Effect of a single day of increased as-needed budesonide–formoterol use on short-term risk of severe exacerbations in patients with mild asthma: a post-hoc analysis of the SYGMA 1 study

O’Byrne, Paul M.; FitzGerald, J. Mark; Bateman, Eric D.; Barnes, Peter J.; Zheng, Jinping; Gustafson, Per; Lamarca, Rosa; Puu, Margareta; Keen, Christina; Alagappan, Vijay; Reddel, Helen

doi:10.1016/s2213-2600(20)30416-1

Cited by 53 publications

(49 citation statements)

References 34 publications

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“…A post-hoc analysis of the Symbicort Given as-needed in Mild Asthma study (SYGMA1) found that as-needed budesonide-formoterol had similar efficacy to maintenance ICS in reducing the frequency of SABA use and risk of subsequent exacerbations. 72 However, there is stronger long-term data on use of regular ICS or ICS/LABA in prevention of asthma-related morbidity and mortality. 73,74 Furthermore, it remains unclear whether the "as-needed" strategy is superior with regard to symptom control and exacerbation prevention, creating an area of ambiguity for TA management.…”

Section: Choice Of Inhaled Therapymentioning

confidence: 99%

Managing Exacerbations in Thunderstorm Asthma: Current Insights

Chatelier

Chan

Tan

et al. 2021

JIR

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Epidemic thunderstorm asthma (ETSA) occurs following a thunderstorm due to the interaction of environmental and immunologic factors. Whilst first reported in the 1980s, the world's largest event in Melbourne, Australia, on November 21, 2016 has led to a wealth of clinical literature seeking to identify its mechanisms, susceptibility risk factors, and management approaches. Thunderstorm asthma (TA) typically presents during an aeroallergen season in individuals sensitized to perennial rye grass pollen (RGP) in Australia, or fungus in the United Kingdom, in combination with meteorological factors such as thunderstorms and lightning activity. It is now well recognized that large pollen grains, which usually lodge in the upper airway causing seasonal allergic rhinitis (SAR), are ruptured during these events, leading to sub-pollen particles respirable to the lower respiratory tract causing acute asthma. The identified risk factors of aeroallergen sensitization, specifically to RGP in Australians with a history of SAR, and individuals born in Australia of South-East Asian descent as a risk factor for TA has been key in selecting appropriate patients for preventative management. Moreover, severity-determining risk factors for ETSA-related asthma admission or mortality, including pre-existing asthma or prior hospitalization, poor inhaled corticosteroid adherence, and outdoor location at the time of the storm are important in identifying those who may require more aggressive treatment approaches. Basic treatments include optimizing asthma control and adherence to inhaled corticosteroid therapy, treatment of SAR, and education regarding TA to increase recognition of at-risk days. Precision treatment approaches may be more beneficial in select individuals, including the use of allergen immunotherapy and even biologic treatment to mitigate asthma severity. Finally, we discuss the importance of environmental health literacy in the context of concerns surrounding the increased frequency of ETSA due to climate change and its implications for the frequency and severity of future events.

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Section: Choice Of Inhaled Therapymentioning

confidence: 99%

Managing Exacerbations in Thunderstorm Asthma: Current Insights

Chatelier

Chan

Tan

et al. 2021

JIR

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“…A severe exacerbation could prompt medical review for consideration of an increase in the treatment step, as such an event is associated with an increased risk of future severe exacerbations ( 10 ). Transition points based on high SABA use could be used for the traditional SABA reliever–based algorithm, as increasing use is a marker of poor asthma control and exacerbation risk ( 10 , 11 ). However, there is a different relationship with increasing ICS/formoterol use, in which higher use reduces the level of risk of an exacerbation, compared with SABA use ( 11 ).…”

mentioning

confidence: 99%

“…Transition points based on high SABA use could be used for the traditional SABA reliever–based algorithm, as increasing use is a marker of poor asthma control and exacerbation risk ( 10 , 11 ). However, there is a different relationship with increasing ICS/formoterol use, in which higher use reduces the level of risk of an exacerbation, compared with SABA use ( 11 ). This could be addressed by guiding the patient to assign the higher reliever use to a higher regularly scheduled maintenance dose for the period of increased use.…”

mentioning

confidence: 99%

A Proposed Revision of the Stepwise Treatment Algorithm in Asthma

Beasley

Bruce

Hatter

et al. 2021

Am J Respir Crit Care Med

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“…Studies have shown that doubling the dose of maintenance ICS when symptoms worsen is not enough to prevent exacerbations, although quadrupling or quintupling it may have the desired effect [46,47]. However, there appears to be a 'window of opportunity' in the 10 days or so leading up to an exacerbation during which timely additional ICS can help to prevent or ameliorate the exacerbation [30,[48][49][50]. Ensuring early usage of the action plan is imperative to taking advantage of the window of opportunity [30].…”

Section: Opportunities For Improvementmentioning

confidence: 99%

The Myth of Mild: Severe Exacerbations in Mild Asthma: An Underappreciated, but Preventable Problem

Kaplan

2021

Adv Ther

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Asthma is a common, chronic inflammatory airway disease, characterised by unpredictable episodes of worsening symptoms, or exacerbations. Causes of asthma exacerbations include viral infections, exposure to allergen and air pollution, all of which increase the underlying inflammation that typifies asthma. Most (50-75%) patients are classed as having mild asthma, with symptoms that can be readily controlled with available inhaled medications. Paradoxically, for the past 30 years, the first treatment recommended in asthma management guidelines was short-acting b 2 -agonists (SABA), which not only have no anti-inflammatory properties but may, in fact, worsen inflammation. The Global Initiative for Asthma (GINA) 2019/2020 broke with this paradox by stating clearly that SABA should no longer be used alone as a reliever, for safety reasons. Instead, GINA now recommends an anti-inflammatory rescue/reliever approach for adult and adolescent patients, based on the combination of an inhaled corticosteroid with a rapid onset b 2 -agonist such as formoterol. This commentary highlights the fact that even patients with well-controlled mild asthma are at risk of severe, potentially life-threatening exacerbations, similar to those in patients with moderate or severe asthma, and therefore 'mild asthma', is a misnomer. The commentary describes the case history of a patient with mild asthma to illustrate how increasing use of SABA alone can worsen and prolong exacerbations when they occur. The author goes on to describe how the management of this patient's exacerbation could have been improved, and provides up-todate advice on broader aspects of the management of mild asthma and exacerbations, supported by the recent changes to the GINA recommendations.

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Effect of a single day of increased as-needed budesonide–formoterol use on short-term risk of severe exacerbations in patients with mild asthma: a post-hoc analysis of the SYGMA 1 study

Cited by 53 publications

References 34 publications

Managing Exacerbations in Thunderstorm Asthma: Current Insights

Managing Exacerbations in Thunderstorm Asthma: Current Insights

A Proposed Revision of the Stepwise Treatment Algorithm in Asthma

The Myth of Mild: Severe Exacerbations in Mild Asthma: An Underappreciated, but Preventable Problem

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