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80&#37; of the clinical benefit at 1&#44;000&#8239;&#956;g&#47;day was achieved at doses of 70&#8211;180&#8239;&#956;g&#47;day and 90&#37; at doses of 100&#8211;250&#8239;&#956;g&#47;day<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; two studies with budesonide&#44; randomized without a placebo arm&#44; in which the authors examined drug doses &#62;800&#8239;&#956;g&#47;day&#44; indicated that there was a minimum additional clinical benefit &#40;if at all&#41; with doses of 3&#44;200&#8239;&#956;g&#47;day compared to 1&#44;600&#8239;&#956;g&#47;day&#44; or 1&#44;600&#8239;&#956;g&#47;day compared to 400&#8239;&#956;g&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></li></ul></p><p id="par0015" class="elsevierStylePara elsevierViewall">Reddel et al&#46; noted that a large percentage of overtreated asthmatic patients &#40;approximately 50&#37;&#41; may achieve lower doses of ICS if long-term &#946;-adrenergic agonists &#40;LABA&#41; are maintained&#44; without increasing inflammatory parameters such as the fraction of nitric oxide in exhaled air &#40;FENO&#41; or eosinophil levels in sputum&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> While it is true that GINA and GEMA recommend reducing the dose of medication once control is achieved&#44; this is done less often than recommended&#58; 85&#37; of changes in medication involve an increase compared to reductions in only 15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">These data are important because we know that high doses of ICS cause adverse effects &#8212;doses &#8805;500&#8239;&#956;g&#47;day of fluticasone propionate or equivalent could be considered high<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> &#8212; and this could be avoided by using T2 inflammation biomarkers to adjust treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> Green et al&#46; showed that using the sputum eosinophil count for therapeutic adjustment helped reduce exacerbations in patients with moderate-severe asthma compared with following guideline recommendations&#44; without the need for higher doses of corticosteroids&#46; In other words&#44; better control was achieved with the same dose&#44; avoiding future therapeutic escalations in a significant percentage of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Another study demonstrated the discriminative ability of FENO &#40;with a cut-off point of 30&#8239;ppb&#41; to predict response to an increase in ICS doses in severe asthma&#44; thus avoiding additional dosing&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Today we know that the inflammatory response is not constant in all asthmatics and that it can change over time in the same individual&#46; The seminal study of Woodruff et al&#46; showed that only asthmatics &#40;with a mild form of the disease&#41; expressing Th2 genes in bronchial epithelium cells responded to ICS&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> These data were corroborated in the SIENA study&#44; which showed a greater clinical response to mometasone than placebo in patients with &#8805;2&#37; eosinophils in sputum&#44; but not in patients below this threshold&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It is also well known that the response to ICS is attenuated in asthmatic patients who smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> A more detailed biological characterization of patients would help clinicians avoid anti-inflammatory escalation in patients who will not respond to high doses and therefore avoid adverse effects in the absence of clinical benefit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">GINA and GEMA recommend therapeutic escalation if asthma control is not achieved and provide a table of ICS equipotency&#44; but do not take into account changes in active ingredients or devices&#46; Yet not all drugs are the same&#46; There are wide differences in potency and therapeutic indexes between the different ICS<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and probably also among LABAs&#46; Despite the paucity of comparative studies between different ICS&#44; clinical experience tells us that control can be achieved by replacing one drug with another without the need to increase the dose&#46;</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">Pointing out defects in a strategic plan is relatively easy&#44; but proposing an alternative is not so simple&#46; We believe that the algorithm described in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> could be appropriate&#44; as it would take into account the underlying biological mechanism and the pharmacological differences between the different ICS&#44; and introduce other anti-inflammatories before reaching potentially dangerous doses&#46; This approach focuses on patients who are a greater risk of being &#8220;overtreated&#8221;&#44; i&#46;e&#46;&#44; those who do not achieve control with 500&#8239;&#956;g fluticasone propionate or equivalent&#46; Adopting this strategy would mean that patients with a biological T2 pattern would have to be precisely identified&#44; requiring us to use biomarkers &#40;FENO&#44; sputum eosinophils&#41; that either do not have a firmly established cut-off point &#40;FENO&#41; or are technically difficult to determine &#40;induced sputum&#41;&#46; The use of FENO is more widespread and more feasible&#44; and a cut-off point of 20&#8722;30&#8239;ppb may be a reasonable possibility according to available studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> Use of a bronchodilator such as tiotropium would be restricted to patients with bronchial obstruction or with a FEV<span class="elsevierStyleInf">1</span> value below their best personal value&#46; To make this strategy more than a proposal&#44; it should be compared with the approach advocated by the guidelines in a prospective&#44; open&#44; two-arm study&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">LPLL has received honoraria and non-financial support from NOVARTIS&#44; grants and honoraria from ASTRA-ZENECA&#44; honoraria and non-financial support from GSK&#44; grants&#44; honoraria and non-financial support from TEVA&#44; honoraria and non-financial support from Boehringer-Ingelheim&#44; grants and honoraria from Chiesi&#44; honoraria from Sanofi&#44; non-financial support from Menarini&#44; honoraria and non-financial support from Mundipharma&#44; and honoraria and non-financial support from Esteve&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">In the past three years&#44; VP has received fees for speaking engagements at sponsored meetings of AstraZeneca&#44; Boehringer-Ingelheim&#44; MSD&#44; and Chiesi&#46; He has received support for attending conferences from AstraZeneca&#44; Chiesi&#44; and Novartis&#46; He has been a consultant for ALK&#44; AstraZeneca&#44; Boehringer&#44; MSD&#44; Mundipharma&#44; and Sanofi&#44; and he has received funding and grants for research projects from various government agencies and non-profit foundations&#44; and from AstraZeneca&#44; Chiesi&#44; and Menarini&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">SQ has organized training and consulting activities and has received speaker fees from ALK&#44; AstraZeneca&#44; Boehringer Ingelheim&#44; Chiesi&#44; GSK&#44; Leti&#44; Novartis&#44; Regeneron Pharmaceuticals&#44; Sanofi&#44; and Teva&#46;</p></li></ul></p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; P&#233;rez de Llano LA&#44; et al&#46; Estrategia para el tratamiento del asma moderada-grave&#58; una alternativa a la recomendada por las gu&#237;as&#46; Arch Bronconeumol&#46; 2021&#59;57&#58;243&#8211;245&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Therapeutic algorithm for the treatment of uncontrolled asthma with high doses of inhaled corticosteroids&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BHR&#58; bronchial hyperresponsiveness&#59; FP&#58; fluticasone propionate&#59; ICS&#58; inhaled corticosteroids&#59; LABA&#58; long-action &#946;-adrenergic agonists&#59; LTRA&#58; leukotriene receptor antagonists &#40;&#42;&#58; especially indicated in patients with predominantly inflammatory changes rather than functional impairment with upper airway involvement&#44; clinically significant allergy&#44; or acetylsalicylic acid-exacerbated respiratory disease&#41;&#59; OCS&#58; oral corticosteroids&#59; T2&#58; inflammation mediated by T helper type 2 &#40;Th2&#41; cells or innate lymphoid cells type 2 &#40;ILC2s&#41;&#46;</p>"
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Editorial
Treatment of moderate-severe asthma: an alternative strategy to the guideline recommendations
Estrategia para el tratamiento del asma moderada-grave: una alternativa a la recomendada por las guías
Luis Pérez de Llanoa
a Servicio de Neumología, Hospital Lucus Augusti, Lugo. Spain
Santiago Quirce Gancedob,
Corresponding author
b Servicio de Alergia, Hospital Universitario La Paz, IdiPAZ, y CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
Vicente Plaza Moralc
c Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Departament de Medicina, Barcelona, Spain
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80&#37; of the clinical benefit at 1&#44;000&#8239;&#956;g&#47;day was achieved at doses of 70&#8211;180&#8239;&#956;g&#47;day and 90&#37; at doses of 100&#8211;250&#8239;&#956;g&#47;day<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; two studies with budesonide&#44; randomized without a placebo arm&#44; in which the authors examined drug doses &#62;800&#8239;&#956;g&#47;day&#44; indicated that there was a minimum additional clinical benefit &#40;if at all&#41; with doses of 3&#44;200&#8239;&#956;g&#47;day compared to 1&#44;600&#8239;&#956;g&#47;day&#44; or 1&#44;600&#8239;&#956;g&#47;day compared to 400&#8239;&#956;g&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></li></ul></p><p id="par0015" class="elsevierStylePara elsevierViewall">Reddel et al&#46; noted that a large percentage of overtreated asthmatic patients &#40;approximately 50&#37;&#41; may achieve lower doses of ICS if long-term &#946;-adrenergic agonists &#40;LABA&#41; are maintained&#44; without increasing inflammatory parameters such as the fraction of nitric oxide in exhaled air &#40;FENO&#41; or eosinophil levels in sputum&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> While it is true that GINA and GEMA recommend reducing the dose of medication once control is achieved&#44; this is done less often than recommended&#58; 85&#37; of changes in medication involve an increase compared to reductions in only 15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">These data are important because we know that high doses of ICS cause adverse effects &#8212;doses &#8805;500&#8239;&#956;g&#47;day of fluticasone propionate or equivalent could be considered high<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> &#8212; and this could be avoided by using T2 inflammation biomarkers to adjust treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> Green et al&#46; showed that using the sputum eosinophil count for therapeutic adjustment helped reduce exacerbations in patients with moderate-severe asthma compared with following guideline recommendations&#44; without the need for higher doses of corticosteroids&#46; In other words&#44; better control was achieved with the same dose&#44; avoiding future therapeutic escalations in a significant percentage of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Another study demonstrated the discriminative ability of FENO &#40;with a cut-off point of 30&#8239;ppb&#41; to predict response to an increase in ICS doses in severe asthma&#44; thus avoiding additional dosing&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Today we know that the inflammatory response is not constant in all asthmatics and that it can change over time in the same individual&#46; The seminal study of Woodruff et al&#46; showed that only asthmatics &#40;with a mild form of the disease&#41; expressing Th2 genes in bronchial epithelium cells responded to ICS&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> These data were corroborated in the SIENA study&#44; which showed a greater clinical response to mometasone than placebo in patients with &#8805;2&#37; eosinophils in sputum&#44; but not in patients below this threshold&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It is also well known that the response to ICS is attenuated in asthmatic patients who smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> A more detailed biological characterization of patients would help clinicians avoid anti-inflammatory escalation in patients who will not respond to high doses and therefore avoid adverse effects in the absence of clinical benefit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">GINA and GEMA recommend therapeutic escalation if asthma control is not achieved and provide a table of ICS equipotency&#44; but do not take into account changes in active ingredients or devices&#46; Yet not all drugs are the same&#46; There are wide differences in potency and therapeutic indexes between the different ICS<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and probably also among LABAs&#46; Despite the paucity of comparative studies between different ICS&#44; clinical experience tells us that control can be achieved by replacing one drug with another without the need to increase the dose&#46;</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">Pointing out defects in a strategic plan is relatively easy&#44; but proposing an alternative is not so simple&#46; We believe that the algorithm described in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> could be appropriate&#44; as it would take into account the underlying biological mechanism and the pharmacological differences between the different ICS&#44; and introduce other anti-inflammatories before reaching potentially dangerous doses&#46; This approach focuses on patients who are a greater risk of being &#8220;overtreated&#8221;&#44; i&#46;e&#46;&#44; those who do not achieve control with 500&#8239;&#956;g fluticasone propionate or equivalent&#46; Adopting this strategy would mean that patients with a biological T2 pattern would have to be precisely identified&#44; requiring us to use biomarkers &#40;FENO&#44; sputum eosinophils&#41; that either do not have a firmly established cut-off point &#40;FENO&#41; or are technically difficult to determine &#40;induced sputum&#41;&#46; The use of FENO is more widespread and more feasible&#44; and a cut-off point of 20&#8722;30&#8239;ppb may be a reasonable possibility according to available studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> Use of a bronchodilator such as tiotropium would be restricted to patients with bronchial obstruction or with a FEV<span class="elsevierStyleInf">1</span> value below their best personal value&#46; To make this strategy more than a proposal&#44; it should be compared with the approach advocated by the guidelines in a prospective&#44; open&#44; two-arm study&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">LPLL has received honoraria and non-financial support from NOVARTIS&#44; grants and honoraria from ASTRA-ZENECA&#44; honoraria and non-financial support from GSK&#44; grants&#44; honoraria and non-financial support from TEVA&#44; honoraria and non-financial support from Boehringer-Ingelheim&#44; grants and honoraria from Chiesi&#44; honoraria from Sanofi&#44; non-financial support from Menarini&#44; honoraria and non-financial support from Mundipharma&#44; and honoraria and non-financial support from Esteve&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">In the past three years&#44; VP has received fees for speaking engagements at sponsored meetings of AstraZeneca&#44; Boehringer-Ingelheim&#44; MSD&#44; and Chiesi&#46; He has received support for attending conferences from AstraZeneca&#44; Chiesi&#44; and Novartis&#46; He has been a consultant for ALK&#44; AstraZeneca&#44; Boehringer&#44; MSD&#44; Mundipharma&#44; and Sanofi&#44; and he has received funding and grants for research projects from various government agencies and non-profit foundations&#44; and from AstraZeneca&#44; Chiesi&#44; and Menarini&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">SQ has organized training and consulting activities and has received speaker fees from ALK&#44; AstraZeneca&#44; Boehringer Ingelheim&#44; Chiesi&#44; GSK&#44; Leti&#44; Novartis&#44; Regeneron Pharmaceuticals&#44; Sanofi&#44; and Teva&#46;</p></li></ul></p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; P&#233;rez de Llano LA&#44; et al&#46; Estrategia para el tratamiento del asma moderada-grave&#58; una alternativa a la recomendada por las gu&#237;as&#46; Arch Bronconeumol&#46; 2021&#59;57&#58;243&#8211;245&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Therapeutic algorithm for the treatment of uncontrolled asthma with high doses of inhaled corticosteroids&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BHR&#58; bronchial hyperresponsiveness&#59; FP&#58; fluticasone propionate&#59; ICS&#58; inhaled corticosteroids&#59; LABA&#58; long-action &#946;-adrenergic agonists&#59; LTRA&#58; leukotriene receptor antagonists &#40;&#42;&#58; especially indicated in patients with predominantly inflammatory changes rather than functional impairment with upper airway involvement&#44; clinically significant allergy&#44; or acetylsalicylic acid-exacerbated respiratory disease&#41;&#59; OCS&#58; oral corticosteroids&#59; T2&#58; inflammation mediated by T helper type 2 &#40;Th2&#41; cells or innate lymphoid cells type 2 &#40;ILC2s&#41;&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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