Gaps in Care Among Uncontrolled Severe Asthma Patients in the United States

BACKGROUND

Understanding the implementation of key guideline recommendations is critical for managing severe asthma (SA) in the treatment of uncontrolled disease.

OBJECTIVE

To assess specialist visits and medication escalation in US patients with SA after events indicating uncontrolled disease (EUD) and associations with health outcomes and social disparity indicators.

METHODS

Patients with SA appearing in administrative claims data spanning 2015 to 2020 were indexed hierarchically on asthma-related EUD, including hospitalizations, emergency department visits with systemic corticosteroid treatment, or outpatient visits with systemic corticosteroid treatment. Patients with SA without EUD served as controls. Eligibility included age 12 or greater, 12 months enrollment before and after index, no biologic use, and no other major respiratory disease during the pre-period. Escalation of care in the form of specialist visits and medication escalation, health care resource use, costs, and disease exacerbations were assessed during follow-up.

RESULTS

We identified 180,736 patients with SA (90,368 uncontrolled and 90,368 controls). Between 35% and 51% of patients with SA with an EUD had no specialist visit or medication escalation. Follow-up exacerbations ranged from 51% to 4% across EUD cohorts, compared with 13% in controls. Among uncontrolled patients with SA who were Black or Hispanic/Latino, 41% and 38%, respectively, had no specialist visit or medication escalation after EUD, compared with 33% of non-Hispanic White patients.

CONCLUSIONS

A substantial proportion of uncontrolled patients with SA had no evidence of specialist visits or medication escalation after uncontrolled disease, and there was a clear relationship between uncontrolled disease and subsequent health care resource use and exacerbations. Findings highlight the need for improved guideline-based care delivery to patients with SA, particularly for those facing social disparities.

Safety and clinical activity of atezolizumab plus erlotinib in patients with non-small-cell lung cancer

BACKGROUND

Acquired resistance limits long-term epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) efficacy in patients with EGFR mutation-positive non-small-cell lung cancer (NSCLC) in whom anti-programmed death-ligand 1 (PD-L1) efficacy is also limited. We hypothesized that combining atezolizumab with erlotinib could enhance antitumor immunity and extend efficacy in these patients.

PATIENTS AND METHODS

This open-label phase Ib trial was conducted in adults aged ≥18 years who had advanced, unresectable NSCLC. Stage 1 (safety evaluation) enrolled EGFR TKI-naive patients regardless of EGFR status. Stage 2 (expansion) enrolled patients with EGFR-mutant NSCLC treated with ≤1 prior non-EGFR TKI therapy. Patients received 150 mg erlotinib orally once daily. After a 7-day erlotinib run-in, atezolizumab 1200 mg was administered intravenously every 3 weeks. The primary endpoint was the safety and tolerability of the combination in all patients; secondary endpoints included antitumor activity per RECIST 1.1 in stage 2 patients.

RESULTS

At the data cut-off on 7 May 2020, 28 patients (8 in stage 1, 20 in stage 2) were assessable for safety. No dose-limiting toxicities or grade 4 or 5 treatment-related adverse events occurred. Grade 3 treatment-related adverse events occurred in 46% of patients; the most common were increased alanine aminotransferase, diarrhea, pyrexia, and rash (each in 7% of patients). Serious adverse events occurred in 50% of patients. Pneumonitis (grade 1) was reported in a single patient (4%). The objective response rate was 75% [95% confidence interval (CI) 50.9% to 91.3%]), median response duration was 18.9 months (95% CI 9.5-40.5 months), median progression-free survival was 15.4 months (95% CI 8.4-39.0 months), and median overall survival was not estimable (NE) (95% CI 34.6-NE).

CONCLUSIONS

Atezolizumab combined with erlotinib demonstrated a tolerable safety profile and encouraging, durable clinical activity in patients with advanced EGFR mutation-positive NSCLC.

Disease burden and treatment adherence among children and adolescent patients with asthma

OBJECTIVE

To assess asthma burden and medication adherence in a US de-identified patient level claims database.

METHODS

This retrospective observational study used the IQVIA PHARMETRICS PLUS database to identify patients aged 5-17 years, diagnosed with asthma between 01/01/2012-09/30/2017 (asthma cohort), and those initiating treatment with twice-daily inhaled corticosteroids (ICS) or twice-daily ICS/long-acting beta₂ agonists (LABA) (treatment cohorts; index date = first dispensing). Patient characteristics, asthma medication, and healthcare resource utilization were assessed over a 12-month baseline period. Treatment cohort endpoints were assessed in a 12-month follow-up period, including: adherence using proportion of days covered (PDC); persistence (no gap >45 days between dispensings).

RESULTS

The asthma cohort included 186,868 patients (112,689 children, mean age 7.9 years; 74,179 adolescents, mean age 14.3 years). During baseline, 34.5% used ICS or ICS/LABA, 24% used oral corticosteroids, 11.1% had ≥1 asthma-related emergency department visit, 2.2% had ≥1 asthma-related hospitalization. Among treatment cohorts, 47,276 and 10,247 patients initiated twice-daily ICS and ICS/LABA, respectively (mean ages: 9.9; 12.5 years). Mean PDC adherence to twice-daily ICS and ICS/LABA was 30% and 34% at 6 months (PDC ≥0.8: 4.3%; 6.1%); 21% and 24% at 12 months (PDC ≥0.8: 1.8%; 2.8%). Persistence with twice-daily ICS and ICS/LABA was 10.1% and 14.2% at 6 months; 5.6% and 8.0% at 12 months.

CONCLUSIONS

A large disease burden and unmet need exist among US children/adolescent asthma patients, evidenced by low use of, and poor adherence to, ICS-containing medication, the notable proportion of oral corticosteroid users, and higher-than-expected asthma-related emergency department and hospitalization rates.

Dispensing of fluticasone propionate/salmeterol combination in the summer and asthma-related outcomes in the fall

BACKGROUND

Asthma exacerbations occur year-round; however, peak asthma-related events occur in the fall and are frequently associated with viral respiratory infections.

OBJECTIVE

To compare the rates of asthma-related emergency department (ED) visits and hospitalizations in the fall (September, October, November) between users and nonusers of fluticasone propionate plus salmeterol in a single inhaler (FSC) in the preceding summer.

METHODS

This was a retrospective, observational study using health care claims from a large managed care database. Patients age 4 to 55 years with both a medical claim for asthma and a pharmacy claim for FSC were categorized into 3 age groups: children (4-11 years), adolescents (12-18 years), and adults (19-55 years).

RESULTS

There were 201,973 observations of FSC dispensings and 184,143 observations without FSC. Across all age groups, summertime dispensings of FSC were associated with a significantly lower (P < .001) risk of an asthma-related ED visit (4-11 years: adjusted odds ratio [OR], 0.54, 95% CI, 0.49-0.60; 12-18 years: OR, 0.59, 95% CI, 0.54-0.64; 19-55 years: OR, 0.53, 95% CI, 0.51-0.55) or hospitalization (4-11 years: OR, 0.43, 95% CI, 0.35-0.54; 12-18 years: OR, 0.49, 95% CI, 0.40-0.60; 19-55 years: OR, 0.61, 95% CI, 0.57-0.65) in the subsequent fall. This protective effect persisted even for patients with fall dispensings of FSC. The risk of oral corticosteroid dispensing in the fall was also significantly reduced in all age groups.

CONCLUSION

Summertime dispensings of FSC were associated with a decreased risk of serious asthma-related outcomes in the subsequent fall. Continuous use of FSC before seasonal viral exposure may decrease seasonally related exacerbations.

Identifying the components of asthma health status in children with mild to moderate asthma

BACKGROUND

Weak and inconsistent correlations between measurements of asthma health status suggest that the disease is composed of nonoverlapping components.

OBJECTIVE

Factor analysis was used to explore the relationships between measures of asthma morbidity and to identify heterogeneous components of asthma health status in children 5 to 12 years old. Results were compared across time (baseline and 48-month visit) and treatment arms.

METHODS

Analyses were conducted in 7 different study windows in a database from a large clinical trial of children with mild to moderate asthma (n = 1041). Measurements of lung function, symptoms, and health care utilization from daily diary cards, serum IgE levels, total eosinophil count, skin test positivity, and airway hyperresponsiveness were included. Data on fractional exhaled nitric oxide and sputum eosinophil cationic protein were included in a subgroup of patients.

RESULTS

In each of the study windows, factor analysis identified 5 factors that explained between 50% and 60% of the common variance. Factors identified included (1) inflammatory markers, (2) symptoms/medication use, (3) asthma exacerbations, and measures of lung function, which subdivided into (4) FEV(1) and forced vital capacity, and (5) bronchodilator response and the FEV(1)/forced vital capacity ratio. Exploratory analyses suggest that fractional exhaled nitric oxide account for the atopy/inflammatory marker factor, and sputum measurements account for a sixth, separate factor.

CONCLUSION

The consistent identification of a 5-factor structure across time and treatment arms suggests that each of these factors provides independent information in the assessment of asthma.

The influence of variation in type and pattern of symptoms on assessment in pediatric asthma

OBJECTIVE

We conducted a national, population-based survey to examine the asthma-related health burden of US children.

METHODS

A telephone-based survey was conducted in 2004 of children 4 to 18 years of age with current asthma in the United States. In 41,433 households screened, 1089 children reported current asthma; 801 interviews were completed by parents of children aged 4 to 15 years and by children themselves aged 16 to 18 years. The survey included questions about symptoms, perceived level of control, activity limitations, health care use, medicines, disease management, and knowledge. Global asthma symptom burden, derived from the National Asthma Education and Prevention Program guidelines, was composed of 3 components: short-term symptom burden (4-week recall), long-term symptom burden (past year), and functional impact (activity limitation).

RESULTS

The majority of children were classified with mild intermittent disease on the basis of recent daytime symptoms alone (80%); yet, when report of nighttime symptoms was included, the proportion of children classified as having mild intermittent symptoms decreased (74%). When asthma burden was assessed on the basis of the global symptom burden construct, only a minority (13%) of individuals was classified as having an asthma symptom burden consistent with mild intermittent disease; the majority (62%) was classified as having moderate/severe disease. In addition, the impact of asthma on the daily activities is substantial; avoiding exertion (47%) and staying inside (34%) are common approaches to improve control of asthma symptoms.

CONCLUSIONS

The goals of therapy for asthma, based on the National Asthma Education and Prevention Program guidelines, have not been achieved for the majority of children. In addition, parents and children overestimate the child's asthma control and commonly restrict activities to control asthma symptoms. Deficiencies in the control of asthma may be related to the underestimation of the burden of disease.

Clinical trial efficacy: what does it really tell you?

The primary goal of most clinical trials is an evaluation of the efficacy of the drug being evaluated. Therefore, it is important to understand if study outcomes are a true reflection of a drug's "real-life" effectiveness. Clinical trials generally evaluate three types of outcomes: subjective, objective, and health-related. Clinical trials that use subjective measures as endpoints usually evaluate outcomes such as symptom scores, the need for rescue medication, and quality-of-life measures. The majority of clinical trials rely on objective measures to test the efficacy of asthma medications. These include lung function (peak expiratory flow rate, forced expiratory volume at one second [FEV1]), level of bronchial hyperresponsiveness (methacholine challenge or exercise challenge), and markers of inflammation (exhaled nitric oxide, sputum eosinophils, bronchoalveolar lavage, and bronchial biopsy). FEV1 remains the gold standard of efficacy measures; however, in pediatrics, where FEV1 values are often within the normal range, re-adjustment of what constitutes various levels of asthma severity should occur. Occasionally, studies will include an assessment of health outcomes, either as a primary or secondary measure, during the course of the study. Commonly measured health outcomes include a reduction in need for rescue systemic glucocorticoids, a reduction in the need for emergent asthma care, a reduction in asthma hospitalizations, and a reduction in asthma deaths. Studies designed to assess impact of treatment regimens on morbidity and mortality remain a high priority, as do studies designed to predict response to current asthma therapies.

Asthma: addressing consistency in results from basic science, clinical trials, and observational experience

The basic science understanding of the pathophysiology of a disease often serves as the basis for clinical investigations. This knowledge is used to propose new directions in care and confirm initial concepts. The basic science of asthma demonstrates that the most comprehensive management of inflammation appears to be associated with the use of inhaled corticosteroids and proposes a mechanism for combination therapy with the addition of salmeterol. Randomized clinical trials are performed to confirm these initial observations and demonstrate both the safety and efficacy of therapeutic agents. These investigations are either placebo-controlled or direct comparisons of 2 medications. For the treatment of asthma, these studies have all consistently demonstrated that inhaled corticosteroids are the most effective primary controller therapy. Greater improvement in both lung function and patient-oriented symptom control is observed with the use of inhaled corticosteroids. For patients whose symptoms are not controlled with single-drug therapy, the addition of a long-acting bronchodilator appears to be the most effective add-on treatment with the greatest improvement in lung function and symptom control. Clinical trials have been used for the purposes of cost modeling. Therapies that produce the greatest effect size at the lowest incremental costs produce the greatest improvement in cost-effectiveness. Retrospective claims analysis, more recently, have been used to validate these observations from clinical trials. These studies measure both resource use and costs or charges. These analyses have confirmed that initial treatment with inhaled corticosteroids and combined treatment with inhaled corticosteroids and long-acting bronchodilators are the most effective stepwise approaches to the treatment of asthma.

Krypton filled flashlamp: a possible new light source for near infrared spectroscopy in vivo

We have designed a reliable and flexible low cost instrument for NIR spectroscopy. A krypton filled flashlamp was used as inexpensive light source. Providing a number of suitable emission peaks in the NIR, this flashlamp is ideal for NIR spectroscopy. Application to other NIR spectroscopy systems, e.g. to CCD (Charge Coupled Device) spectrophotometers, should be possible. The introduced system was tested on human arm tissue during arterial occlusion. Results equivalent to those described by other authors could be obtained by this new technical approach.