Combined-drug inhaler provides better mild asthma symptom control than SABA alone, researchers find

Use of an inhaled glucocorticoid plus a fast-acting beta-2-agonist provided superior asthma symptom control in patients with mild asthma, compared to use of a short-acting beta agonist (SABA) alone, a study published in The New England Journal of Medicine (17 May 2018) has found^[1]
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The researchers conducted a 52-week, double-blind, randomised, phase III trial to evaluate the efficacy and safety of one of three regimens: twice-daily placebo plus terbutaline, twice-daily placebo plus budesonide-formoterol, or twice-daily budesonide plus terbutaline (budesonide maintenance therapy) in more than 3,000 patients with uncontrolled asthma symptoms.

In terms of the mean percentage of electronically recorded weeks with well-controlled asthma per patient, budesonide-formoterol used as needed was superior to terbutaline used as needed (34.4% of weeks vs. 31.1% of weeks), but inferior to budesonide maintenance therapy (34.4% and 44.4% respectively).

The researchers calculated that the odds of having a week with well-controlled asthma during the 52-week trial period was 14% higher in the budesonide-formoterol group than in the terbutaline group.

Budesonide-formoterol used as needed also resulted in a 64% lower rate of severe exacerbations and a 60% lower rate of moderate-to-severe exacerbations than terbutaline used as needed. However, the rates of severe exacerbations in the budesonide-formoterol and budesonide maintenance groups did not differ significantly.

Additional inhaled or systemic glucocorticoids for asthma were prescribed in fewer patients (12.8%) receiving budesonide-formoterol compared to those receiving terbutaline (27.0%) or budesonide maintenance therapy (14.6%), and adverse events were more frequent in the terbutaline group compared to the other two groups.

The authors concluded that an inhaled glucocorticoid plus a fast-acting beta-2-agonist, in the form of budesonide-formoterol, used as needed was superior to the SABA terbutaline used as needed both for asthma symptom control and for reducing the risk of asthma exacerbations among patients with mild asthma.

“Short-acting beta-agonists, also known as rescue inhalers, work quickly but they do not treat the underlying problem of inflammation,” said Paul O’Byrne, principal investigator on the study.

“The secret in this new approach is that it not only relieves symptoms but at the same time delivers steroids required for overall control of asthma.”

Another study, published in Thorax (14 May 2018), has shown that, despite declines in national asthma mortality and hospital admission rates, significant differences in socioeconomic status and region remain^[2]
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The researchers looked at asthma deaths in England between 2002–2015, emergency asthma admissions between 2001–2011 and the prevalence of asthma in England, according to the Health Survey for England (HSE) 2010. During these time periods there were 14,830 recorded asthma deaths, of which 68% occurred in females. Between 2001–2011 there were 542,877 emergency asthma admissions in individuals over the age of 5 years. The HSE data revealed that of 12,077 people over the age of 5 years, 1,156 reported having been diagnosed and treated for asthma, and 721 reported severe symptoms of asthma in the last year.

Analysis of the data revealed that asthma mortality decreased among more deprived groups at younger ages. Among 5–44 year olds, mortality was 19% lower for those in the most deprived areas, compared to those in the least deprived quintile.

However, this pattern was seen to be reversed in older adults. Adults aged 45-74 years in the most deprived areas had a 37% higher asthma mortality rate than those in the least deprived areas.

“This previously undocumented inverse relation between deprivation and mortality in the young requires further investigation,” the authors concluded.

“More detailed clinical information could identify a distinct and troublesome asthma phenotype which has become more common in England in recent years, particularly in more affluent areas, as well as helping identify the role of concurrent allergic disease or any overlap with chronic obstructive pulmonary disease in older age groups.”