Effect of High-Intensity Interval Training on Inhaled Corticosteroid Dose in Asthma Patients: A Randomized Controlled Trial

BACKGROUND

Inhaled corticosteroids (ICS) are the cornerstone of asthma treatment. However, ICS has side effects, and dose reduction is recommended when possible. Physical exercise improves asthma control, but it is unknown whether it reduces the reliance on ICS.

OBJECTIVE

To assess whether supervised high-intensity interval training reduces the need for ICS in untrained asthma patients.

METHODS

An assessor-blinded single-center randomized controlled trial, Copenhagen, Denmark. One hundred fifty untrained ICS-treated adults with symptomatic asthma were randomly assigned (2:1) to 6 months of supervised exercise 3 times weekly or a lifestyle as usual control group. Every second month, a clinical algorithm based on symptom control was applied in both groups to adjust ICS dose. Primary outcome was the proportion who had their ICS dose reduced by 25% or more after 6 months. Secondary outcomes included actual ICS dosage in micrograms per day.

RESULTS

Between October 2017 and December 2019, 102 patients were allocated to exercise intervention (86% completed) and 48 to the control (85% completed). At the 6-month visit, 63% versus 50% met the primary outcome in the exercise and control groups, respectively (adjusted risk difference 9.6% [95% CI -3.8 to 18.8]; P = .15). Daily ICS dose was reduced in favor of the exercise group, with a mean difference of -234 μg (95% CI -391 to -77; P = .0037), corresponding to a 24% reduction from baseline. This effect was sustained at 12 months. The intervention was safe and well tolerated.

CONCLUSIONS

Six months of regular exercise results in reduction in daily ICS dose without compromising asthma control.

Influence of wind direction on the ventilation and pollutant dispersion in different 3D street canyon configurations: numerical simulation and wind-tunnel experiment

Configuration of street canyon and the wind environment have a great influence on the self-ventilation capacity of the canyon, but the couple-effect of these two factors could not be considered in the previous study. The purpose of this study is to clarify the couple effect of street canyon configuration and wind environment on the ventilation and pollutant dispersion inside the street canyon. For this purpose, five wind directions of α = 90°, 60°, 45°, 30°, and 0° (α is the angle between the approaching wind and street canyon) and three canyon configurations (flat, step-up, and step-down canyons) were considered with numerical simulation and wind-tunnel experiment. Meanwhile, ACH (air exchange rate) and NEV (net escape velocity) were used to evaluate the ventilation capacity of the canyon. The results reveal that the wind direction has a vital influence on the ventilation in the different canyon configurations. Under the parallel wind direction (α = 0°), the airflow and ventilation capacity inside the three canyons are similar. Relative difference of ACH, named as RDA ((ACH_asymmetric-ACH_symmetric)/ACH_symmetric [Formula: see text] 100%), is 1.82%. However, under the oblique (α = 30°, 45°, and 60°) and perpendicular wind direction (α = 90°), the airflow of the step-down canyon is very different from the step-up and flat canyons. In step-down canyons, reverse flow occurs under the oblique and perpendicular wind direction, and the strength of the reverse flow increases as α increases. Due to this reverse flow, the ventilation capacity of the step-down canyon is lower than that of the step-up and flat canyons. As for the ventilation capacity in the pedestrian respiration domain, the ventilation capacity of the leeward pedestrian domain (leeward NEV) is higher in the step-down canyon than in the step-up canyon and the flat canyon (when α = 90°, leeward NEV of step-down canyon is 2.47 times the flat canyon). Conversely, the ventilation capacity of the windward pedestrian domain is lower in step-down canyons than in step-up or flat canyon (when α = 90°, windward NEV of step-down canyon is 0.1 times that of step-up canyon). The aforementioned findings are helpful to understand the effects of canyon configurations together with wind directions on the airflow as well as pollutant concentration inside the canyon. Although further researches are still required to provide practical guidelines, this study present effective methodologies to quantify the influences of street configurations and wind directions on street canyon ventilation for urban design purpose.

Interpositional vein grafting for significant size discrepancy: The important role for short, sequential grafts in step-up and step-down microvascular anastomoses

INTRODUCTION

Anastomotic vessel size discrepancy may be addressed by numerous techniques, including the end-to-side. Most of these conventional methods are less suited with larger flap vessels relative to recipients, such as the vessel-depleted oncological neck with prior radiotherapy or in supermicrosurgical techniques with perforator recipients. We describe how short segment (single or double) interpositional vein grafts can be used to safely graduate this discrepancy in a 'step-up' or 'step-down' manner.

METHODS

We conducted a retrospective review of all cases where interpositional vein grafts had been utilised. Furthermore, the technique for harvest, vessel preparation and anastomotic sequence is described.

RESULTS

Over fifteen years, 116 short segment interpositional vein grafts (in 83 patients) were employed to address vessel discrepancy. Concerning patient demographics, there were 81 male:2 female, mean age 51 years (range 27-68 years), and aetiology was oral cancer (75), trauma(7) and congenital(1). Single (50) and double (33) grafts were used for 65 arterial anastomoses (8 step-down: 57 step-up) and 18 for venous anastomoses (12 step-down: 6 step-up). Flaps employed were osteocutaneous fibula (28), anterolateral thigh (24), free ileocolon (11), radial forearm (11), SCIP (7) and others (2). Six flaps (of 83) were lost (5 arterial and 1 venous thrombosis).

CONCLUSION

Short segment interpositional vein grafts may be safely utilised for 'step-up' and 'step-down' anastomoses. Planned use in the primary case, minimum required length and meticulous preparation are fundamental for success and to dispel traditional concerns over poorer outcomes when vein grafts are used.

Pragmatic Randomized Controlled Trial for Stepping Down Asthma Controller Treatment in Patients Controlled with Low-Dose Inhaled Corticosteroid and Long-Acting β2-Agonist: Step-Down of Intervention and Grade in Moderate Asthma Study

BACKGROUND

Current asthma guidelines recommend stepping down controller treatment when the condition is well-controlled for a certain time. However, the optimal step-down strategy for well-controlled patients receiving a low-dose inhaled corticosteroid (ICS) with a long-acting β₂-agonist (LABA) remains unclear.

OBJECTIVE

This study was a randomized, open-label, three-arm, parallel pragmatic trial comparing two kinds of step-down approaches for maintaining treatment.

METHODS

Adults with asthma who were aged 18 years or older, and who had been stable with low-dose ICS/LABA for at least 3 months, were enrolled. Subjects (n = 225) were randomly allocated into one of three groups (maintaining low-dose ICS/LABA [G1], discontinuing LABA [G2], and reducing ICS/LABA to once daily [G3]), and were observed for 6 months. The primary end point was a change in Asthma Control Test (ACT) scores between randomization and the final 6-month follow-up.

RESULTS

The change in ACT was analyzed in the per-protocol population; noninferiority was not demonstrated in either step-down group compared with the maintenance group (95% confidence interval of the difference, G2 vs G1 = -1.40-0.55; G3 vs G1 = -1.19-0.77). Although over 90% of patients were fine, higher rates of treatment failure were observed in step-down groups (G1: 0%; G2: 9.46%; and G3: 9.09%; P = .027). There were no significant differences between step-down approaches in terms of ACT change or treatment failure.

CONCLUSIONS

Both step-down methods were not noninferior to maintenance of treatment. Step-down therapy can be attempted when patients are stable, but appropriate monitoring and supervision are necessary with precautions regarding loss of disease control.

Examining Health Literacy Levels in Homeless Persons and Vulnerably Housed Persons with Mental Health Disorders

Health care use is high in persons who are homeless and vulnerably housed, but their health literacy (ability to read and understand health information) is often not known. The purpose of this study was to determine health literacy rates in a Canadian population of homeless and vulnerably housed individuals with mental health disorders. Higher levels of health literacy were associated with being housed, higher levels of education, non-psychotic mental health diagnoses and lower levels of drug use. This suggests that health literacy may be a potential barrier for accessing and utilizing health services and information for vulnerable populations.

Mepolizumab effectiveness on small airway obstruction, corticosteroid sparing and maintenance therapy step-down in real life

BACKGROUND

Mepolizumab (MEP) has been recently introduced to treat severe eosinophilic asthma. Trials have demonstrated a significant effectiveness in this asthma phenotype. We evaluated MEP efficacy on lung function, symptoms, asthma exacerbations, biologic markers, steroid dependence and controller treatment level in real-life.

METHODS

We retrospectively analyzed 134 severe asthmatics (61 males; mean age 58.3 ± 11; mean FEV₁%:72 ± 21), treated with MEP for at least 6 months (mean duration:10.9 ± 3.7 months).

RESULTS

FEV₁% improved significantly after MEP. Mean FEF_25-75 also increased from 37.4 ± 25.4% to 47.2 ± 27.2% (p < 0.0001). Mean baseline blood eosinophil level was 712 ± 731/μL (8.4 ± 5.2%) decreasing to 151 ± 384/μL (1.6 ± 1.6%) (p < 0.0001), FENO levels decreased likewise. MEP treatment also led to a significant ACT improvement (mean pre:14.2 ± 4.4; mean post:20.5 ± 28) and exacerbations significantly fell from 3.8 ± 1.9 to 0.8 ± 1.1 (p < 0.0001). 74% of patients were steroid-dependent before MEP. 45.4% and 46.4% of them showed a suspension and dose reduction respectively (p < 0.0001). A significant number reduced also ICS doses. Only 67% of subjects used SABA as needed before MEP, falling to 20% after MEP. About 40% of patients highlighted a maintenance therapy step-down. Subjects showing an omalizumab treatment failure before MEP had a similar positive response when compared with omalizumab untreated patients.

CONCLUSION

In real-life, MEP improved significantly all outcomes even small airway obstruction, suggesting its possible role also in distal lung region treatment. Furthermore, it demonstrated its high effectiveness in OC/ICS-sparing, in reducing SABA as needed and in stepping-down maintenance therapy. MEP is a valid alternative for patients with previous omalizumab treatment failure.

Factors that determine the loss of control when reducing therapy by steps in the treatment of moderate-severe asthma in standard clinical practice: A multicentre Spanish study

BACKGROUND

Although the clinical practice guidelines recommend continuous adjustment of asthma treatment and reducing the maintenance drugs when achieving control (step-down), there are few studies of standard clinical practice aimed at collecting information on the factors that determine step-down failure.

OBJECTIVE

To determine the factors that determine step-down failure in standard clinical practice of patients with moderate-severe asthma controlled by a combination of inhaled glucocorticoids and long-acting beta agonists.

METHODS

A multicentre retrospective study included 374 patients with moderate-severe asthma controlled with inhaled glucocorticoids and long-acting beta agonists for whom the physician indicated a step-down in 2016.

RESULTS

The step-down failed in 41.7% of the patients. The following factors were related to failure: greater patient age (P=.006), presence of at least 2 comorbidities (P=.016), greater severity level (severe persistent vs. moderate persistent) (P<.001), greater age at diagnosis (>40 years) (P=.045), the higher the therapeutic step before (P=.003) and after the change (P<.001), the shorter the time of improvement/control prior to the change (P=.019), lower FEV₁ (P=.001) and a poorer Asthma Control Test score or Asthma Control Questionnaire score before the step-down (P<.001). The logistic regression analysis showed a higher probability of step-down failure in the more elderly patients (OR, 0.983; 95% CI 0.969-0.997) and those with severe asthma compared to those with moderate asthma (OR, 0.537; 95% CI 0.292-0.985), as well as an increased probability of success if the patients had the disease controlled for more than 6 months (OR, 2.253; 95% CI 1.235-4.112).

CONCLUSION

In standard clinical practice conditions, step-down fails in a high percentage of patients, and the suggestion is to indicate step-down when the patient has had more than 6 months of disease control.

Routine admission to step-down unit as an alternative to intensive care unit after pediatric supraglottoplasty

OBJECTIVE

To evaluate the feasibility and the outcomes for step-down (SD) unit admission as an alternative to intensive care unit (ICU) admission after supraglottoplasty in the pediatric patient.

METHODS

A review of 98 patients who underwent supraglottoplasty from 2012 to 2017 at a tertiary referral pediatric hospital was performed. An SD unit had 1-to-3 nurse-to-patient ratio with noninvasive positive pressure ventilation capability. Data variables included demographics, comorbidities, preoperative and postoperative respiratory requirements, and length of stay.

RESULTS

Routine admission to SD occurred for 85% patients while 15% patients were selectively admitted to ICU due to intubation requirement or perioperative respiratory distress. In SD, noninvasive respiratory support was required for 28 (34%) patients. Three (4%) required re-intubation and ICU transfer without delay in care. Patients at high risk for requiring respiratory support after surgery have a neurologic condition (OR 7.0, 95% 2.4-20.2, p < 0.01) or intrinsic pulmonary disease (OR 4.5, 95% CI 1.5-13.3, p < 0.01). Median length of stay was shorter for patients in step-down (1 day, IQR 1-2).

CONCLUSION

Patients can be managed safely in a SD unit after supraglottoplasty supporting de-escalation of care. Patients with neurologic and pulmonary comorbidities may have higher respiratory needs postoperatively. Prospective studies are warranted to further optimize resource allocation.

Health care utilization and cost after discharge from a mental health hospital; an RCT comparing community residential aftercare and treatment as usual

BACKGROUND

Community residential aftercare (step-down) services can ease the transition after a mental health hospital stay for patients with severe mental illness (SMI).

AIMS

To investigate use of community and specialised mental health care services and costs in patients with SMI the first 12 months after discharge from a mental health hospital (MHH), comparing community residential aftercare (CRA) and treatment as usual.

METHODS

An open parallel group randomised controlled trial with 41 participants. Data on use of specialist services (hospital, ambulant treatment and outpatient treatment) and community services (residential stays, home help, home care nursing, mental health consultation) were collected from specialist and community registers and health records.

RESULTS

For the primary outcome, utilisation of community mental health services, the intervention group used, on average, 29% fewer hours (mean differences - 21.6 h, 95% CI -93.1 to 44.9, p = .096) with a cost saving of 29% (mean differences - 1845 EUR, 95% CI -8267 to 4171, p = .102), but the estimates were imprecise. For the secondary outcome, the study groups had the same total number of inpatient days (66 days), but the intervention group had on average of 13.4 fewer inpatient days in the mental health hospital (95% CI -29.9 to 0.9. p = .008). The number of inpatient admissions (mean difference - 0.9 admissions, 95% CI -3.5 to 1.5, p = .224) and readmissions (- 0.8, 95% CI -2.5 to 0.9. p = .440) was lower in the intervention group. The intervention group had on average a total cost saving of 38.5% (mean differences - 23,071 EUR, 95% CI -45,450 to 3027. p = .057). A post hoc multivariable regression analysis controlling for baseline characteristics gave a reduction in total cost in favour of the intervention group of - 19,781 EUR (95% CI -44,072 to 4509, p=,107).

CONCLUSION

In this study, it was not possible to draw a definite conclusion about the effect, due to the small sample and imprecision of the estimates. The direction of the results and size of the point estimate, in addition to findings in other studies, indicates that transferring patients ready for discharge from mental hospital to community residential aftercare can have the potential to reduce total consumption of health services and costs without increased hospital admissions.

TRIAL REGISTRATION

Registered in clinicaltrials.gov ( NCT01719354 ).

A Simple Score for Future Risk Prediction in Patients with Controlled Asthma Who Undergo a Guidelines-Based Step-Down Strategy

BACKGROUND

The minimum controlling dose of treatment must be established in patients with asthma, but the outcome of step-down is unpredictable.

OBJECTIVE

To identify factors associated with risk of control loss when stepping down asthma treatment and to develop a score to predict this risk.

METHODS

A prospective, multicenter study including adults with well-controlled asthma was performed. Treatment was stepped up or stepped down over a 12-month period to maintain asthma control. We determined associations between clinical and functional variables and step-down failure. Finally, we derived a score to predict loss of control in 1 cohort and validated it in an independent cohort.

RESULTS

The derivation cohort consisted of 228 patients; 218 completed at least 1 step-down episode and a total of 495 step-down episodes were evaluated. A medical-record documented postbronchodilator spirometry result of <70% forced expiratory volume in 1 second (FEV₁)/forced vital capacity (odds ratio [OR] = 2.08; 95% confidence interval [CI]: 1.26-3.43), current FEV₁ < 80% (OR = 1.80; 95% CI: 1.03-3.14), ≥1 severe exacerbation in the previous 12 months (OR = 2.43; 95% CI: 1.48-4.01), and Asthma Control Test score < 25 (OR = 2.30; 95% CI: 1.35-3.92) were independently associated with failure. The score showed an area under the curve of 0.690 (95% CI: 0.633-0.747; P < .05) in the derivation cohort and 0.76 (95% CI: 0.643-0.882; P < .001) in a validation cohort of 114 patients. A score <4.5 implies a low risk of failure (<20%), whereas a score >8 implies a high risk (>40%).

CONCLUSION

This score can facilitate the prediction of step-down failure before medication taper in patients with well-controlled asthma.

Asthma and Medicines - Long-Term Side-Effects, Monitoring and Dose Titration

Asthma is a major pediatric respiratory morbidity requiring long-term management. A thorough knowledge of long-term medication side-effects in children is, thus, essential for every physician dealing with childhood asthma. Establishing diagnosis and initiating treatment is just a beginning of the journey. Ongoing monitoring is an essential component of comprehensive asthma management programme. Monitoring includes not only assessment of asthma control but also checking for adherence to treatment, technique of inhaler device use, associated co-morbities, if any, and potential environmental exposure. Various tools - both subjective and objective - are available for assessment of asthma control. However, evidence for their optimum use in different settings and patient groups is lacking and monitoring has to be customized depending on available resources and individual patient characteristics. Patient education is an important component of long-term asthma therapy. The ultimate aim is to achieve optimum asthma control i.e., achieve and maintain control of clinical symptoms, decrease future risk to patients (risk of exacerbations, progressive loss of lung function and development of fixed airflow obstruction, adverse effects of medications) and enabling the child to lead a life without restrictions, at lowest possible dose of drugs. This article reviews the side-effects of medications used for long-term management of asthma and discusses current literature on asthma monitoring and dose titration in pediatric population to help the asthma therapist not only prescribe the drugs rationally but also help the family make right choices for treatment.

Low Variability in Peak Expiratory Flow Predicts Successful Inhaled Corticosteroid Step-Down in Adults with Asthma

BACKGROUND

The prognosis for patients beyond 1 year after reduction of their inhaled corticosteroid (ICS) dose remains unknown. Predictive factors that can be evaluated before the initiation of asthma treatment or at ICS dose reduction are unknown.

METHODS

We prospectively studied 223 patients in 6 hospitals in the National Hospital Organization of Japan during the 36 months after 50% reduction of their daily ICS dose. All patients recorded their morning and evening peak expiratory flows (PEFs) in their diaries. Lung function, bronchial hyperresponsiveness, fractional nitric oxide levels, number of eosinophils in sputum, and serum IgE levels were measured in most patients. Serum levels of IL-10, IL-33, and thymic stromal lymphopoietin before ICS dose reduction were measured in all patients.

RESULTS

During the 36-month study period, asthma control was retained in 127 (59.6%) of the 213 enrolled patients who underwent ICS dose reduction. Multivariate logistic regression analysis revealed that, at the initiation of dose reduction, the factors most predictive of maintenance of asthma control after ICS dose reduction were a low serum IL-33 level (P < .01), low PEF variability over 1 week (P = .014), childhood onset of asthma (at age <10 years) (P = .03), and high serum IL-10 level (P = .035).

CONCLUSIONS

We demonstrated that low PEF variability over 1 week, high serum IL-10 level, and low serum IL-33 concentration were useful factors for predicting that an adult's asthma will remain in control for months to years after a 50% reduction in the daily ICS dose.

Assessing Mongolian gerbil emotional behavior: effects of two shock intensities and response-independent shocks during an extended inhibitory-avoidance task

Despite step-down inhibitory avoidance procedures that have been widely implemented in rats and mice to study learning and emotion phenomena, performance of other species in these tasks has received less attention. The case of the Mongolian gerbil is of relevance considering the discrepancies in the parameters of the step-down protocols implemented, especially the wide range of foot-shock intensities (i.e., 0.4–4.0 mA), and the lack of information on long-term performance, extinction effects, and behavioral patterning during these tasks. Experiment 1 aimed to (a) characterize gerbils’ acquisition, extinction, and steady-state performance during a multisession (i.e., extended) step-down protocol adapted for implementation in a commercially-available behavioral package (Video Fear Conditioning System—MED Associates Fairfax, VT, USA), and (b) compare gerbils’ performance in this task with two shock intensities – 0.5 vs. 1.0 mA—considered in the low-to-mid range. Results indicated that the 1.0 mA protocol produced more reliable and clear evidence of avoidance learning, extinction, and reacquisition in terms of increments in freezing and on-platform time as well as suppression of platform descent. Experiment 2 aimed to (a) assess whether an alternate protocol consisting of a random delivery of foot shocks could replicate the effects of Experiment 1 and (b) characterize gerbils’ exploratory behavior during the step-down task (jumping, digging, rearing, and probing). Random shocks did not reproduce the effects observed with the first protocol. The data also indicated that a change from random to response-dependent shocks affects (a) the length of each visit to the platform, but not the frequency of platform descends or freezing time, and (b) the patterns of exploratory behavior, namely, suppression of digging and rearing, as well as increments in probing and jumping. Overall, the study demonstrated the feasibility of the extended step-down protocol for studying steady performance, extinction, and reacquisition of avoidance behavior in gerbils, which could be easily implemented in a commercially available system. The observation that 1.0 mA shocks produced a clear and consistent avoidance behavior suggests that implementation of higher intensities is unnecessary for reproducing aversive-conditioning effects in this species. The observed patterning of freezing, platform descents, and exploratory responses produced by the change from random to periodic shocks may relate to the active defensive system of the gerbil. Of special interest is the probing behavior, which could be interpreted as risk assessment and has not been reported in other rodent species exposed to step-down and similar tasks.

Interaction between harmane, a class of β-carboline alkaloids, and the CA1 serotonergic system in modulation of memory acquisition

This study set to assess the involvement of dorsal hippocampus (CA1) serotonergic system on harmane induced memory acquisition deficit. We used one trial step-down inhibitory avoidancetask to evaluate memory retention and then, open field test to evaluate locomotor activity in adult male NMRI mice. The results showed that pre-training intra-peritoneal (i.p.) administration of harmane (12mg/kg) induced impairment of memory acquisition. Pre-training intra-CA1 administration of 5-HT1B/1D receptor agonist (CP94253; 0.5 and 5ng/mouse) and 5-HT2A/2B/2C receptor agonist (α-methyl 5-HT; 50ng/mouse) impaired memory acquisition. Furthermore, intra-CA1 administration of 5-HT1B/1D receptor antagonist (GR127935; 0.5ng/mouse) and 5-HT2 receptor antagonist (cinancerine; 5ng/mouse) improved memory acquisition. In addition, pre-training intra-CA1 injection of sub-threshold dose of CP94253 (0.05ng/mouse) and α-methyl 5-HT (5ng/mouse) potentiated impairment of memory acquisition induced by harmane (12mg/kg, i.p.). On the other hand, pre-training intra-CA1 infusion of sub-threshold dose of GR127935 (0.05ng/mouse) and cinancerine (0.5ng/mouse) with the administration of harmane (12mg/kg, i.p.) weakened impairment of memory acquisition. Moreover, all above doses of drugs did not change locomotor activity. The present findings suggest that there is an interaction between harmane and the CA1 serotonergic system in modulation of memory acquisition.

A Randomized Pragmatic Trial of Changing to and Stepping Down Fluticasone/Formoterol in Asthma

BACKGROUND

Guidelines recommend reducing treatment in patients with well-controlled asthma after 3 months of stability. However, there is inadequate real-life data to guide physicians on therapy change in daily practice.

OBJECTIVE

To assess asthma control after change to and step-down of fluticasone propionate/formoterol fumarate dihydrate (FP/FOR) in real-life patients.

METHODS

In a randomized controlled, pragmatic, open-label trial, 225 well-controlled patients with asthma were randomized (1:2) to maintain high-dose fluticasone propionate/salmeterol xinafoate (FP/SAL, 1000/100 μg) or switch to FP/FOR (1000/40 μg) daily for 12 weeks (phase 1). One hundred sixteen patients stable on FP/FOR at week 12 were subsequently randomized (1:1) to maintain this therapy, or stepped down to FP/FOR (500/20 μg) daily for 12 weeks (phase 2). The primary end point was the 7-question Asthma Control Questionnaire (ACQ7) score.

RESULTS

In phase 1, FP/FOR (1000/40 μg) (n = 126) was noninferior to FP/SAL (1000/100 μg) (n = 73) for ACQ7 (difference in means, -0.12; 95% CI, -0.32 to 0.09). In phase 2, FP/FOR (500/20 μg) (n = 52) was noninferior to FP/FOR (1000/40 μg) (n = 52) for ACQ7 (difference in means, 0.01; 95% CI, -0.20 to 0.22). There was no significant difference in exacerbation rate between the groups in either phase. However, 1 to 2 exacerbations in 12 months before phase 1 were associated with the occurrence of an exacerbation after step-down (P = .007).

CONCLUSIONS

In patients with well-controlled asthma, a change from FP/SAL to FP/FOR did not compromise asthma control. Step-down of FP/FOR was well tolerated; however, in contrast to current guidelines, our data suggest caution in stepping down patients uncontrolled in the last 12 months. Larger step-down studies are required to confirm these findings.

Step-down treatment from medium-dosage of budesonide/formoterol in controlled asthma

BACKGROUND

The stepping down of asthma treatment can be considered when asthma symptoms have been well controlled with inhaled corticosteroids (ICSs)/long-acting β2 adrenergic agonists (LABAs). However, few data are available comparing the efficacy between two step-down strategies, to reduce ICS/LABA dose or to withdraw LABA continuing ICS, in well-controlled asthmatics.

METHODS

This was a prospective multicentre randomized, two-arm, controlled study. Ninety-one asthmatic patients controlled by budesonide/formoterol combination (BFC) 320/9 μg twice daily were assigned to 2 stepping-down treatments as follows: the BFC group; BUD/FM 160/4.5 μg twice daily, and the ICS group; ICS (budesonide 400 μg twice daily or equivalent dose of ICS) without LABA, and followed for 12 weeks. The primary outcome was the incidence of asthma exacerbations. Asthma control, pulmonary function tests, and fraction of exhaled nitric oxide (FeNO) were evaluated at the beginning and end of the period.

RESULTS

The incidence of exacerbations was 16.3% in the BFC groups and 12.5% in the ICS group, which were not different between the groups (p = 0.766). No significant differences were found in QOL score and FeNO between 0 week and 12 week in the both group. FEV1 and FEV1 percentage of the predicted value were lower at week 12 than at week 0 in the ICS group, but not in the BFC group.

CONCLUSIONS

The two step-down strategies for 12 weeks have equal acceptability in well-controlled asthmatics treated with medium-dose of BFC, however, withdrawal of LABA may have potential risk to deteriorate FEV1.

CLINICAL TRIAL REGISTRATION

This study was registered to UMIN-CTR (http://www.umin.ac.jp/ctr/), UMIN000010333.