New approaches to basic treatment of asthma
Among chronic respiratory diseases, asthma is one of the most common diseases. The current goal of asthma treatment is to achieve asthmacontrol. Despite the fact that, according to the data of randomized trials, this goal is achievable in most patients, in real clinical practice the proportion of patients who have achieved asthmacontrol does not exceed 42–49%. The article provides an analysis of these recommendations and a literature review of those studies that justify their changes. A key change in the new GINA recommendations is the rejection of shortacting beta2agonists as monotherapy in patients with mild stage I asthma.
The priority regimen of basic therapy at this stage of treatment is now a fixed combination of budesonide/formoterol, taken on demand. Such therapy, according to the literature, was significantlymoreeffectivethanshortactingbeta2 agonists monotherapy. In addition, budesonide/ formoterol is also considered as a priority drug for relieving symptoms on demand, and short acting beta2agonists is currently classified as an alternative drug.
The recommendation is based on the data of randomized trials, in which it was proved that the use of a fixed combination of budesonide/ formoterol on demand, significantly reduces the number of exacerbations of asthma compared with the use of shortacting beta2agonists on demand. The introduction of new GINA recommendations into practice will improve the effectiveness of basic therapy for asthma.
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2019. www.ginasthma.org.
Rehman A. Prevalence of asthma andits management: areview/A. Rehman, F. Amin, S. Sadeeqa//J. Pak. Med. Assoc. 2018; 68 (12): 1823–7.
Pawankar R. Allergic disease sand asthma: a global public health concernandac all to action/R. Pawankar//World Allergy Organ J. 2014; 7 (1):12.
Bateman E.D. Can guideline – defined asthmacontrol be achieved? The Gaining Optimal Asthma Control study/E.D. Bateman, H.A. Boushey, J. Bousquet [et al.]//Am. J. Respir. Crit. Care Med. 2004; 170: 836–844.
Chapman K.R. Suboptimal asthmacontrol: prevalence, detection and consequencesin primary practice/K.R. Chapman//Eur. Respir. J. 2008; 31: 320–325.
Partridge M.R. Attitudes and actions of asthma patients on regular maintenance therapy: the INSPIRE study/M.R. Partridge, T. van der Molen, S.F. Myrseth, W.W. Busse//BMC Pulm. Med. 2006; 6:13.
Dusser D. Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations/D. Dusser, D. Montani, P. Chanez [et al.]//Allergy. 2007; 62 (6): 591–604.
Price D. Asthmacontrol and management in 8,000 European patients: the recognise asthma and link to symptoms and experience (REALISE) survey/D. Price, M. Fletcher, T. van der Molen// NPJ Prim. Care Respir. Med. 2014; 24: 14009.
Barnes C.B. Asthma and adherence to inhaled corticosteroids: current status and future perspectives/C.B. Barnes, C.S. Ulrik. Respir.// Care. 2015; 60 (3): 455–468.
Partridge Martyn R. Attitudes and actions of asthma patients on regular maintenance therapy: the INSPIRE stady/Martyn R. Partridge, Thys van der Molen, SvenErik Myrseth [et al.]// BMC Pulm. Med. / 2006 Iun. 13; 6–13.
Rabe K.F. Clinical management of asthma in 1999: the Asthma Insights in Europe (AIRE) study/K.F. Rabe, P.A. Vermeire, J.B. Soriano [et al.]//Eur. Respir. J. 2000; 16, 802807.
Gauvreau G.M. Effect of regular inhaled albuterol on allergeninduced late responses and sputum eosinophils in asthmatic subjects/G.M. Gauvreau, M. Jordana, R.M. Watsonetal//Am. J. Respir. Crit. Care Med. 1997; 156 (6): 1738–1745.
Sears M.R. Regular inhaled betaagonist treatment in bronchial asthma/M.R. Sears, D.R. Taylor, C.G. Print [et al.]//Lancet. 1990; 336 (8728): 1391–1396.
Hancox R.J. Tolerance to betaagonists during acute bronchoconstriction/R.J. Hancox, R.E. Aldridge, J.O. Cowan [et al.]//Eur. Respir. J. 1999; 14 (2): 283–287.
Stanford R.H. Shortacting betaagonist use and its ability to predict future asthma related outcomes/R.H. Stanford, M.B. Shah, A.O. D'Souza [et al.]//Ann. Allergy Asthma Immunol. 2012; 109 (6): 403–7.
Suissa S.A. Cohort analyses mortality in asthma and the use of inhaled beta agonists/S. Suissa, P. Erust, J.F. Boivin [et al.]// Am J. Respir. Crit. Care Med. 1994 Mar; 149 (3 Pt 1): 604–10.
Pauwels R.A. Early intervention with budesonide in mild persistent asthma: a randomised, doubleblind trial/R.A. Pauwels, S. Pedersen, W.W. Busse [et al.]//Lancet. 2003; 361 (9363): 1071–1076.
Boulay M.E. Discordance between asthmacontrol clinical, physiological and inflammatory parameters in mild asthma/ M.E. Boulay, L.P. Boulet//Respir. Med. 2013; 107 (4): 511–518.
Barnes P.J. Pathophysiology of asthma/ P.J. Barnes//Br. J. Clin. Pharmacol. 1996 Jul; 42 (1): 3–10.
Reddel H.K. Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: a posthoc efficacy analysis of the START study/ H.K. Reddel, W.W. Busse, S. Pedersen [et al.]// Lancet. 2017; 389 (10065): 157–166.
Papi A. BEST Study Group. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma/A. Papi, G.W. Canonica, P. Maestrelli [et al.]//N. Engl. J. Med. 2007; 356 (20): 2040–2052.
Seberova E. Oxis (formoterol given by Turbuhaler) showed as rapid an onset of action as salbutamol given by a pMDI / E. Seberova, A. Anderssen//Respir. Med. 2000. Jun; 94 (6): 607–611.
Lazarinis N. Combination of budesonide/ formoterol on demand improves asthma control by reducing exerciseinduced bronchoconstriction/ N. Lazarinis, Leif Jorgensen, Tommy Ekström [et al.]//Thorax, 2014 Feb; 69 (2):1306.
O'Byrne P.M. Inhaled combined budesonideformoterol as needed in mild asthma/ P.M. O'Byrne, J.M. FitzGerald, E.D. Bateman [et al.]//N. Engl. J. Med. 2018; 378 (20): 1865–1876.
Beasley R. Controlled trial of budesonide formoterol as needed for mild asthma/R. Beasley, M. Holliday, H.K. Reddel [et al.]//N. Engl. J. Med. 2019; 380 (21): 2020–30.
Sumino K.A. Pragmatic trial of symptom based inhaled corticosteroid use in african american children with mild asthma/K. Sumino, L.B. Bacharier, J. Taylor [et al.]//J. Allergy Clin. Immunol. Pract. 2020 Jan; 8 (1):176–185.
Bateman E.D. Asneeded budesonide formoterol versus maintenance budesonide in mild asthma/E.D. Bateman, H.K. Reddel, P.M. O’Byrne [et al.]//N. Engl. J. Med. 2018 May 17; 378 (20): 1877–1887.
Domingo C. Asneeded ICSLABA in Mild Asthma: What does the evidence say?/C. Domingo, J. Rello, A. Sogo//Drugs, 2019 Nov; 79 (16): 1729–1737.
Papi A. Regular versus asneeded budesonide and formoterol combination treatment for moderate asthma: a noninferiority, randomised, doubleblind clinical trial / A. Papi, B. Marku, N. Scichilone [et al.]//Lancet Respir. Med. 2015; 3 (2): 109–119.
Rabe K.F. Effect of budesonide in combination with formoterol for reliever therapy in asthma exacerbations: a randomised controlled, doubleblind study/K.F. Rabe, T. Atienza, P. Magyar [et al.]//Lancet. 2006; 368 (9537): 744–753.
Patel M. Efficacy and safety of maintenance and reliever combination budesonideformoterol inhaler in patients with asthma at risk of severe exacerbations: a randomised controlled trial/M. Patel, J. Pilcher, A. Pritchard [et al.]//Lancet Respir. Med. 2013; 1 (1): 32–42.
Jorup C. Budesonide/formoterol maintenance and reliever therapy in adolescent patients with asthma/C. Jorup, D. Lythgoe, H. Bisgaard// Eur. Respir. J. 2018; 51 (1): 1701688.
Bisgaard H. Budesonide/formoterol maintenance plus reliever therapy: a new strategy in pediatric asthma/H. Bisgaard, P. Le Roux, D. Bjamer [et al.]//Chest. 2006; 130 (6): 1733–1743.
Masoli M. Doseresponse relationship of inhaled budesonide in adult asthma: a meta analysis/M. Masoli, S. Holt, M. Weatherall [et al.] // Eur. Respir. J. 2004; 23: 552–558.
Holt S. Doseresponse relation of inhaled fluticasone propionate in adolescents and adults with asthma: metaanalysis / S. Holt, A. Suder, M. Weatherall [et al.]//Br. Med. J. 2001 Aug 4; 323 (7307): 253–6.
Cates C.J. Combination formoterol and budesonide as maintenance and reliever therapy versus current best practice (including inhaled steroid maintenance), for chronic asthma in adults and children/C.J. Cates, C. Karnes//Cochrane Database Syst. Rev. 2013 Apr. 30; (4): CD007313.
Kerstjens H.A. Tiotropium in asthma poorly controlled with standard combination therapy/H.A. Kerstjens, M. Engel, R. Dahl [et al.]//N. Engl. J. Med. 2012; 367: 1198–1207.
Rodrigo G.J. What is the role of tiotropium in asthma? a systematic review with meta analysis/G.J. Rodrigo, J.A. CastroRodriguez// Chest 2015;147: 388–96.
Dahl R. Oncedaily tiotropium improves lung function and reduces asthma exacerbation/ worsening in patients with symptomatic asthma, regardless of allergic status / R. Dahl, P. Paggiaro, M. Egel//Allergy. 2013; 68 (Suppl. 97): 40–41.
Rodrigo G.J. Efficacy and safety of subcutaneous omalizumab vs placebo as add on therapy to corticosteroids for children and adults with asthma: a systematic review/G.J. Rodrigo, H. Neffen, J.A. Castro Rodriguez//Chest. 2011;139: 28–35.
Castro M. Reslizumab for inadequately controlled asthma with elevated blood eosinophil counts: results from multicenter, parallel, doubleblind, randomized, placebo controlled, phase 3 trials/M. Castro, J. Zangrilli, M.E. Wechsler [et al.]//Lancet Respir. Med. 2015; 3: 355–66.
Ankerst J. Combination inhalers containing inhaled corticosteroids and longacting beta2 agonists: improved clinical efficacy and dosing options in patients with asthma/J. Ankerst//J. Asthma, 2005, 42 (9): 715–24.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.