate/formoterol and fluticasone propionate/salmeterol combination treatment in subjects with persistent asthma. Allergy Asthma Clin Immunol 2011; 7:21. [PMID: 22152089 PMCID: PMC3298511 DOI: 10.1186/1710-1492-7-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 12/07/2011] [Indexed: 11/14/2022] Open
Abstract
Background Mometasone furoate/formoterol (MF/F) is a novel combination therapy for treatment of persistent asthma. This noninferiority trial compared the effects of MF/F and fluticasone propionate/salmeterol (FP/S) combination therapies on pulmonary function and onset of action in subjects with persistent asthma. Methods Following a 2- to 4-week run-in period with MF administered via a metered-dose inhaler (MDI) 200 μg (delivered as 2 inhalations of MF-MDI 100 μg) twice daily (BID), subjects (aged ≥12 y) were randomized to MF/F-MDI 200/10 μg BID (delivered as 2 inhalations of MF/F-MDI 100/5 μg) or FP/S administered via a dry powder inhaler (DPI) 250/50 μg (delivered as 1 inhalation) BID for 12 weeks. The primary assessment was change from baseline to week 12 in area under the curve for forced expiratory volume in 1 second measured serially for 0-12 hours postdose (FEV1 AUC0-12 h). Secondary assessments included onset of action (change from baseline in FEV1 at 5 minutes postdose on day 1) and patient-reported outcomes. Results 722 subjects were randomized to MF/F-MDI (n = 371) or FP/S-DPI (n = 351). Mean FEV1 AUC0-12 h change from baseline at week 12 for MF/F-MDI and FP/S-DPI was 3.43 and 3.24 L × h, respectively (95% CI, -0.40 to 0.76). MF/F-MDI was associated with a 200-mL mean increase from baseline in FEV1 at 5 minutes postdose on day 1, which was significantly larger than the 90-mL increase for FP/S-DPI (P < 0.001). The overall incidence of adverse events during the 12-week treatment period that were considered related to study therapy was similar in both groups (MF/F-MDI, 7.8% [n = 29]; FP/S-DPI, 8.3% [n = 29]). Conclusions The results of this 12-week study indicated that MF/F improves pulmonary function and asthma control similar to FP/S with a superior onset of action compared with FP/S. Both drugs were safe, improved asthma control, and demonstrated similar results for other secondary study endpoints. Trial registration ClinicalTrials.gov: NCT00424008
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Affiliation(s)
- David I Bernstein
- Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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