Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma

Sobieraj, Diana M; Weeda, Erin R.; Nguyen, Elaine; Coleman, Craig I.; White, C Michael; Lazarus, Stephen C.; Blake, Kathryn; Lang, Jason E.; Baker, William L.

doi:10.1001/jama.2018.2769

Cited by 279 publications

(248 citation statements)

References 47 publications

Supporting

Mentioning

231

Contrasting

Unclassified

Order By: Relevance

“…The fifth paradox is that, although ICS/fast-onset LABA as reliever therapy has greater efficacy than SABA reliever therapy across steps 3 and 4 [29], in clinical practice most patients receive SABA reliever therapy at these steps. Furthermore, even those prescribed ICS/fast-onset LABA maintenance and reliever therapy are commonly co-prescribed a SABA [30].…”

Section: Fifth Paradoxmentioning

confidence: 99%

The further paradoxes of asthma management: time for a new approach across the spectrum of asthma severity

et al. 2018

View full text Add to dashboard Cite

@ERSpublicationsA paradigm shift in asthma management that addresses the paradoxes of SABA reliever therapy is required; consideration needs to be given to replacement of SABA reliever with ICS/fast-onset β-agonist reliever therapy across the range of asthma severity http://ow.ly/ccff30lNLPv Cite this article as: Beasley R, Bird G, Harper J, et al. The further paradoxes of asthma management: time for a new approach across the spectrum of asthma severity. Eur Respir J 2018; 52: 1800694 [https://doi.org/ 10.1183/13993003.00694-2018].Should short-acting β-agonist (SABA) reliever monotherapy be replaced by combination inhaled corticosteroid (ICS)/fast-onset β-agonist as reliever therapy in asthma patients at Global Initiative for Asthma step 1 [1]? This uncertainty is the latest chapter in the controversy relating to the risks and benefits of β-agonist therapy in asthma management [2]. This 70-year controversy began with the introduction of isoprenaline and the concerns that it caused severe refractory asthma and an increased risk of death [3][4][5].The dilemma of evaluating the relative efficacy and risk of β-agonists has persisted since then. Two asthma mortality epidemics in the 1960s and 1970s/1980s were primarily caused by use of high-dose preparations of the potent, yet poorly β 2 -selective agonists, isoprenaline [6] and fenoterol [7], respectively. The epidemics ended abruptly with regulatory restriction and withdrawal of these agents [2,8]. In response to evidence that regular scheduled use of SABAs could increase asthma severity and the risk of exacerbations, the recommendation for their use was changed to "as required for relief of symptoms". This therapeutic approach, together with the increasing use of ICSs, both as separate inhalers and combination ICS/long-acting β-agonist (LABA) inhalers, has been associated with a marked reduction in asthma mortality since the 1990s, although the global rates of asthma mortality have now plateaued [9]. There is clearly a need for alternative treatment strategies to achieve further reductions in global asthma mortality.One strategy is to reduce the potential risks associated with starting SABA reliever monotherapy in intermittent and mild persistent asthma. This strategy was the focus of a recent review in the European Respiratory Journal [1], which identified five paradoxes of this therapeutic approach. The review summarised evidence that SABA reliever monotherapy exposes patients to significant avoidable risk and leads to learned behaviours, which result in difficulties for both patients and doctors (table 1). SABA reliever therapy not only reduces the potential to achieve optimal control at step 1, but also when patients progress to higher treatment steps in the stepwise approach to pharmacological therapy. In this editorial,

show abstract

Section: Fifth Paradoxmentioning

confidence: 99%

The further paradoxes of asthma management: time for a new approach across the spectrum of asthma severity

et al. 2018

View full text Add to dashboard Cite

show abstract

“…8,9,[18][19][20][21][22][23] We excluded 11 trials (Table S2). [24][25][26][27][28][29][30][31][32][33][34] The characters of the 8 trials randomizing 3866 patients are presented in Table 1. All trials were conducted in developed countries.…”

Section: Re Sultsmentioning

confidence: 99%

Increased versus stable dose of inhaled corticosteroids for asthma exacerbations: A systematic review and meta‐analysis

Zhang

Yuan

et al. 2019

Clin Experimental Allergy

View full text Add to dashboard Cite

Asthma is one of the most common chronic diseases, with an estimated 300 million people affected worldwide. 1 Asthma exacerbations are frightening for patients, associated with considerable morbidity and mortality, and pose a considerable economic burden on the healthcare system. [2][3][4] The daily use of inhaled corticosteroids (ICS) effectively controls the day-to-day asthma symptoms but have only partial efficacy in aborting exacerbations. Asthma guidelines recommend Abstract Background: Increasing the dose of inhaled corticosteroids (ICS) is commonly used at early signs of loss of asthma control. However, the potential benefits and harms of this strategy remain unclear. We performed a systematic review and meta-analysis to compare increased dose with stable dose of ICS among adults and children with asthma. Methods: We searched MEDLINE, EMBASE and Cochrane Central Register ofControlled Trials from inception to August 02, 2018. Randomized clinical trials comparing increased doses vs stable doses of ICS for home management of asthma exacerbations in adults or children were included. Results:The analyses included 8 trials totalling 3866 patients. Four trials were judged as low risk of bias, three were unclear risk, and one was ranked as high risk. Increased dose of ICS was associated with a significantly reduced risk of treatment failure compared with stable dose (OR 0.82, 95% CI 0.70-0.97, I 2 = 6%; 314 (281 to 351) vs 358 events per 1000 patients; moderate-quality evidence). There was no significant difference in unscheduled physician visits or hospital admission between increased or stable dose of ICS. However, increased dose of ICS increased the risk of non-serious adverse events (OR 3.50, 95% CI 1.93-6.35, I 2 = 0%) but not serious adverse events.Conclusions: Current evidence of moderate quality supports increasing the dose of ICS as part of a self-initiated action plan to reduce risk of requiring a course of systemic corticosteroids in people with an asthma exacerbation. However, we did not find evidence for an impact on hospital admissions or unscheduled physician visits, and increased ICS dose increased risk of non-serious adverse events. K E Y W O R D Sasthma, clinical immunology, pharmacology and pharmacogenomics

show abstract

“…The early 2000s saw the development of regimens based on the fast‐onset LABA formoterol delivered as a combination inhaler with ICS used for both maintenance and reliever therapy (MART) in moderate and severe asthma. The MART regimen reduced the number of severe asthma exacerbations and the number of beta agonist overuse episodes in adolescents and adults when compared with ICS–LABA combination therapy given as maintenance with SABA reliever therapy . With LABA monotherapy contraindicated in asthmatic patients, ICS–LABA combination therapy was increasingly used and ICS were recommended for all asthmatic patients with at least moderately severe disease.…”

mentioning

confidence: 99%

“…The MART regimen reduced the number of severe asthma exacerbations and the number of beta agonist overuse episodes in adolescents and adults when compared with ICS-LABA combination therapy given as maintenance with SABA reliever therapy. 6,7 With LABA monotherapy contraindicated in asthmatic patients, ICS-LABA combination therapy was increasingly used and ICS were recommended for all asthmatic patients with at least moderately severe disease. SABA monotherapy in mild asthma remained as the last example of guideline-recommended bronchodilator therapy delivered without concomitant antiinflammatory ICS.…”

mentioning

confidence: 99%

The history and future of short‐acting beta₂‐agonist therapy in asthma

Hills

Beasley

2019

Respirology

View full text Add to dashboard Cite

Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma

Cited by 279 publications

References 47 publications

The further paradoxes of asthma management: time for a new approach across the spectrum of asthma severity

The further paradoxes of asthma management: time for a new approach across the spectrum of asthma severity

Increased versus stable dose of inhaled corticosteroids for asthma exacerbations: A systematic review and meta‐analysis

The history and future of short‐acting beta₂‐agonist therapy in asthma

Contact Info

Product

Resources

About

Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma

Cited by 279 publications

References 47 publications

The further paradoxes of asthma management: time for a new approach across the spectrum of asthma severity

The further paradoxes of asthma management: time for a new approach across the spectrum of asthma severity

Increased versus stable dose of inhaled corticosteroids for asthma exacerbations: A systematic review and meta‐analysis

The history and future of short‐acting beta2‐agonist therapy in asthma

Contact Info

Product

Resources

About

The history and future of short‐acting beta₂‐agonist therapy in asthma