scholarly journals Management of Asthma with ICS and LABAs: Different treatment strategies

2009 ◽  
Vol 1 ◽  
pp. CMT.S2283
Author(s):  
M Van Den Berge ◽  
NHT Ten Hacken ◽  
HAM Kerstjens ◽  
DS Postma
Keyword(s):  
Asthma Control ◽  
Inhaled Corticosteroids ◽  
Asthma Management ◽  
Treatment Strategies ◽  
Rapid Onset ◽  
Onset Of Action ◽  
Persistent Symptoms ◽  
Patient Symptom ◽  
Asthma Patients ◽  
Long Acting

In recent years considerable insight has been gained in the optimal management of adult asthma. In asthma patients who have persistent symptoms despite the daily use of (a low dose) inhaled corticosteroids (ICS), adding a long-acting β2-agonist to ICS improves asthma control and decreases the number of exacerbations. Currently two different LABAs are available, ie formoterol and salmeterol. The most important difference between both LABAs is a more rapid onset of action of formoterol (2-5 minutes) when compared to salmeterol (15-30 minutes). Partly based on these pharmacological differences, two major different approaches have been put forward to asthma management. The first approach (Gaining Optimal Asthma Control) is promoted by the producers of fluticasone/salmeterol and recommends to step up ICS to the dose needed to achieve optimal asthma control in order to keep the patient symptom free and to prevent exacerbations. The second approach is promoted by the producers of budesonide/formoterol and recommends a low maintenance dose which can be adjusted up or down according to the clinical control of asthma. Initially, a treatment strategy with Adjustable Maintenance Dosing with budesonide/formoterol was introduced. At a later time, this concept was changed to the Symbicort Maintenance And Reliever Therapy (SMART) approach. The aim of this manuscript is to review the current literature on the management of asthma with ICS and LABAs and to discuss the different treatment strategies.

The Management of Mild Asthma

2020 ◽  
pp. 2003051
Author(s):  
Paul M. O'Byrne ◽  
Helen K. Reddel ◽  
Richard Beasley
Keyword(s):  
Severe Asthma ◽  
Maintenance Treatment ◽  
Inhaled Corticosteroids ◽  
Symptom Relief ◽  
Rapid Onset ◽  
Mild Asthma ◽  
Asthma Exacerbations ◽  
Reliever Medication ◽  
Asthma Patients ◽  
Long Acting

Inhaled corticosteroids (ICS) have been recommended as a maintenance treatment, either alone or together with long-acting inhaled β2-agonists, for all asthma patients. Short acting β2-agonists (SABA) are rapid onset bronchodilators, which provide symptom relief, but have no anti-inflammatory properties, yet are the most widely used as-needed reliever treatment for asthma, and often the only treatment prescribed. Asthma patients can find adhering to daily preventative medication with ICS difficult and will often revert to using as-needed SABA as their only treatment, increasing their risk of exacerbations. The purpose of this review was to evaluate the efficacy of reliever medications that contain an ICS when compared to SABA as a reliever, or to maintenance ICS and SABA as reliever, in mild asthma patients.Nine studies were identified which have evaluated the use of ICS as a component of an as-needed reliever in patients with mild asthma. Four of the most recent studies compared the combination of ICS/formoterol to SABA as reliever.An ICS containing reliever medication was superior to SABA as reliever alone, and was equivalent to maintenance ICS and SABA as reliever, particularly in reducing risks of severe asthma exacerbations, in studies which compared these reliever options.SABAs should not be used as a reliever without ICS. The concern about patients with mild asthma not being adherent to maintenance ICS, supports a recommendation that ICS/formoterol should be considered as a treatment option instead of maintenance ICS, to avoid the risk of patients reverting to SABA alone.

Combination Therapy with Budesonide and Formoterol in Single Inhaler of Asthma

2010 ◽  
Vol 2 ◽  
pp. 1179559X1000200
Author(s):  
Mohammad Hamzavi
Keyword(s):  
Inhaled Corticosteroids ◽  
Rescue Therapy ◽  
Persistent Asthma ◽  
Clinical Results ◽  
Rapid Onset ◽  
Fixed Dose ◽  
Onset Of Action ◽  
Severe Asthma Exacerbation ◽  
Dose Combination ◽  
Long Acting

Inhaled corticosteroids are the mainstay of asthma therapy, but there is now compelling evidence that addition of a long-acting inhaled β2-agonist, such as formoterol, gives better control in terms of reduced symptoms, improved lung function and reduced exacerbations in patients with mild to severe persistent asthma than increasing the dose of corticosteroids in patients not fully in control by low dose. This has led to development of fixed dose combination inhalers such as budesonide/formoterol. Budesonide/formoterol combination in a single inhaler represents a safe, effective and convenient treatment option for management of patients with unstable asthma than inhaled steroid alone. This combination has shown effectiveness for both maintenance and rescue therapy. Clinical results show that the budesonide/formoterol by SMART approach prolongs the time to first severe asthma exacerbation, reduces frequency of exacerbation and maintains day to day asthma control at a reduced corticosteroid load and cost when compared with higher fixed maintenance dose of combination inhalers. With regular maintenance therapy by this approach it is more likely to improve patient compliance. Budesonide/formoterol combination inhaler has shown to have a faster bronchodialatory effect compared with other combination inhalers, a quality highly in demand during exacerbation episodes. Due to this rapid onset of action, budsonide/formoterol in a single inhaler lends itself to be used as a rescue medication, as well.

scholarly journals Higher Omega-3 Index Is Associated with Better Asthma Control and Lower Medication Dose: A Cross-Sectional Study

Nutrients ◽  
2019 ◽  
Vol 12 (1) ◽  
pp. 74 ◽  
Author(s):  
Isobel Stoodley ◽  
Manohar Garg ◽  
Hayley Scott ◽  
Lesley Macdonald-Wicks ◽  
Bronwyn Berthon ◽  
...  
Keyword(s):  
Fatty Acids ◽  
Asthma Control ◽  
Inhaled Corticosteroids ◽  
Asthma Management ◽  
Airway Disease ◽  
Cross Sectional Study ◽  
Erythrocyte Membranes ◽  
Omega 3 ◽  
Asthma Control Questionnaire ◽  
Cross Sectional

Asthma is a chronic inflammatory airway disease, associated with systemic inflammation. Omega-3 polyunsaturated fatty acids (n-3 PUFA) have established anti-inflammatory effects, thus having potential as an adjunct therapy in asthma. This study aimed to compare erythrocyte n-3 PUFA in adults with (n = 255) and without (n = 137) asthma and determine the relationship between erythrocyte n-3 PUFA and clinical asthma outcomes. Subjects had blood collected, lung function measured and Juniper Asthma Control Questionnaire (ACQ) score calculated. Fatty acids were measured in erythrocyte membranes by gas chromatography, and the omega-3 index (O3I) was calculated (% eicosapentaenoic acid + % docosahexaenoic acid). O3I was similar in subjects with and without asthma (p = 0.089). A higher O3I was observed in subjects with controlled or partially controlled asthma (ACQ < 1.5) compared to subjects with uncontrolled asthma (ACQ ≥ 1.5) (6.0% (5.4–7.2) versus 5.6% (4.6–6.4) p = 0.033). Subjects with a high O3I (≥8%) had a lower maintenance dose of inhaled corticosteroids (ICS) compared to those with a low O3I (<8%) (1000 μg (400–1000) versus 1000 μg (500–2000) p = 0.019). This study demonstrates that a higher O3I is associated with better asthma control and with lower ICS dose, suggesting that a higher erythrocyte n-3 PUFA level may have a role in asthma management.

scholarly journals Health-Related Effects of Home Nebulization With Glycopyrronium on Difficult-to-Treat Asthma: Post-Hoc Analyses of an Observational Study (Preprint)

2020 ◽  
Author(s):  
Deepak Talwar ◽  
Salil Bendre
Keyword(s):  
Adverse Events ◽  
Asthma Control ◽  
Inhaled Corticosteroids ◽  
Moderate Intensity ◽  
Serious Adverse Events ◽  
Female Ratio ◽  
Mean Values ◽  
Control Score ◽  
Long Acting ◽  
Post Hoc

BACKGROUND Bronchial asthma remains a clinical enigma with poorly controlled symptoms or exacerbations despite regular use of inhaled corticosteroids. Home nebulization offers a simplified solution for the delivery of rescue and maintenance bronchodilators, which is especially true for patients with frequent exacerbations during management of uncontrolled or difficult-to-treat asthma. OBJECTIVE We aimed to assess the clinical impact and outcomes associated with home nebulization—delivered long-acting bronchodilators for uncontrolled or difficult-to-treat asthma. METHODS This observational, concurrent study was conducted with 60 patients at 2 centers during November 2018. Statistical analyses for prebronchodilator forced expiratory volume in one second (FEV1) and Global Initiative for Asthma (GINA) asthma control score in patients on long-acting bronchodilators and corticosteroids were conducted, with two-tailed <i>P</i> values &lt;.05 considered statistically significant. RESULTS Per protocol analyses (53/60) for consecutive cases receiving home nebulization with long-acting bronchodilators and corticosteroids were conducted. The baseline demographics included a male-to-female ratio of 30:23 and mean values of the following: age, 60.3 years (SD 11.8 years); weight, 64 kg (SD 16.8 kg); FEV1, 43% (SD 16%); GINA asthma control score, 3.0 points (SD 0.8 points); serum eosinophil level, 4% (SD 3%); fractional exhaled nitric oxide (FeNO), 12.1 ppb (SD 6 ppb). Of the patients, 100% (53/53) had uncontrolled symptoms, 69.8% (37/53) had prior exacerbations, 100% (53/53) used formoterol/budesonide, and 75.5% (40/53) used glycopyrronium. The per protocol group (n=53) had significantly improved mean prebronchodilator FEV1 (23.7%, SD 29.8%; 0.46 L, SD 0.58 L; <i>P</i>&lt;.001) and GINA asthma control score (2.1 points, SD 0.8 points, <i>P</i>&lt;.001). At baseline, patients (n=40) receiving glycopyrronium/formoterol/budesonide (25/20/500 mcg) nebulization admixture had the following mean values: prebronchodilator FEV1, 38% (SD 15%); GINA asthma control score, 3.0 points (SD 0.8 points); reversibility, 12% (SD 6%); peripheral eosinophil level, 4% (SD 3%); FeNO, 12 ppb (SD 5.7 ppb). In the post hoc analyses, these patients had significantly improved mean prebronchodilator FEV1 of 27.7% (SD 26.2%; 0.54 L, SD 0.51 L; <i>P</i>&lt;.001) at 8 weeks compared with baseline. At baseline, patients (n=13) receiving formoterol/budesonide (20/500 mcg) nebulization had the following mean values: FEV1, 55% (SD 12%); GINA asthma control score, 3.0 points (SD 1.2 points); reversibility, 14% (SD 7%); serum eosinophil level, 4% (SD 3%); FeNO, 13.3 ppb (SD 6.8 ppb). In the post hoc analyses, these patients showed a significant improvement in prebronchodilator FEV1 of 11.2% (SD 13.1%; 0.22 L, SD 0.25 L; <i>P</i>&lt;.001) from baseline. Breathlessness of mild to moderate intensity was reported by 10 cases (10/53, 18.9%), with no other treatment-emergent adverse events or serious adverse events. CONCLUSIONS Home nebulization remains a viable option for symptomatic difficult-to-treat asthma cases with frequent use of rescue medications. Glycopyrronium as add-on therapy offers a synergistic response in patients on corticosteroids with difficult-to-treat asthma. CLINICALTRIAL Clinical Trial Registry of India CTRI/2018/11/016319; https://tinyurl.com/y78cctm3

Wirksamkeit und Sicherheit von Dupilumab bei ganzjähriger allergischer Rhinitis und gleichzeitigem Asthma

2019 ◽  
Vol 7 (1) ◽  
pp. 27-28
Author(s):  
Susanne Lau
Keyword(s):  
Allergic Rhinitis ◽  
Inhaled Corticosteroids ◽  
Persistent Asthma ◽  
High Dose ◽  
Specific Response ◽  
Pivotal Phase ◽  
Runny Nose ◽  
Asthma Patients ◽  
Long Acting ◽  
Snot 22

Background: Dupilumab, an anti-IL-4 receptor a mAb, inhibits IL-4/IL-13 signaling, key drivers of type 2/TH2 immune diseases (eg, atopic/allergic disease). In a pivotal, phase 2b study (NCT01854047), dupilumab reduced severe exacerbations, improved lung function and quality of life, and was generally well tolerated in patients with uncontrolled persistent asthma despite using medium-to-high-dose inhaled corticosteroids plus long-acting b2-agonists. Objective: To examine dupilumabʼs effect on the 22-item Sino-Nasal Outcome Test (SNOT-22) total score and its allergic rhinitis (AR)-associated items in asthma patients with comorbid perennial allergic rhinitis (PAR). Methods: A post hoc analysis reporting data from the phase 2b study for the 200 and 300 mg every 2 week (q2w) doses under investigation in phase 3 (NCT02414854) was carried out. PAR was defined at study entry as a specific response to typical perennial antigens (IgE >0.35 Ku/L). Results: Overall, 241 (61%) patients had PAR. In asthma patients with PAR, dupilumab 300 mg q2w versus placebo significantly improved SNOT-22 total score (least squares mean difference, 25.98; 95% CI, 210.45 to 21.51; P 5.009) and all 4 AR-associated symptoms evaluated (nasal blockage, 20.60; 95% CI, 20.96 to 20.25; runny nose, 20.67; 95% CI, 21.04 to 20.31; sneezing, 20.55; 95% CI, 20.89 to 20.21; postnasal discharge, 20.49; 95% CI, 20.83 to 20.16; all P < .01). Dupilumab 200 mg q2w demonstrated numerical, but not statistically significant, decreases in SNOT-22 total score (21.82; 95% CI, 26.46 to 2.83; P 5 .443 vs placebo) and in each ARassociated symptom. In patients without PAR, no differences were observed for these measures versus placebo. Conclusions: Dupilumab 300 mg q2w significantly improved AR-associated nasal symptoms in patients with uncontrolled persistent asthma and comorbid PAR.

scholarly journals Assessment of disease control in patients with asthma

Medicina ◽  
2009 ◽  
Vol 45 (12) ◽  
pp. 943 ◽  
Author(s):  
Guoda Pilkauskaitė ◽  
Kęstutis Malakauskas ◽  
Raimundas Sakalauskas
Keyword(s):  
Lung Function ◽  
Asthma Control ◽  
Control Level ◽  
Asthma Management ◽  
Control Test ◽  
Uncontrolled Asthma ◽  
Asthma Control Test ◽  
Inhaled Steroids ◽  
Asthma Patients ◽  
Β2 Agonists

International guidelines indicate that the main criterion of asthma management is asthma control level. The aim of this study was to assess asthma control and its relation with age, gender, and lung function. Material and methods. A total of 106 family physicians and 13 pulmonologists and allergists took part in this study. Each doctor had selected 10–15 asthma patients and had sent invitations to them by post. On the visit day, the patients themselves filled in the Asthma Control Test. The doctors interviewed the patients and filled in a special questionnaire. Pulmonologists and allergists also assessed lung function by performing spirometry. According to the results of the Asthma Control Test, the disease control level was indicated as “totally controlled” (25 points), “well controlled” (24–20 points), and “uncontrolled” (19 points or less). Results. A total of 876 asthma patients were examined. Uncontrolled asthma was diagnosed to 56.2% of the patients, 36.5% of patients had well controlled and 7.3% totally controlled asthma. There was no significant difference in asthma control level comparing men and women. A correlation between asthma control level and age was found revealing poorer asthma control in older patients. Ninety-five percent of patients were treated with inhaled steroids; most of them had used inhaled steroids in combination with long-acting β2 agonists. It was found that lung function correlated with clinical symptoms of asthma, the demand of shortacting β2 agonists, and asthma control level. Conclusion. The study showed that uncontrolled asthma was diagnosed to more than half of the patients, despite most of them used inhaled steroids. Asthma control was worsening with the age of patients with asthma and it correlated with lung function. We suggest that periodical assessment of asthma control should help to optimize asthma management.

scholarly journals Association of Inhaled Corticosteroids and Long-Acting Muscarinic Antagonists With Asthma Control in Patients With Uncontrolled, Persistent Asthma

JAMA ◽  
2018 ◽  
Vol 319 (14) ◽  
pp. 1473 ◽  
Author(s):  
Diana M. Sobieraj ◽  
William L. Baker ◽  
Elaine Nguyen ◽  
Erin R. Weeda ◽  
Craig I. Coleman ◽  
...  
Keyword(s):  
Asthma Control ◽  
Inhaled Corticosteroids ◽  
Persistent Asthma ◽  
Muscarinic Antagonists ◽  
Long Acting

Diagnosis and Management of Severe Asthma

2018 ◽  
Vol 39 (01) ◽  
pp. 091-099 ◽  
Author(s):  
Kian Fan Chung
Keyword(s):  
Severe Asthma ◽  
Inhaled Corticosteroids ◽  
Immunoglobulin E ◽  
High Dose ◽  
Blood Eosinophil ◽  
Exhaled Breath ◽  
Eosinophilic Asthma ◽  
Severe Eosinophilic Asthma ◽  
Asthma Patients ◽  
Long Acting

AbstractSevere therapy-resistant asthma has been defined as “asthma which requires treatment with high dose inhaled corticosteroids (ICSs) plus a second controller (and/or systemic corticosteroids) to prevent it from becoming ‘uncontrolled’ or which remains ‘uncontrolled’ despite this therapy”. Patients who usually present with ‘difficult-to-treat asthma’ should first be assessed to determine whether he/she has asthma with the exclusion of other diagnoses and if so, whether the asthma can be classified as severe therapy-resistant. This necessitates an assessment of adherence to medications, confounding factors, and comorbidities. Increasingly, management of severe therapy-resistant asthma will be helped by the determination of phenotypes to optimize responses to existing and new therapies. Severe asthma patients are usually on a combination of high dose ICS and long-acting β-agonist (LABA) and, in addition, are often on a maintenance dose of oral corticosteroids. Phenotyping can be informed by measuring blood eosinophil counts and the level of nitric oxide in exhaled breath, and the use of sputum granulocytic counts. Severe allergic asthma and severe eosinophilic asthma are two defined phenotypes for which there are efficacious targeted biologic therapies currently available, namely anti-immunoglobulin E (IgE) and anti-interleukin (IL)-5 antibodies, respectively. Further progress will be realized with the definition of noneosinophilic or non-T2 phenotypes. It will be important for patients with severe asthma to be ultimately investigated and managed in specialized severe asthma centers.

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