ICS/formoterol in the management of asthma in the clinical practice of pulmonologists: an international survey on GINA strategy

Abstract Background The treatment with short-acting beta-2 agonists (SABA) alone is no longer recommended due to safety issues. Instead, the current Global Initiative for Asthma (GINA) Report recommends the use of the combination of inhaled corticosteroids (ICS) with the rapid/long-acting beta-2 agonist formoterol, although the use in steps 1 and 2 is still off-label in the EU and in many countries. It is important to understand clinicians’ knowledge and opinions on the issue with the ultimate goal to encourage the implementation of the new approach in clinical practice. Methods We performed an international survey, directed to pulmonologists interested in the management of patients with asthma. Results Most participants reported that SABA alone should not be used in GINA Step 1 asthma treatment. As-needed low-dose ICS/formoterol combination to patients in step 1, and as-needed low-dose ICS/formoterol as reliever therapy in any step were found to be of current use prescribed in their real-life settings. SABA alone was still prescribed to a proportion of patients, although the pulmonologists’ opinion was that it should no longer be used. Conclusions Most specialists are up to date and understand the relevance of the changes in GINA reports from 2019. Nevertheless, dissemination and implementation of GINA novel management strategy is still needed.

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2. Inhaled Corticosteroids/long Acting ^|^beta;2-agonists Combination.

Nihon Naika Gakkai Zasshi ◽

10.2169/naika.99.1536 ◽

2010 ◽

Vol 99 (7) ◽

pp. 1536-1541

Author(s):

Mitsuru Adachi ◽

Takashi Hirose

Keyword(s):

Inhaled Corticosteroids ◽

Beta 2 ◽

Long Acting

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LATE-BREAKING ABSTRACT: Real life impact of long acting beta-2-agonist withdrawal in controlled step 3 asthma patients

10.1183/13993003.congress-2016.oa4829 ◽

2016 ◽

Author(s):

Sunny Jabbal ◽

Arvind Manoharan ◽

William Anderson ◽

Joseph Lipworth ◽

Brian Lipworth

Keyword(s):

Real Life ◽

Asthma Patients ◽

Life Impact ◽

Beta 2 ◽

Long Acting

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Impact of extrafine formulations of inhaled corticosteroids/long-acting beta-2 agonist combinations on patient-related outcomes in asthma and COPD

Patient Related Outcome Measures ◽

10.2147/prom.s55276 ◽

2014 ◽

pp. 153 ◽

Cited By ~ 1

Author(s):

Alberto Papi ◽

Nicola Scichilone ◽

Alida Benfante ◽

Luca Morandi ◽

Federico Bellini

Keyword(s):

Inhaled Corticosteroids ◽

Beta 2 ◽

Long Acting

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Efficacy and safety of the CRTh2 antagonist AZD1981 as add-on therapy to inhaled corticosteroids and long-acting β2-agonists in patients with atopic asthma

Drug Design Development and Therapy ◽

10.2147/dddt.s147389 ◽

2018 ◽

Vol Volume 12 ◽

pp. 1093-1106 ◽

Cited By ~ 7

Author(s):

Eric D. Bateman ◽

Christopher O'Brien ◽

Paul Rugman ◽

Sally Luke ◽

Stefan Ivanov ◽

...

Keyword(s):

Inhaled Corticosteroids ◽

Atopic Asthma ◽

Efficacy And Safety ◽

Beta 2 ◽

Long Acting

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Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes

European Respiratory Journal ◽

10.1183/13993003.02730-2021 ◽

2021 ◽

pp. 2102730

Author(s):

Helen K. Reddel ◽

Leonard B. Bacharier ◽

Eric D. Bateman ◽

Christopher E. Brightling ◽

Guy G. Brusselle ◽

...

Keyword(s):

Severe Asthma ◽

Inhaled Corticosteroids ◽

Age Groups ◽

Skills Training ◽

Mild Asthma ◽

Executive Summary ◽

Global Initiative For Asthma ◽

Global Initiative ◽

Long Acting ◽

Beta2 Agonist

The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes.GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as- needed combination ICS-formoterol reduces severe exacerbations by >60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA.Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4.Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.

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Comparing LAMA with LABA and LTRA as add-on therapies in primary care asthma management

npj Primary Care Respiratory Medicine ◽

10.1038/s41533-020-00205-9 ◽

2020 ◽

Vol 30 (1) ◽

Author(s):

Alan Kaplan ◽

J. Mark FitzGerald ◽

Roland Buhl ◽

Christian Vogelberg ◽

Eckard Hamelmann

Keyword(s):

Primary Care ◽

Lung Function ◽

Inhaled Corticosteroids ◽

Asthma Management ◽

Global Initiative For Asthma ◽

Control Asthma ◽

Global Initiative ◽

Long Acting ◽

Randomised Controlled ◽

Meta Analyses

Abstract The Global Initiative for Asthma recommends a stepwise approach to adjust asthma treatment to the needs of individual patients; inhaled corticosteroids (ICS) remain the core pharmacological treatment. However, many patients remain poorly controlled, and evidence-based algorithms to decide on the best order and rationale for add-on therapies are lacking. We explore the challenges of asthma management in primary care and review outcomes from randomised controlled trials and meta-analyses comparing the long-acting muscarinic antagonist (LAMA) tiotropium with long-acting β2-agonists (LABAs) or leukotriene receptor antagonists (LTRAs) as add-on to ICS in patients with asthma. In adults, LAMAs and LABAs provide a greater improvement in lung function than LTRAs as add-on to ICS. In children, results were positive and comparable between therapies, but data are scarce. This information could aid decision-making in primary care, supporting the use of add-on therapy to ICS to help improve lung function, control asthma symptoms and prevent exacerbations.

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Perceptions of COPD patients of the proposed withdrawal of inhaled corticosteroids prescribed outside guidelines: A qualitative study

Chronic Respiratory Disease ◽

10.1177/1479973119855880 ◽

2019 ◽

Vol 16 ◽

pp. 147997311985588 ◽

Cited By ~ 1

Author(s):

Gill Gilworth ◽

Timothy Harries ◽

Chris Corrigan ◽

Mike Thomas ◽

Patrick White

Keyword(s):

Side Effects ◽

Inhaled Corticosteroids ◽

Qualitative Interviews ◽

Chronic Obstructive Lung Disease ◽

Airflow Limitation ◽

Individual Risk ◽

Chronic Obstructive ◽

Copd Patients ◽

Global Initiative ◽

Long Acting

Global Initiative for Chronic Obstructive Lung Disease guidelines support the prescription of fixed combination inhaled corticosteroids (ICS) and long-acting β-agonists in symptomatic COPD patients with frequent or severe exacerbations, with the aim of preventing them. ICS are frequently also prescribed to COPD patients with mild or moderate airflow limitation, outside guidelines, with the risk of unwanted effects. No investigation to date has addressed the views of these milder COPD patients on ICS withdrawal. The objective is to assess the views of COPD patients with mild or moderate airflow limitation on the staged withdrawal of ICS prescribed outside guidelines. One-to-one semi-structured qualitative interviews exploring COPD patients’ views about ICS use and their attitudes to proposed de-prescription were conducted. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was completed. Seventeen eligible COPD patients were interviewed. Many participants were not aware they were using an ICS. None was aware that prevention of exacerbations was the indication for ICS therapy or the risk of associated side effects. Some were unconcerned by what they perceived as low individual risk. Others expressed fears of worsening symptoms on withdrawal. Most with mild or moderate airflow limitation would have been willing to attempt withdrawal or titration to a lower dosage of ICS if advised by their clinician, particularly if a reasoned explanation were offered. Attitudes in this study to discontinuing ICS use varied. Knowledge of the drug itself, the indications for its prescription in COPD and potential for side effects, was scant. The proposed withdrawal of ICS is likely to be challenging and requires detailed conversations between patients and respiratory healthcare professionals.

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