Letter to the Editor
Cortico-dependent Asthma: Our Clinical Experience
Asma corticodependiente: nuestra experiencia clínica
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"paginaFinal" => "661" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Luis Alejandro Pérez de Llano, Juan Luis García Rivero, Abel Pallares, Noemí Mengual, Rafael Golpe" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Luis Alejandro" "apellidos" => "Pérez de Llano" "email" => array:1 [ 0 => "eremos26@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juan Luis" "apellidos" => "García Rivero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Abel" "apellidos" => "Pallares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Noemí" 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"titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asma corticodependiente: nuestra experiencia clínica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Corticosteroid-dependent asthma is defined as the need for daily administration of oral corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> This definition, however, is ambiguous, since it includes both patients who receive this treatment and experience little improvement, and those who benefit from it (with a varying degree of response). The GOAL study showed that only 7% of patients who were uncontrolled at maximum doses of fluticasone/salmeterol achieved control with an oral steroid regimen.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Few studies have been conducted in this specific patient group, despite their clinical relevance. We report the case of a patient with corticosteroid-dependent asthma, and review the management and progress of all corticosteroid-dependent asthmatics seen in our specialist clinic (10 of a total of 475 patients).</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 69-year-old woman, non-smoker, with a diagnosis of late-onset, non-allergic asthma, IgE 770<span class="elsevierStyleHsp" style=""></span>kU/l, eosinophils 900/mm<span class="elsevierStyleSup">3</span>, FENO 31<span class="elsevierStyleHsp" style=""></span>ppb. Asthma was initially poorly controlled with a combination of maximum doses of budesonide/formoterol, as indicated by asthma control test (ACT) 15, a severe exacerbation in the previous year, FEV<span class="elsevierStyleInf">1</span> 64%, and positive bronchodilator challenge. Significant comorbidities included rhinosinusitis and obesity. Treatment with deflazacort 30<span class="elsevierStyleHsp" style=""></span>mg for 3 weeks increased ACT to 23 and FEV<span class="elsevierStyleInf">1</span> to 67%, but when it was withdrawn, ACT returned to 16 and FEV<span class="elsevierStyleInf">1</span> to 67%. Tiotropium (18<span class="elsevierStyleHsp" style=""></span>μg/day) was added to the combination of fluticasone/salmeterol (500/50<span class="elsevierStyleHsp" style=""></span>μg), but ACT remained unchanged, while FEV<span class="elsevierStyleInf">1</span> rose to 70%. Treatment was subsequently switched to inhaled fluticasone (1000<span class="elsevierStyleHsp" style=""></span>μg/day), tiotropium (18<span class="elsevierStyleHsp" style=""></span>μg/day) and indacaterol (150<span class="elsevierStyleHsp" style=""></span>μg/day). The patient is currently free of exacerbations, her ACT is 24 and FEV<span class="elsevierStyleInf">1</span> is 79%.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In our opinion, a patient who is uncontrolled and presents bronchial obstruction despite treatment with a combination of maximum dose inhaled corticosteroids (IC)-long-acting β-2 agonist (LABA) has corticosteroid-dependent asthma. In the case of our patient, her FEV<span class="elsevierStyleInf">1</span> normalized (at least to >70%) and ACT rose to ≥20 after 3–4 weeks of treatment with deflazacort 30<span class="elsevierStyleHsp" style=""></span>mg. Subsequently, when the oral corticosteroid was discontinued, her clinical and functional status returned to the previous situation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical characteristics, treatment, and progress of patients with corticosteroid-dependent asthma</span><p id="par0020" class="elsevierStylePara elsevierViewall">Ten of our patients (of 475 regularly seen in our consulting rooms) had corticosteroid-dependent asthma. They were typically middle-aged (49.2±15.1 years), with late onset of symptoms (7/10 cases), intense peripheral eosinophilia (eosinophils 565.0±286.8/mm<span class="elsevierStyleSup">3</span>), elevated IgE (379.7±357.3<span class="elsevierStyleHsp" style=""></span>kU/l), FENO (31.7±13.2<span class="elsevierStyleHsp" style=""></span>ppb), and significant comorbidities (particularly obesity, rhinosinusitis, and polyposis). Despite the correct use of IC/LABA at maximum doses, these patients remained symptomatic with signs of bronchial obstruction, yet only 2 developed 2 or more severe exacerbations in a period of 1 year. It seems that in most cases, standard treatment can prevent exacerbations, while failing to provide full control of symptoms or normalization of lung function. This was achieved in all cases when an oral corticosteroid was added, although this treatment was unacceptable due to adverse events.</p><p id="par0025" class="elsevierStylePara elsevierViewall">These 10 patients were managed by the same pulmonologist. For the 2 patients in whom severe exacerbations persisted, the treatment strategy consisted, firstly, of adding omalizumab to the regimen. The response of the patients who received omalizumab confirm its efficacy in reducing exacerbations, but also its lack of effect on lung function.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Persisting bronchial obstruction may explain why optimal control of symptoms is elusive in many patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The next step for all patients consisted of adding a long-acting muscarinic antagonist, a medication that has already demonstrated its efficacy in this clinical setting.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> This intervention helped improve patients’ lung function and symptoms, but to an insufficient degree in 7 cases. We decided to add indacaterol to these 7 patients’ regimens: this potent bronchodilator has demonstrated efficacy in chronic obstructive pulmonary disease, but little experience is available in asthma.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> This combined therapeutic strategy resulted in a significant improvement in lung function and symptoms (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) among corticosteroid-dependent asthma patients, while avoiding the use of oral steroids.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authorship</span><p id="par0035" class="elsevierStylePara elsevierViewall">Study concept and design, data collection, analysis of results, interpretation of findings, and drafting the manuscript: Pérez de Llano.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Study design and data collection: García Rivero and Pallares.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Data collection: Mengual.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Data analysis and interpretation of results: Golpe.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of Interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">Dr Pérez de Llano has received payment from Novartis, Boehringer, Chiesi, Almirall, Esteve and Ferrer, for presentations at medical congresses, consultancy, and coordination or participation in clinical research projects. He has also been invited to attend national or international congresses by some of these companies.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical characteristics, treatment, and progress of patients with corticosteroid-dependent asthma" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authorship" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of Interests" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez de Llano LA, García Rivero JL, Pallares A, Mengual N, Golpe R. Asma corticodependiente: nuestra experiencia clínica. Arch Bronconeumol. 2015;51:660–661.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ACT: asthma control tests; FEV<span class="elsevierStyleInf">1</span>%: forced expiratory volume in 1 second; LAMA: long-acting anticholinergics.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ACT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.9±3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.5±2.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Exacerbations/patient/year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span>% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.5±14.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76.4±13.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Oral corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Omalizumab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">LAMA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Indacaterol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab958658.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical Progress and Treatment Modifications in the 10 Patients Diagnosed With Corticosteroid-dependent Asthma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oral corticosteroid-dependent asthma: a 30-year review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Randhawa" 1 => "W.B. Klaustermeyer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1081-1206(10)60543-1" "Revista" => array:6 [ "tituloSerie" => "Ann Allergy Asthma Immunol" "fecha" => "2007" "volumen" => "99" "paginaInicial" => "291" "paginaFinal" => "302" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17941275" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.D. Bateman" 1 => "H.A. Boushey" 2 => "J. Bousquet" 3 => "W.W. Busse" 4 => "T.J. Clark" 5 => "R.A. Pauwels" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200401-033OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2004" "volumen" => "170" "paginaInicial" => "836" "paginaFinal" => "844" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15256389" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Omalizumab therapy in severe asthma: Experience from the Spanish registry – some new approaches" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Vennera Mdel" 1 => "L. Pérez de Llano" 2 => "S. Bardagí" 3 => "P. Ausin" 4 => "C. Sanjuas" 5 => "H. González" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3109/02770903.2012.668255" "Revista" => array:6 [ "tituloSerie" => "J Asthma" "fecha" => "2012" "volumen" => "49" "paginaInicial" => "416" "paginaFinal" => "422" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22443408" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tiotropium in asthma poorly controlled with standard combination therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.A.M. Kerstjens" 1 => "M. Engel" 2 => "R. Dahl" 3 => "P. Paggiaro" 4 => "E. Beck" 5 => "M. Vandewalker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1208606" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2012" "volumen" => "367" "paginaInicial" => "1198" "paginaFinal" => "1207" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22938706" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Indacaterol: a novel beta2-agonist, provides sustained 24-h bronchodilation in asthma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.M. Beeh" 1 => "E. Derom" 2 => "F. Kanniess" 3 => "R. Cameron" 4 => "M. Higgins" 5 => "A. van As" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00060006" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2007" "volumen" => "29" "paginaInicial" => "871" "paginaFinal" => "878" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17251236" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005100000012/v1_201512080104/S1579212915003201/v1_201512080104/en/main.assets" "Apartado" => array:4 [ "identificador" => "45358" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005100000012/v1_201512080104/S1579212915003201/v1_201512080104/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915003201?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 2 | 16 |
| 2024 October | 151 | 18 | 169 |
| 2024 September | 189 | 20 | 209 |
| 2024 August | 234 | 33 | 267 |
| 2024 July | 143 | 19 | 162 |
| 2024 June | 185 | 38 | 223 |
| 2024 May | 228 | 52 | 280 |
| 2024 April | 60 | 39 | 99 |
| 2024 March | 134 | 26 | 160 |
| 2024 February | 100 | 30 | 130 |
| 2023 March | 28 | 5 | 33 |
| 2023 February | 126 | 21 | 147 |
| 2023 January | 97 | 42 | 139 |
| 2022 December | 131 | 41 | 172 |
| 2022 November | 140 | 32 | 172 |
| 2022 October | 121 | 31 | 152 |
| 2022 September | 115 | 39 | 154 |
| 2022 August | 111 | 35 | 146 |
| 2022 July | 130 | 41 | 171 |
| 2022 June | 111 | 32 | 143 |
| 2022 May | 138 | 37 | 175 |
| 2022 April | 117 | 42 | 159 |
| 2022 March | 113 | 47 | 160 |
| 2022 February | 126 | 46 | 172 |
| 2022 January | 146 | 38 | 184 |
| 2021 December | 80 | 30 | 110 |
| 2021 November | 82 | 61 | 143 |
| 2021 October | 105 | 49 | 154 |
| 2021 September | 97 | 63 | 160 |
| 2021 August | 84 | 42 | 126 |
| 2021 July | 78 | 36 | 114 |
| 2021 June | 129 | 42 | 171 |
| 2021 May | 116 | 42 | 158 |
| 2021 April | 256 | 70 | 326 |
| 2021 March | 171 | 63 | 234 |
| 2021 February | 123 | 29 | 152 |
| 2021 January | 106 | 29 | 135 |
| 2020 December | 124 | 24 | 148 |
| 2020 November | 95 | 24 | 119 |
| 2020 October | 63 | 19 | 82 |
| 2020 September | 59 | 14 | 73 |
| 2020 August | 81 | 17 | 98 |
| 2020 July | 113 | 25 | 138 |
| 2020 June | 79 | 9 | 88 |
| 2020 May | 82 | 29 | 111 |
| 2020 April | 73 | 27 | 100 |
| 2020 March | 63 | 17 | 80 |
| 2020 February | 65 | 22 | 87 |
| 2020 January | 88 | 24 | 112 |
| 2019 December | 40 | 26 | 66 |
| 2019 November | 40 | 28 | 68 |
| 2019 October | 35 | 11 | 46 |
| 2019 September | 34 | 9 | 43 |
| 2019 August | 47 | 11 | 58 |
| 2019 July | 30 | 27 | 57 |
| 2019 June | 31 | 26 | 57 |
| 2019 May | 43 | 30 | 73 |
| 2019 April | 46 | 26 | 72 |
| 2019 March | 50 | 22 | 72 |
| 2019 February | 47 | 13 | 60 |
| 2019 January | 36 | 15 | 51 |
| 2018 December | 41 | 21 | 62 |
| 2018 November | 43 | 13 | 56 |
| 2018 October | 80 | 20 | 100 |
| 2018 September | 45 | 9 | 54 |
| 2018 May | 21 | 2 | 23 |
| 2018 April | 21 | 6 | 27 |
| 2018 March | 34 | 5 | 39 |
| 2018 February | 33 | 6 | 39 |
| 2018 January | 93 | 7 | 100 |
| 2017 December | 96 | 7 | 103 |
| 2017 November | 33 | 6 | 39 |
| 2017 October | 27 | 7 | 34 |
| 2017 September | 17 | 7 | 24 |
| 2017 August | 29 | 13 | 42 |
| 2017 July | 22 | 7 | 29 |
| 2017 June | 23 | 14 | 37 |
| 2017 May | 33 | 3 | 36 |
| 2017 April | 29 | 8 | 37 |
| 2017 March | 18 | 3 | 21 |
| 2017 February | 25 | 6 | 31 |
| 2017 January | 23 | 4 | 27 |
| 2016 December | 43 | 11 | 54 |
| 2016 November | 37 | 15 | 52 |
| 2016 October | 51 | 23 | 74 |
| 2016 September | 37 | 13 | 50 |
| 2016 August | 42 | 9 | 51 |
| 2016 July | 33 | 9 | 42 |
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