What’s New in Asthma Therapy? An Update on Medication Choices

What’s new in the treatment of asthma-and how might new developments affect your practice?

Here, Barbara Yawn, MD, MSc, answers these questions. She summarizes recent studies from the literature and comments on the implications for selecting medication and modifying asthma management.

In updates to follow, Dr Yawn reviews research on asthma education and self-management, the role of diet and nutrition, and the potential for gene therapy in asthma management. 

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Abbreviation Key
ICS = inhaled corticosteroids
LABA = long acting bronchodilator; in most cases for asthma, 
related to long-acting β₂-agonists.
LTRA = leukotriene receptor antagonist-the asthma pill

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Real-World Trial: LTRAs as Effective at 1 Year as ICS or LABAs 
In this randomized trial that studied “real world” patients with asthma seen in primary care offices in the UK, at 2 months LTRAs were equivalent to ICS as first-line therapy and equivalent to LABAs as add-on therapy to an ICS. That equivalence, however, was not maintained at 2-year follow-up. Patients may need modifications (eg, replacement, add-on therapy) after a period on the LTRAs. 

What the results suggest: These results do mirror day-to-day clinical practice where primary care physicians have found that LTRAs are effective for many patients with asthma. It’s important, however, to continue to assess control using a tool such as the Asthma APGAR that helps detect and address any new problems. You may want to help patients understand that LTRAs are an acceptable alternative to ICS but may need to be replaced or combined with other drugs after a few years.

Source: Price D, Musgrave SD, Shepstone L, et al. Leukotriene antagonists as first-line or add-on asthma-controller therapy. N Engl J Med. 2011;364:1695-1707.

Tiotropium as Good as, Maybe Superior to, Standard Therapy in Some People With Asthma
The addition of tiotropium-a long-acting anticholinergic agent-reduced asthma symptoms in people treated with ICS and LABAs. Tiotropium was also effective in a subgroup of patients (ie, those with variations in the genetic loci of B16-Arg/Arg) who are often less responsive to ICS and the usual LABA.

What the results suggest: Stayed tuned for the inclusion of tiotropium in the asthma therapies recommended by guidelines. The recommendation will likely be only for special groups for the next couple of years.

Source: Bateman ED, Kornmann O, Schmidt P, et al. Tiotropium is noninferior to salmeterol in maintaining improved lung function in B16-Arg/Arg patients with asthma. J Allergy Clin Immunol. 2011;128:315-322.
 
Source: Kerstjens HA, Disse B, Schrader-Babo W, et al. Tiotropium improves lung function in patients with severe uncontrolled asthma: a randomized controlled trial. J Allergy Clin Immunol. 2011;128:308-314.

Dexamethasone  vs Prednisone for Asthma Exacerbations
In a study of adult asthma patients visiting the ED for an asthma exacerbation, 2 days of therapy with dexamethasone rather than 5 days of high-dose prednisone improved rate of return to normal activities within 3 days from 80% to 90%. 

What the results suggest: Without assessing cost differences, I don’t think we can recommend this change. The good news was that 80% or more of patients improve rapidly when given a corticosteroid burst for an asthma exacerbation. If it is an asthma exacerbation and there are no contraindications -use corticosteroids.  

Source: Kravitz J, Dominici P, Ufberg J, et al. Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial. Ann Emerg Med. 2011;58:200-204.

Omalizumab for Difficult-to-Control Allergy-Based Asthma
Omalizumab, a recombinant monoclonal antibody, can provide additional benefit in patients (adolescents and adults) whose asthma is not controlled with combination high-dose ICS plus daily LABAs.

What the results suggest: Consider referring to an allergist for omalizumab evaluation in patients with asthma that is difficult to control. But first, please check treatment adherence and inhaler technique. No one should be using this expensive therapy if additional behavioral support and good inhaler technique would solve the problem!

Source: Hanania NA, Alpan O, Hamilos DL. Omalizumab in severe allergic asthma inadequately controlled with standard therapy: a randomized trial. Ann Intern Med. 2011;154:573-582.

Source: Busse WW, Morgan WJ, Gergen PJ, et al. Randomized trial of omalizumab (anti-IgE) for asthma in inner-city children. N Engl J Med. 2011;364:1005-1015.

ICS Safe During Pregnancy
We all worry about giving pregnant women any medications but know that uncontrolled asthma can lead to poor pregnancy outcomes (eg, preterm births and babies small for gestational age). Hodyl and colleagues looked at the metabolic effects of ICS given to pregnant women and found no impact on the glucocorticoid-regulated pathways in the fetus.

What the results suggest: ICS given to mothers with asthma is unlikely to adversely affect fetal growth and development. This lends further support to the use of ICS and if necessary, bronchodilators during pregnancy. Using proper medications to maintain good control improves outcomes.

Source: Hodyl NA, Stark MJ, Osei-Kumah A, et al. Fetal glucocorticoid-regulated pathways are not affected by inhaled corticosteroid use for asthma during pregnancy. Am J Respir Crit Care Med. 2011;183:716-722.
 
ICS and Pneumonia in Patients With Asthma
Some large trials studying people with COPD have shown that ICS therapy increases the risk of pneumonia. A review of clinical trial data from asthma studies performed for other purposes suggests that there is no increased risk of pneumonia when ICS is used in people with asthma.
The differences in response to ICS therapy between the patients with COPD and those with asthma may be the result of primary differences in underlying disease pathophysiology and of disparities in age and general health status among these patients.

What the results suggest: Please don’t add the fear of ICS-induced pneumonia to your list of concerns: this drug is the fundamental basis for most asthma care.

Source: O'Byrne PM, Pedersen S, Carlsson LG, et al. Risks of pneumonia in patients with asthma taking inhaled corticosteroids. Am J Respir Crit Care Med. 2011;183:589-595.

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