New review examines extended uses of inhaled corticosteroids in asthma

Naveed Saleh, MD, MS, for MDLinx | April 26, 2018

In a recent Comparative Effectiveness Review published by the Agency for Healthcare Research and Quality, researchers found support for extending uses of intermittent inhaled corticosteroids (ICS) and long-acting muscarinic antagonists (LAMAs).

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In children younger than 5 with recurrent wheezing, intermittent ICS during an upper respiratory infection reduces asthma exacerbations.

According to the researchers, the purpose of this systematic review with meta-analysis was to assess the efficacy of ICS in different populations of patients with asthma, and to assess whether adding LAMAs would improve outcomes in patients with uncontrolled, persistent asthma. It was listed as one of the six high-priority asthma topics by the National Heart, Lung, and Blood Institute Advisory Council Asthma Expert Working Group.

The preferred method of control for persistent asthma in patients of all ages is scheduled, daily dosages of ICS. A limited amount of research has elucidated the efficacy of ICS dosing alone. However, according to the researchers, “This lack of evidence should not be equated to lack of benefit necessarily.”

The review comprised 56 studies—54 randomized controlled trials and 2 observational studies.  Of the 54 randomized controlled trials, 15 dealt with LAMA therapy in patients who were aged 12 and older.

In this study, “controller therapy” was defined as drugs taken daily on a chronic basis to achieve and maintain control of persistent asthma.

The following drugs were included for review:

  • ICS
    • Beclomethasone
    • Budesonide
    • Ciclesonide
    • Flunisolide
    • Fluticasone
    • Mometasone
    • Triamcinolone
  • Long-acting β2-agonists (LABAs)
    • Arformoterol
    • Formoterol
    • Olodaterol
    • Salmeterol
    • Vilanterol
  • LAMAs
    • Aclidinium
    • Glycopyrrolate
    • Tiotropium
    • Umeclidinium

This review did not specifically detail the effects of different doses of drugs.

“Comparisons were class-based, and thus this review does not inform the impact of specific doses on outcomes,” wrote the authors. “Rather, it more globally addresses classes and broad dosing strategies (ie, intermittent dosing of ICS).”

The researchers reported three key findings.

First, in children younger than 5 with recurrent wheezing, intermittent ICS during an upper respiratory infection reduces asthma exacerbations. Second, in patients older than 12 years with persistent asthma, differences between intermittent ICS versus controller use of ICS was not observed, with few studies available for review.

Third, in patients older than 12 years with uncontrolled, persistent asthma, adding LAMAs to ICS decreases asthma exacerbations and improves lung function. Furthermore, addling LAMAs to ICS and LABA controllers improves asthma control and lung function.

The researchers point out that their findings need further verification.

“Given most outcomes were rated with low strength of evidence, future research could change the direction or magnitude of effect or the strength of evidence as the consistency and precision in effect estimates improve.”

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