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Once-daily inhaled steroid use in asthmatic children improves adherence

18th February 2022

Once-daily dosing of inhaled steroids in young children with asthma improved medicine adherence compared with a twice daily regime

The use of a once-daily dosing regime for inhaled steroids in young children is associated with an improvement in medication adherence according to a study by researchers at the Department of Pediatrics, Faculty of Medicine, Université de Montréal, Canada.

Asthma is caused by inflammation and a subsequent narrowing of the small airways in the lungs, leading to the typical symptoms, which include any combination of cough, wheeze, shortness of breath and chest tightness. According to the World Health Organisation, in 2019, asthma affected an estimated 262 million people in 2019 and caused 461000 deaths. Moreover, among children aged 5-14 years, asthma is among the top 10 causes of disability-adjusted life years.

Inhaled steroids are the most effective drugs used in asthma to suppress airway inflammation and suitable for both adults and children. However, adherence to inhaled steroids remains low with one systematic review finding that 24% of asthma exacerbations and 60% of asthma-related hospitalisations could be attributed to poor inhaled steroid adherence. Simplifying regimes for instance, use of a once-daily inhaled steroid has been shown to significantly increase adherence compared to twice daily usage. However, this study was in adults and there is a lack of robust data for children. Consequently, in the present study, the Canadian team wanted to examine the real-life impact of prescribing inhaled steroids once-daily compared to twice-daily and how this affected adherence. They performed a retrospective analysis of children visiting an asthma clinic at their hospital who had been prescribed daily inhaled steroid therapy and compared those prescribed either once or twice daily therapy. They set the primary outcome as the secondary adherence to the inhaled steroid based on the proportion of prescribed days covered (PPDC), which was the total number of days for which the drug was dispensed divided by the total number of days for which the drug was prescribed. The secondary outcome as secondary adherence as either good (> 75%) or poor (< 75%).

Once-daily inhaled steroid use and PPDC

A total of 232 participants with a mean age of 5.8 years (61% male) of whom 110 were prescribed once-daily inhaled steroids were included in the analysis and followed-up for a median of 10.7 months.

The once-daily regime was associated with a higher PPDC compared to twice daily (66.8% vs 58%). After adjustment, children prescribed a once-daily regime had a significantly higher PPDC (7.2%, 95% CI 1.3 – 13.1%) and a higher odds of having a PPDC > 75% (Odds ratio, OR = 1.80, 95% CI 1.01 – 3.26).

However, there were no significant differences between once and twice daily regimes on the time to the first asthma exacerbation (hazard ratio, HR = 0.71, 95% CI 0.38 – 1.31).

Based on these findings, the authors concluded that once-daily dosing improved absolute adherence compared to twice-daily but added that further studies are required to determine whether better adherence leads to clinically meaningful improvements in asthma control.

Citation
Drouin O et al. Adherence to inhaled corticosteroids prescribed once- vs twice-daily in children with asthma Ann Allergy Asthma Immunol 2022

Inhaled budesonide appears to prevent worsening of COVID-19

12th April 2021

Patients with asthma have been under-represented in those hospitalised with COVID-19 prompting researchers to wonder if this was this due to a protective effect from inhaled steroids.

While a good deal of research has focused on treating patients hospitalised with COVID-19, far less attention has been paid to therapeutic interventions among those with milder disease. Apart from increasing age, obesity and, to some extent, gender, there are few prognostic factors of which patients will ultimately need to be hospitalised. It has been suggested that inhaled corticosteroids (ICSs) may offer a protective effect against the virus, by moderating the hyper-inflammatory response observed among hospitalised patients. However, no trials have specifically examined the therapeutic benefit of ICSs and this served as a rational for the steroids in COVID-19 (STOIC) trial by a team from the Nuffield Department of Clinical Medicine, Oxford University, UK. The trial was a randomised, open-label, parallel-group, Phase II trial designed to evaluate the efficacy of a widely used ICS, budesonide in patients with early COVID-19 in the community. It included adults (18 years and over) experiencing symptoms of COVID-19 (cough and fever or anosmia or both) within 7 days of onset. Participants who had recently used either inhaled or systemic corticosteroids were excluded and patients were randomised (1:1) to either usual care or budesonide, given at a dose of 800 micrograms (2 puffs) twice daily whereas usual care was simply defined as supportive therapy. All of the participants were seen at home on days 0, 7 and 14 to provide inhalers and collect samples for PCR testing. The primary outcome was defined as COVID-19-related urgent visits e.g., emergency visits or hospitalisation whereas secondary outcomes included self-reported time to clinical recovery and an assessment of COVID-19 viral load.

Findings
A total of 146 participants were included, well matched and randomised to either budesonide or usual care. The mean age of those assigned to budesonide was 44 years (56% female) with 93% of white ethnicity. The primary outcome occurred in 11 (15%) of patients in the usual care group compared to 2 (3%) in the budesonide group (p = 0.009) and self-reported clinical recovery was 1 day earlier for the budesonide group (7 vs 8 days). At day 14, self-reported symptoms were present in 10% of those assigned to budesonide vs 30% for usual care.

The authors calculated that the number needed to treat with inhaled budesonide to reduce COVID-19 deterioration was 8 and concluded that budesonide appears to be an effective treatment for early COVID-19, reducing the time to recovery but also noted how their findings required urgent validation.

Citation
Ramakrishnan S et al. Inhaled budesonide in the treatment of early COVID-19 (STOIC): a phase 2, open-label, randomised controlled trial. Lancet Respir Med 2021