How to control asthma well: Experts’ perspectives

Early and sustained treatments with simplified regimen are the key to achieving good asthma control, said experts during a presentation at the ERS 2020 Congress.

According to international guidelines, the goal of asthma management is to improve disease control and reduce future risk, particularly with regard to exacerbations.

The two goals are interrelated — as patients with inadequate asthma control are at high risk for future exacerbations, said Professor Alberto Papi from the University of Ferrara at S. Anna University Hospital, Ferrara, Italy.

Control of inflammation = control of symptoms?

Anti-inflammatory therapy with inhaled corticosteroids (ICS) reduced asthma symptoms with a concomitant decrease in inflammatory cells involved in asthma pathogenesis. [Am Rev Respir Dis 1992;145:669-674]

"So, there is a clear association between control of inflammation and clinical outcome,” said Papi.

“Also, the higher the T2 inflammation, as indicated by blood eosinophil count, the greater the efficacy of maintenance ICS in preventing exacerbations,” he added, citing a phase III trial involving patients with mild asthma. [Lancet Respir Med 2020;8:671-680]

Additionally, another important endpoint, death from asthma, was progressively decreased with increasingly more regular use of low-dose ICS. [N Engl J Med 2000;343:332-336]

How to achieve good asthma control?

“Begin anti-inflammatory therapy early if possible,” said Professor Kenneth Chapman from the University of Toronto, Ontario, Canada. “Those who begin later would have suffered irreversible airway remodelling.”

In a prospective study, children who started budesonide therapy >5 years after the onset of asthma had worse FEV₁ than those who initiated the therapy within the first 2 years of onset (p<0.05). [Respir Med 1994;88:373-381]

“Early intervention with ICS can prevent the development of irreversible airway obstruction that occurs over time,” noted Chapman.

Sustaining the early benefit of ICS therapy, however, requires adherence and persistence, he highlighted. “To encourage patients to use their medications regularly, simplicity in dosing regimen has an important role in promoting adherence and persistence in the long run.” 

In an observational retrospective study of 3,503 patients, adherence to fluticasone and salmeterol in a single inhaler was significantly better compared with fluticasone and salmeterol in separate inhalers or fluticasone alone (p<0.05). [Respir Med 2005;99:1263-1267]

Real-world data also showed that a simplified regimen of just once-daily FF/VI* led to greater persistence and adherence (p<0.0001 for both) than twice-daily BUD/FM and BDP/FM**. [Adv Ther 2020;37:2916-2931]

“Early and sustained anti-inflammatory treatment of asthma is associated with better long-term outcomes,” Chapman stated.

The importance of a simplified treatment regimen in asthma control was further demonstrated in The Salford Lung Study — a large randomized comparative study of 4,233 patients in routine clinical practice. [Lancet 2017;390:2247-2255]

Improved asthma control was seen with the use of a simple, once-daily combination treatment of FF/VI without an increased risk of serious adverse events, said Professor Ashley Woodcock from Manchester University, UK.

At week 24, significantly more patients who initiated FF/VI responded to treatment than those on usual care (71 percent vs 56 percent; odds ratio, 2.00; p<0.0001). Also, asthma control based on ACT*** score showed significantly greater improvements with FF/VI vs usual care (mean increase from baseline, 4.4 vs 2.8 points; p<0.0001).

Not all ICS are created equal

“While ICS therapies are generally considered therapeutically similar, ICS molecules with increased binding affinity and selectivity for glucocorticoid receptor not only have increased anti-inflammatory activity, but also … reduce systemic exposure, thereby producing a wider therapeutic window,” explained Chapman.

Such are the properties of FF, he said, which binds with high affinity to glucocorticoid receptor and provides a longer duration of action vs other ICS therapies.