Exacerbation patterns indicate potential benefits with stepping up asthma therapy
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Key takeaways:
- Single-inhaler fluticasone furoate/umeclidinium/vilanterol triple therapy meets Global Initiative for Asthma guidelines.
- Nonadherence to ICS/LABA therapy ranged from 58.8% to 69.8%.
SAN DIEGO — Patients with asthma exacerbations despite inhaled corticosteroids and long-acting beta 2 agonists may benefit from stepping up treatment, according to a study presented at the American Thoracic Society International Conference.
Rapid treatment escalation may alleviate disease burden and unmet needs among these patients, Stephen G. Noorduyn, MSc, global director, value evidence and outcomes, GSK, and colleagues wrote.
“One practical clinical question in asthma treatment is how a physician can optimize the available therapies for asthma,” Noorduyn told Healio. “In this case, we were interested in better understanding the types of patients that physicians in the U.S. considered appropriate for escalation from dual to triple therapy.”
Patients treated with inhaled corticosteroids (ICS) and long-acting beta 2 agonists (LABA) often step up to single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) and other ICS/LABA/long-acting muscarinic antagonist (LAMA) therapies.
But although these escalations follow Global Initiative for Asthma guidelines, the researchers said, real-world data that characterize treatment and exacerbation patterns in these patients before they begin single-inhaler triple therapy are needed.
The researchers analyzed commercial claims data from IQVIA PharMetrics Plus including 5,747 adults with asthma who began FF/UMEC/VI treatment between September 2016 and September 2022 after using ICS/LABA.
This cohort included 800 (mean age, 52.3 years; 58.1% women) who initiated an FF/UMEC/VI-100 dose between Sept. 18, 2017, and March 15, 2020, identified as the pre-COVID period; 1,940 (mean age, 49.8 years; 62.6% women) who initiated an FF-UMEC-VI-100 dose between March 16, 2021, and Sept. 30, 2022, identified as the post-COVID period; and 3,007 (mean age, 49.9 years; 61.9% women) who initiated an FF/UMEC/VI-200 dose also in the post-COVID period.
“We looked at this in both pre- and post-COVID pandemic periods to see if there were any changes to patient and [health care provider] behavior over that time,” Noorduyn said.
“In general, we see relatively consistent results pre- and post-pandemic and are able to see evidence of physicians channeling more severe and complex cases toward higher doses of inhaled steroid within FF/UMEC/VI,” he said.
Among the pre-COVID FF/UMEC-VI-100 group, 38% were treated by their primary care physician, and 33.3% were treated by a pulmonologist or an allergist.
The post-COVID FF/UMEC/VI-100 group included 38.4% who were treated by their primary care physician and 29.7% who were treated by a pulmonologist or an allergist.
A primary care physician treated 28.6% of the FF/UMEC/VI-200 group, and a pulmonologist or an allergist treated 42.9%.
Mean Quan-Charleson comorbidity index scores included 1.44 for the pre-COVID FF/UMEC/VI-100 group, 1.38 for the post-COVID FF/UMEC/VI-100 group and 1.44 for the post-COVID FF/UMEC/VI-200 group.
Also, 75.1% of the pre-COVID FF/UMEC/VI-100 group, 74.8% of the post-COVID FF/UMEC/VI-100 group and 80.2% of the post-COVID FF/UMEC/VI-200 group used short-acting beta agonist (SABA) rescue medication.
Comorbidities for the three groups included 47.6%, 41.7% and 41.3% with hypertension; 43.9%, 44.8% and 50.7% with allergic rhinitis; 38%, 29.5% and 30.6% with upper respiratory tract infection; and 36.2%, 21.7% and 24.6% with sinusitis.
Before stepping up treatment, 43.3%, 33.4% and 36.9% of the groups used FF/VI; 28.4%, 30.9% and 25.8% used budesonide/formoterol; and 22.8%, 30.9% and 31.7% used fluticasone propionate/salmeterol.
Nonadherence rates to ICS/LABA treatment ranged from 58.8% to 69.8% before the start of triple therapy.
Percentages of patients who experienced one or more exacerbations before triple therapy included 41.3% for the pre-COVID FF/UMEC/VI-100 group, 29.3% for the post-COVID FF/UMEC/VI-100 group and 37.7% for the post-COVID FF/UMEC/VI-200 group.
Mean numbers of exacerbations before triple therapy included 0.67 for the pre-COVID FF/UMEC/VI-100 group, 0.39 for the post-COVID FF/UMEC/VI-100 group and 0.55 for the post-COVID FF/UMEC/VI-200 group.
These findings indicate that patients who use ICS/LABA can continue to experience uncontrolled asthma and may benefit from single inhaled triple therapy.
“In general, dual therapy with ICS/LABA was not sufficient for these patients. Many of them had comorbid conditions, and between 30% and 40% experienced an exacerbation in the year prior to initiation of FF/UMEC/VI,” Noorduyn said.
In addition, he continued, most patients were “on treatment” for less than 80% of the year, which is an important signal for suboptimal adherence to treatment.
“All of these factors can play an important role in clinical decision-making,” Noorduyn said.
The researchers did not have any findings indicating outcomes after initiation of triple therapy.
“From a scientific perspective, it is important to first understand the profile of patients within the dataset and identify any potential challenges before doing more sophisticated effectiveness analysis,” Noorduyn said.
Still, he said, these results provide some foundational understanding of current practice. Importantly, he continued, health care providers already are choosing to initiate FF/UMEC/VI for appropriate patients.
“In addition, this study raises a question about timeliness of intervention — that is, how can we be more ambitious for patients?” he said. “Is it possible to identify these appropriate patients earlier and prevent further impact of disease?”
The next step in this research should build on these results, Noorduyn said.
“I hope we can continue to answer important questions about timely intervention, optimization of therapy, and ambitious but attainable goals for all patients with asthma,” he said.