RESUMO
The widespread use of systemic corticosteroids (SCS) in asthma is associated with significant comorbidities and mortality. A dose-response relationship for cumulative SCS exposure with most adverse outcomes began at cumulative exposures of 1.0-<2.5 g, equivalent to four lifetime SCS courses. The purpose of creating the SCS credit concept was to increase awareness of the risks of SCS exposure and to promote better therapeutic alternatives. Consuming the lifetime SCS credit of 1.5 g/yr significantly increased morbidity and mortality.
RESUMO
BACKGROUND: The choice of bronchodilators for responsiveness testing (BRT) is a clinical decision according to ATS/ERS. Since January 2019 we use budesonide/formoterol for BRT in asthma at our center in Argentina. The aim was to compare budesonide/formoterol with salbutamol for BRT in stable asthmatic patients that were followed up in a short-acting beta2 agonist (SABA)-free asthma center. METHODS: From the Hospital database, we found for the same patient at least one BRT using salbutamol 200 µg and another with budesonide/formoterol 320/9 µg. RESULTS: We found similar BRT between salbutamol and budesonide/formoterol in 101 asthmatic individuals (26 males) aged 38.14 ± 16.1 yrs (mean ± Standard deviation). The absolute response was 0.18 ± 0.21 L in FEV1 after salbutamol and 0.20 ± 0.22 L in FEV1 after budesonide/formoterol. Afterwards, we showed 202 patients tested with budesonide/formoterol; the mean absolute response was 0.21 ± 0.22 L in FEV1. There were no unexpected safety findings. CONCLUSIONS: In asthmatic patients, we demonstrated similar efficacy between Budesonide/formoterol and salbutamol for BRT.
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Why not directly eradicate SABA from asthma management? The time to leave behind SABA in asthma management is now. We wasted enough time identifying the key issue in asthma morbidity and mortality. Please, eradicate SABA. https://bit.ly/3DU4mmo.
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Resumen En las últimas décadas ha habido un importante desarrollo de dispositivos inhalados (DI) que permiten aumentar la eficacia de las drogas y disminuir los eventos adversos. Su correcto uso es de fundamental importancia para el control de las enfermedades respiratorias obstructivas. En la Argentina no existen recomendaciones locales sobre el uso de los DI. Se revisó la base biofísica, indicación, ventajas y limitaciones, técnica de correcto uso, errores frecuentes, mantenimiento y limpieza de cada DI. El uso de nebulizaciones ha quedado restringido a la administración de drogas que no están disponibles en otros DI (ejemplo: tratamiento de fibrosis quística), o ante la falla de los otros DI. No deben ser usados durante la pandemia de SARS-CoV2. Los inhaladores de dosis medida (aerosol) deben ser indicados siempre con aerocámaras (AC), las que reducen la incidencia de eventos adversos y aumentan el depósito de la droga en el pulmón. Son los dispositivos de elección junto a los inhaladores de polvo seco. Los aerosoles se deben usar en pacientes que no generan flujos inspiratorios altos. Los inhaladores de polvo seco deben recomendarse en aquellos que pueden realizar flujos inspiratorios enérgicos. Se revisaron los diferentes DI en fibrosis quística y en pacientes con asistencia respiratoria mecánica. La elección del DI dependerá de varios factores: situación clínica, edad, experiencia previa, preferencia del paciente, disponibilidad de la droga y entrenamiento alcanzado con el correcto uso.
Abstract Last decades, a broad spectrum of inhaled devices (ID) had been developed to enhance efficacy and reduce adverse events. The correct use of IDs is a critical issue for controlling obstructive respiratory diseases. There is no recommendation on inhalation therapy in Argentina. This document aims to issue local recommendations about the prescription of IDs. Each device was reviewed regarding biophysical laws, indication, strength, limitations, correct technique of use, frequent mistakes, and device cleaning and maintenance. Nebulization should be restricted to drugs that are not available in other IDs (for example, for treatment of cystic fibrosis) or where other devices fail. Nebulization is not recommended during the SARS-CoV2 pandemic. A metered-dose inhaler must always be used with an aerochamber. Aerochambers reduce the incidence of adverse events and improve lung deposition. Metered-dose inhalers must be prescribed to patients who cannot generate a high inspiratory flow and dry powders to those who can generate an energetic inspiratory flow. We reviewed the use of different IDs in patients with cystic fibrosis and under mechanical ventilation. The individual choice of an ID will be based on several variables like clinical status, age, previous experience, patient preference, drug availability, and correct use of the device.
Assuntos
Humanos , Asma , COVID-19 , Argentina , RNA Viral , Doença Pulmonar Obstrutiva Crônica , SARS-CoV-2RESUMO
Last decades, a broad spectrum of inhaled devices (ID) had been developed to enhance efficacy and reduce adverse events. The correct use of IDs is a critical issue for controlling obstructive respiratory diseases. There is no recommendation on inhalation therapy in Argentina. This document aims to issue local recommendations about the prescription of IDs. Each device was reviewed regarding biophysical laws, indication, strength, limitations, correct technique of use, frequent mistakes, and device cleaning and maintenance. Nebulization should be restricted to drugs that are not available in other IDs (for example, for treatment of cystic fibrosis) or where other devices fail. Nebulization is not recommended during the SARS-CoV2 pandemic. A metered-dose inhaler must always be used with an aerochamber. Aerochambers reduce the incidence of adverse events and improve lung deposition. Metered-dose inhalers must be prescribed to patients who cannot generate a high inspiratory flow and dry powders to those who can generate an energetic inspiratory flow. We reviewed the use of different IDs in patients with cystic fibrosis and under mechanical ventilation. The individual choice of an ID will be based on several variables like clinical status, age, previous experience, patient preference, drug availability, and correct use of the device.
En las últimas décadas ha habido un importante desarrollo de dispositivos inhalados (DI) que permiten aumentar la eficacia de las drogas y disminuir los eventos adversos. Su correcto uso es de fundamental importancia para el control de las enfermedades respiratorias obstructivas. En la Argentina no existen recomendaciones locales sobre el uso de los DI. Se revisó la base biofísica, indicación, ventajas y limitaciones, técnica de correcto uso, errores frecuentes, mantenimiento y limpieza de cada DI. El uso de nebulizaciones ha quedado restringido a la administración de drogas que no están disponibles en otros DI (ejemplo: tratamiento de fibrosis quística), o ante la falla de los otros DI. No deben ser usados durante la pandemia de SARS-CoV2. Los inhaladores de dosis medida (aerosol) deben ser indicados siempre con aerocámaras (AC), las que reducen la incidencia de eventos adversos y aumentan el depósito de la droga en el pulmón. Son los dispositivos de elección junto a los inhaladores de polvo seco. Los aerosoles se deben usar en pacientes que no generan flujos inspiratorios altos. Los inhaladores de polvo seco deben recomendarse en aquellos que pueden realizar flujos inspiratorios enérgicos. Se revisaron los diferentes DI en fibrosis quística y en pacientes con asistencia respiratoria mecánica. La elección del DI dependerá de varios factores: situación clínica, edad, experiencia previa, preferencia del paciente, disponibilidad de la droga y entrenamiento alcanzado con el correcto uso.
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Asma , COVID-19 , Doença Pulmonar Obstrutiva Crônica , Argentina , Humanos , RNA Viral , SARS-CoV-2RESUMO
Resumen Introducción: A nivel mundial, la mortalidad por asma sigue siendo un tema no resuelto a pesar de existir tratamientos muy eficaces. Esto mismo ocurre en Argentina, donde también se dispone de tratamientos efectivos, pero se desconoce si existe vinculación entre mortalidad por asma y las ventas de medicación inhalatoria. El objetivo fue analizar las ventas en farmacias de medicación para enfermedades respira torias obstructivas y las muertes por asma, antes y después de la aparición de los corticosteroides inhalados (ICS) y sus combinaciones. Materiales y métodos: Los datos de mortalidad por asma de 1983 a 2018 en Argentina se obtuvieron de un informe oficial. Todos los datos sobre ventas en farmacias fueron brindados por la misma fuente (IQVIA Solutions Argentina), pero no hay datos de ventas desde 1990 a 1999. Resultados: El promedio ± desvío standard del cociente entre el total de ventas de broncodilatadores agonistas β2 adrenérgicos de acción corta (SABA) sobre total de ventas de ICS y sus combinaciones fue 13,68 ± 2,85 entre 1983-1988 y 1,03 ± 0,12 entre 2010 a 2019 (p < 0.0001). Hubo una significativa correlación entre los cocientes SABA/ICS y el número de muertes por asma desde 1983 a 2018 (correlación de Pearson: r = 0,977, p < 0,0001). Durante el período 2010 a 2018 hubo una significativa caída en las muertes comparado con 1980-1989 (145,9 ± 28,58 vs 43,1 ± 5,2; p < 0,0001). Las ventas de SABA mostraron una declinación a partir del 2016 y fueron superados por las combinaciones de ICS/ Broncodilatadores de acción prolongada (LABA) en 2019. Conclusiones: La significativa correlación entre el cociente de ventas SABA/ICS y las muertes por asma haría replantear el estereotipo de tratamiento muy arraigado del uso de SABA en el manejo de asma.
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Pneumopatias Obstrutivas , Asma , Mortalidade , Comercialização de MedicamentosRESUMO
Abstract Introduction: Global asthma mortality is still an unresolved issue, despite the existence of highly effective treatments. This occurs in Argentina, where there are also some effective treatments, but there is few information about the relationship between asthma mortality and sales of inhaled medication. The purpose of this study was to analyze sales in pharmacies of medication for obstructive respiratory diseases and asthma deaths, before and after the appearance of inhaled corticosteroids (ICSs) and their combinations. Materials and Methods: An official bulletin was the source document for data about asthma mortality in Argentina between 1983 and 2018. All data on pharmacy sales were provided by the same source (IQVIA Solutions Argentina), but there are no sales data from 1990 to 1999. Results: The mean ± standard deviation of the ratio between total sales of short-acting β2-adrenergic agonist bronchodilators (SABAs) over total sales of ICS and their combinations was 13.68 ± 2.85 between 1983-1988 and 1.03 ± 0.12 between 2010-2019 (p < 0.0001). There was a significant correlation between the SABA/ICS ratios and the number of asthma deaths from 1983 to 2018 (Pearson correla tion: r = 0.977, p < 0.0001). During the period from 2010 to 2018 there was a significant decrease in the number of deaths compared to 1980-1989 (145.9 ± 28.58 vs. 43.1 ± 5.2; p <0.0001). Since 2016, SABA sales started to decrease and were overtaken in 2019 by the combinations of ICS/long-acting b2-agonist bronchodilators (LABAs). Conclusions: The significant correlation between the SABA/ICS sales ratio and asthma deaths would make us rethink the long-established treatment stereotype of SABAs for the management of asthma.
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Pneumopatias Obstrutivas , Asma , Mortalidade , Comercialização de MedicamentosRESUMO
After 25 years of GINA, we need an overarching strategy. The resounding changes in GINA 2019 should be accompanied by another major change in general strategy of asthma management. The concept of control asthma and step strategy was established in 1997 by GINA; but still there is a great gap between GINA objectives and outcomes. O'Byrne and colleagues proposed a continuum of care approach; where patient-adjusted therapy would comprise both a controller and reliever (usually ICS/fast-acting LABA) in a single inhaler. We use a similar approach in our asthma centre.