Regular Inhaled Corticosteroid Treatment Research Articles

Risk factors and prognostic value of osteoporosis in hospitalized patients with bronchiectasis

BackgroundThe risk factors for osteoporosis and its prognostic value in patients with bronchiectasis is not well characterized. We explored the risk factors for osteoporosis and its prognostic impact in hospitalized non-cystic fibrosis bronchiectasis (NCFB) patients in Southeast China.MethodsThis observational cohort study consecutively enrolled 179 hospitalized patients with NCFB bronchiectasis between 2017 and 2021. The risk factors and the impact of osteoporosis on all-cause mortality were assessed.Results21.2% (38/179) of hospitalized NCFB patients were diagnosed with osteoporosis. Patients with osteoporosis had more severe symptoms (assessed by chronic airway assessment test, CAT, median 22 vs. 17, P = 0.017), poorer quality of life (assessed by St. George Respiratory Questionnaires, SQRC, median 42 vs. 27, P = 0.007), more severe disease stage (assessed by bronchiectasis severity index, BSI, median 14 vs. 11, P = 0.02), more comorbidities (assessed by Bronchiectasis Aetiology Comorbidity Index, BACI, median 5 vs. 4, P = 0.021) than patients without. Age, female sex, anemia, post-infection, and history of regular inhaled corticosteroid treatment were independent risk factors for osteoporosis in those patients. 21 patients (11.7%) died over a median follow-up period of 32 months. The all-cause mortality in NCFB patients with osteoporosis [28.94% (11/38)] was significantly higher than those without osteoporosis [7.09% (10/141)] [hazard ratio (HR) 5.34, 95% confidence interval (CI) 2.26–12.67, P < 0.001]. After adjusting for BSI and other confounding factors, osteoporosis was still independently associated with all-cause mortality in hospitalized NCFB patients (HR 4.29, 95% CI 1.75–10.49, P < 0.001).ConclusionsOsteoporosis had an independent effect on all-cause mortality in hospitalized NCFB patients. Management of comorbidities, including bone health, is a critical aspect of treating NCFB patients.

The effect of the COVID-19 pandemic on long-term treatment compliance and disease control in children with persistent asthma.

No long-term data exists on asthma treatment compliances (ATC), exacerbations (AE), and control (AC) during the COVID-19 pandemic in children. This study aimed to evaluate ATC, AE, AC and the related factors among children with persistent asthma (PA) within the first year of the pandemic Methods. Children aged 6-18 years with PA who were under regular inhaled corticosteroid treatment for at least a year prior to the first COVID-19 case in Türkiye were included. Data on AE and AC were collected from medical files. Factors affecting ATC and AC as well as COVID-19 history were assessed by means of a questionnaire. The study included 247 cases. COVID-19 was detected in 14.5% of them. In the first year of the pandemic, ATC decreased to 56.7% and the most common reason was the absence of asthma symptoms. There was a significant improvement in AC (p < 0.001). The number of upper respiratory tract infections (URTI) and AE were significantly decreased during the first year of the pandemic (p < 0.001). COVID-19 infection, smoking in the household, school attendance, a family member working outside the home, house dust mite sensitization or allergic rhinitis had no significant effect on AC (p > 0.05). Regression analysis determined that children who did not have any URTI had 2.4 times better AC compared to those who had (p= 0.02; %95 CI: 1.1-5.4). Although ATC decreased significantly in the long-term in the first year of the pandemic, significant improvement was observed in AE and AC compared to the previous year, which was related only to not having URTI.

Advances in the treatment of mild asthma: recent evidence.

Asthma affects about 300 million individuals worldwide. Although most patients have mild disease, the majority of them do not have good control and are at risk of exacerbations. Poor compliance with regular maintenance treatment is a considerable problem and is believed to be the main reason for poor control in asthma. In patients with moderate to severe asthma, maintenance and as-needed treatment with one inhaler containing an inhaled corticosteroid (ICS) and the long-acting inhaled β2-agonist formoterol has been proved effective in reducing the risk of severe exacerbations. Recently, the results of 2 large double-blind randomized trials assessing the use of as-needed budesonide/formoterol in patients with mild asthma, who had indications for a regular controller treatment, were published. In comparison with as-needed terbutaline treatment, as-needed budesonide/formoterol treatment improved symptom control and reduced the risk of exacerbations. In comparison with regular ICS treatment, exacerbation rates were similar, but regular treatment schedule was associated with better asthma control (despite a higher cumulative ICS dose). The results of these trials have shown that as-needed budesonide/formoterol therapy has acceptable efficacy in mild asthma and may be viewed as a therapeutic option for these patients. As-needed treatment may be preferred by patients who fear the side effects of ICS treatment or by those who experience difficulty in following a fixed-dose regimen. Patients with mild asthma wishing to achieve optimal asthma control may prefer regular maintenance treatment with an ICS.

Why aren't we doing better in asthma: time for personalised medicine?

After decades of improvement, asthma outcomes have stalled. Mortality, hospitalisations, exacerbations and symptom control remain sub-optimal. In controlled trials, most patients gain high levels of control, but in ‘real-life’ routine clinical practice most patients do not. Avoidable factors are found in most asthma deaths and hospital admissions. This perspective paper considers and contextualises the factors underlying poor asthma outcomes, and it suggests approaches that could improve the situation. Factors discussed include severe, therapy-resistant disease and the role of new and upcoming pharmacological therapies in improving outcomes. These are likely to be beneficial when targeted on patients with severe disease and discrete phenotypic characteristics, identified through biomarkers. However, for the majority of patients treated in the community, they are unlikely to be used widely, and better use of current therapy classes will be more important. Non-adherence with regular inhaled corticosteroid treatment and over-use of rescue bronchodilators are common, and many patients have poor inhaler technique. Self-management is frequently poor, particularly in those with psychosocial disadvantages and co-morbidities. Communication between clinicians and patients is sometimes poor, with failure to detect avoidable poor control and non-adherence, and failure to provide the necessary information and education to support efficient self-management. Strategies for improving monitoring and clinician–patient interactions to allow personalised treatment are considered. These strategies have the potential to allow individual patient needs to be recognised and efficient targeting of the variety of effective pharmacological and non-pharmacological interventions that we possess, which has the potential to improve both individual and population outcomes.

Impact of Inhaled Corticosteroid Treatment on 15-Year Longitudinal Respiratory Function Changes in Adult Patients with Bronchial Asthma

Background: Bronchial asthma is mainly controlled by inhaled corticosteroid (ICS) treatment, and discontinuation of ICS treatment can worsen asthma symptoms and reduce respiratory function. However, the longitudinal impact of ICS on lung function in adult patients is unknown. Methods: To determine whether regular ICS treatment can prevent long-term lung function deterioration in adults with bronchial asthma, we recruited 167 adult asthma patients who first visited Fukuoka National Hospital in 1995 and underwent lung function tests in 1995, 1996 and 2010. Regular ICS treatment was continued in 102 patients (regular group), while 39 patients received irregular ICS treatment (irregular group). Changes in lung function were compared retrospectively between the groups. The influences of smoking, disease severity and disease duration were also analyzed. Results: The forced expiratory volume in 1 s (FEV₁) values increased in the regular group 1 year after the initiation of therapy, but they decreased in the irregular group. At year 15, the predicted FEV₁% had decreased significantly more in the irregular group than in the regular group (p < 0.05); FEV₁ decreased by 28.2 ml/year (SD 24.5) in the regular group and by 44.6 ml/year (32.5) in the irregular group (p < 0.05). The decrease in FEV₁ was greater in smokers than in nonsmokers, despite regular ICS treatment, and it was significantly greater in patients with severe asthma than in those with mild or intermittent disease. Delay in ICS initiation also affected the annual FEV₁ decrease. Conclusions: Regular ICS, introduced early when symptoms are mild, could prevent lung function from worsening significantly. Smoking should be strongly discouraged in asthma patients.

Anti-inflammatory Treatment of Atopic Asthma Guided by Exhaled Nitric Oxide: A Randomized, Controlled Trial

Atopic asthma is characterized by Th2 cytokine-driven inflammation of the airway mucosa, which is signaled by the fraction of exhaled nitric oxide (FENO). We tested whether an FENO-guided anti-inflammatory treatment algorithm could improve asthma-related quality of life and asthma symptom control, and reduce exacerbations in atopic asthmatics within primary care. Altogether, 187 patients with asthma and who were nonsmokers (age range, 18-64 years) with perennial allergy and who were on regular inhaled corticosteroid treatment were recruited at 17 primary health care centers, randomly assigned to 2 groups and followed up for 1 year. For the controls (n = 88), FENO measurement was blinded to both operator and patient, and anti-inflammatory treatment was adjusted according to usual care. In the active group (n = 93), treatment was adjusted according to FENO. Questionnaires on asthma-related quality of life (Mini Asthma Quality of Life Questionnaire) and asthma control (Asthma Control Questionnaire) were completed, and asthma events were noted. The Asthma Control Questionnaire score change over 1 year improved significantly more in the FENO-guided group (-0.17 [interquartile range {IQR}, -0.67 to 0.17] vs 0 [-0.33 to 0.50]; P = .045), whereas the Mini Asthma Quality of Life Questionnaire score did not (0.23 [IQR, 0.07-0.73] vs 0.07 [IQR, -0.20 to 0.80]; P = .197). The change in Asthma Control Questionnaire was clinically important in subpopulations with poor control at baseline (P = .03). Furthermore, the exacerbation rate (exacerbations/patient/y) was reduced by almost 50% in the FENO-guided group (0.22 [CI, 0.14-0.34] vs 0.41 [CI, 0.29-0.58]; P = .024). Mean overall inhaled corticosteroid use was similar in both groups (P = .95). Use of FENO to guide anti-inflammatory treatment within primary care significantly reduced the exacerbation rate and improved asthma symptom control without increasing overall inhaled corticosteroid use.

The role of inhaled corticosteroids in management of asthma in infants and preschoolers

This review analyses published data on the treatment of wheezing in infants and preschoolers with inhaled corticosteroids (ICS), including the effect in subgroups of patients such as 'multiple trigger wheeze' and 'episodic viral wheeze'. Therapy with ICS at daily doses of 100-200 μg results in significant clinical improvements in several outcomes in preschoolers and infants suspected of having asthma (multiple trigger wheeze). Such treatment is normally considered well tolerated. Although not well studied, higher daily doses may be associated with measurable effects on growth, which are not cumulative with continued treatment. In children who only wheeze in association with viral infections (episodic viral wheeze), preemptive treatment with high doses of ICS has demonstrated significant clinical effects on several outcomes, whereas lower doses seem to have little effect. Intermittent use of high doses of ICS has been associated with significant reductions in height and weight gain over 1 year. The review illustrates the complexity of treating wheezing in infants and preschoolers and interpreting the study results. It emphasizes the need for more studies in clinical subgroups, more long-term studies and dose-response studies to assess the optimal doses and safety of intermittent as well as regular ICS treatment.

Peanut allergy and allergic airways inflammation

Asthma is a major risk cofactor for anaphylactic deaths in children with peanut allergy. Peanut allergy is generally thought to be a lifelong condition, but some children outgrow their coexistent asthma. It has recently been shown that children who have 'outgrown' their asthma symptoms may have ongoing eosinophilic airways inflammation. The need for regular inhaled corticosteroid treatment in peanut allergic children and adolescents who have outgrown their asthma is however unclear. The aims of our study were to look at fractional exhaled nitric oxide levels (FeNO), as a non-invasive marker of eosinophilic airways inflammation, in peanut allergic children and assess whether children with outgrown asthma had elevated levels. Children with peanut allergy were recruited at two pediatric allergy clinics in Belfast, UK. Exhaled nitric oxide levels (FeNO) were measured using the Niox Mino in all children. Of the 101 peanut allergic children who consented for enrollment in the study, 94 were successfully able to use the NIOX Mino. Age range was 4-15 yr (median 10 yr); 61% were boys. Thirty (32%) had never wheezed, 37 (39%) had current treated asthma, 20 (21%) had at least 1 wheezing episode within the last year but were not taking any regular asthma medication (wheeze no treatment), and 7 (7%) had outgrown asthma. All children with outgrown asthma had elevated levels of FeNO (> 35 ppb), and 75% of children defined as 'wheeze no treatment' had elevated FeNO levels (> 35 ppb). Outgrown asthma and children defined as 'wheeze no treatment' had higher levels of FeNO than those with no history of wheeze or current treated asthma (p = 0.003). In children with peanut allergy, we found that those who had outgrown asthma had elevated FeNO levels in keeping with ongoing eosinophilic airways inflammation.

Ozone exposure enhances mast-cell inflammation in asthmatic airways despite inhaled corticosteroid therapy

Asthmatics are recognised to be more susceptible than healthy individuals to adverse health effects caused by exposure to the common air pollutant ozone. Ozone has been reported to induce airway neutrophilia in mild asthmatics, but little is known about how it affects the airways of asthmatic subjects on inhaled corticosteroids. We hypothesised that ozone exposure would exacerbate the pre-existent asthmatic airway inflammation despite regular inhaled corticosteroid treatment. Therefore, we exposed subjects with persistent asthma on inhaled corticosteroid therapy to 0.2 ppm ozone or filtered air for 2 h, on 2 separate occasions. Lung function was evaluated before and immediately after exposure, while bronchoscopy was performed 18 h post exposure. Compared to filtered air, ozone exposure increased airway resistance. Ozone significantly enhanced neutrophil numbers and myeloperoxidase levels in airway lavages, and induced a fourfold increase in bronchial mucosal mast cell numbers. The present findings indicate that ozone worsened asthmatic airway inflammation and offer a possible biological explanation for the epidemiological findings of increased need for rescue medication and hospitalisation in asthmatic people following exposure to ambient ozone.