Consultas a urgencia y valores espirométricos tras el reemplazo de salmeterol/fluticasona por budesonida/formoterol en pacientes con asma moderada a grave / Emergency consultations and spirometric values after replacement of salmeterol/fluticasone with budesonide/formoterol in patients with moderate to severe asthma

El asma se caracteriza por su impacto deletéreo que incluye gran coste económico para el sistema de salud. En pacientes con asma mal controlada a pesar del tratamiento, se propone un régimen de mantenimiento con corticoides inhalados y formoterol. El objetivo del presente estudio observacional retrospectivo fue evaluar las modificaciones espirométricas tras el cambio del medicamento controlador en pacientes con asma moderada a severa asistidos en el Hospital Clínico de Magallanes de Punta Arenas, así como también cuantificar la modificación en el número de exacerbaciones graves (consulta a un servicio de urgencia y/u hospitalización por asma). Participaron 61 adultos con asma moderada a severa (mediana de edad: 60 años [rango: 21-87], mujeres: 69,4%; comorbilidad atópica/alérgica: 79%; otras comorbilidades: 46,8%) en los que se cambió el tratamiento con fluticasona/salmeterol 250/25 μg por budesónida/formoterol 160/4,5 μg. No se observaron cambios significativos en los índices espirométricos tras el cambio. Con el tratamiento inicial, el 46,9% presentó ≥ 1 visita a urgencias (total: 50 consultas). Tras el cambio por budesonida/formoterol, el 21% requirió al menos una visita a urgencias (total: 14 consultas; p < 0,01). La proporción de pacientes con ≥ 2 consultas a urgencias fue de 19,7% con el tratamiento basal y de 1,6% tras el cambio a budesonida/formoterol (p < 0,01). No se observaron diferencias significativas en la cantidad de hospitalizaciones. En este estudio del mundo real de pacientes con asma moderada a grave, el cambio del tratamiento a budesonida/formoterol se asoció con reducción significativa de las consultas a urgencias, a pesar de no detectarse cambios de significación estadística en los índices espirométricos habituales.

Asthma is characterized by its deleterious impact, including a high cost to the healthcare system. In patients with poorly controlled asthma despite treatment, a maintenance regimen of inhaled corticosteroids and formoterol is proposed. The aim of this retrospective, observational study was to evaluate the spirometric changes after switching the controller medication in patients with moderate to severe asthma attended in our institution ("Hospital Clínico de Magallanes"), as well as the variation in the number of severe exacerbations (consultation to an emergency department and/or hospitalization for asthma). Sixty-one adults with moderate to severe asthma (median age: 60 years-old [range: 21-87], women: 69.4%; atopic/allergic comorbidity: 79%; other comorbidities: 46.8%) in whom treatment with fluticasone/salmeterol 250/25 μg was switched to budesonide/formoterol 160/4.5 μg participated in our study. No significant changes in spirometric parameters were observed after the replacement treatment. With the initial treatment, 46.9% patients presented ≥ 1 visit to the emergency department (total: 50 visits). After the switch to budesonide/formoterol, 21% required at least one emergency department visit (total: 14 consultations; p < 0.01). The proportion of patients with ≥ 2 emergency department visits was 19.7% with baseline treatment and 1.6% after switching to budesonide/formoterol (p < 0.01). No significant differences were observed in the number of hospitalizations. In this real-world study of moderate to severe asthma patients, switching to budesonide/formoterol was associated with a significant reduction in emergency department visits, despite no statistically significant changes in the usual spirometric parameters.

Eficácia e segurança de tripla terapia broncodilatadora comparada à dupla terapia em DPOC grave: revisão rápida de evidências / Effectiveness and safety of triple bronchodilator therapy compared to dual therapy in severe COPD: rapid response review of evidence

Tecnologia: Tripla terapia broncodilatadora (vilanterol/ umeclidínio/ fluticasona, formoterol/ glicopirrônio/ beclometasona) e dupla terapia. Indicação: Tratamento de doença pulmonar obstrutiva crônica (DPOC), formas grave e muito grave. Pergunta: Há diferenças de efeito nos principais desfechos de eficácia e segurança entre a tripla terapia broncodilatadora e as duplas terapias no tratamento de pacientes com DPOC, formas grave e muito grave? Métodos: Revisão rápida de evidências (overview) de revisões sistemáticas, com levantamento bibliográfico realizado na base de dados PUBMED, utilizando estratégia estruturada de busca. A qualidade metodológica das revisões sistemáticas foi avaliada com AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews). Resultados: Foram selecionadas e incluídas 2 revisões sistemáticas. Conclusão: A tripla terapia broncodilatadora era mais eficaz que a dupla terapia para reduzir a taxa anual de exacerbações moderadas a severas, mas não tinha superioridade para obter ganhos clínicos em outros desfechos (volume expiratório forçado no primeiro segundo, qualidade de vida, índice de dispneia, mortalidade geral, mortalidade respiratória), exceto que a tripla terapia era superior à dupla terapia com agonistas beta-2/ antagonistas antimuscarínicos e similar à dupla terapia com agonistas beta-2/ corticoesteróides inalatórios para reduzir mortalidade. A tripla terapia tinha perfil de segurança similar à dupla terapia, com mesmo risco para eventos adversos e eventos adversos graves. A tripla terapia tinha maior risco para pneumonias que a dupla terapia com agonistas beta-2/ antagonistas antimuscarínicos

Technology: Triple bronchodilator therapy (vilanterol/ umeclidinium/ fluticasone, formoterol/ glycopyrronium/ beclomethasone) and dual therapy. Indication: Treatment of chronic obstructive pulmonary disease (COPD), severe and very severe forms. Question: Are there differences in effects of efficacy and safety outcomes between triple bronchodilator therapy and dual therapies in treating patients with severe and very severe forms of COPD? Methods: Rapid review of evidence (overview) from systematic reviews, with a bibliographic search in the PUBMED database, using a structured strategy. The methodological quality of systematic reviews was assessed with AMSTAR-2 (Methodological Quality Assessment of Systematic Reviews). Results: Two systematic reviews were selected and included. Conclusion: Triple bronchodilator therapy was more effective than dual therapy in reducing the annual rate of moderate to severe exacerbations, but had no superiority for clinical gains in other outcomes (forced expiratory volume in first second, quality of life, dyspnea index, general mortality, respiratory mortality), except that, for reducing mortality, triple therapy was superior to dual therapy with beta-2 agonists/ antimuscarinic antimuscarinics and similar to dual therapy with beta 2 agonists/ inhaled corticosteroids. The triple therapy had a similar safety profile to dual therapy, with the same risk for adverse events and serious adverse events. The triple therapy had a higher risk for pneumonia than a dual therapy with beta-2 agonists/ antimuscarinic antagonists

TeleCondutas: asma / TeleGuides: asthma

Asma é uma doença respiratória crônica frequente no atendimento da Atenção Primária à Saúde (APS) com prevalência nacional de 4,4% em adultos e cerca de 20% em crianças e adolescentes. Conforme a gravidade da doença, apresenta diversos graus de incapacidade e piora na qualidade de vida. A doença tem características heterogêneas, usualmente com inflamação crônica das vias aéreas, sendo definida pela história de sintomas respiratórios (sibilância, dispneia, desconforto torácico e tosse), que variam no tempo e em intensidade, associados a limitação variável de fluxo aéreo expiratório. O diagnóstico é baseado nas características clínicas da doença e testes de função pulmonar que identificam limitação variável do fluxo aéreo. Esta guia apresenta informação que orienta a conduta para casos de asma no contexto da Atenção Primária à Saúde, incluindo: Avaliação clínica Teste de função pulmonar Controle dos sintomas Riscos para desfechos desfavoráveis Tratamento Farmacológico Medidas complementares Técnica inalatória Plano de ação Manejo da exacerbação Encaminhamento para serviço especializado.

Three-month Treatment Response and Exacerbation in Chronic Obstructive Pulmonary Disease

The aim of this study was to investigate relationships between acute exacerbation and Forced Expiratory Volume 1 second (FEV1) improvement after treatment with combined long-acting beta-agonist (LABA) and inhaled corticosteroid (ICS) in patients with chronic obstructive pulmonary disease (COPD). A total of 137 COPD patients were classified as responders or nonresponders according to FEV1 improvement after 3 months of LABA/ICS treatment in fourteen referral hospitals in Korea. Exacerbation occurrence in these two subgroups was compared over a period of 1 yr. Eighty of the 137 COPD patients (58.4%) were classified as responders and 57 (41.6%) as nonresponders. Acute exacerbations occurred in 25 patients (31.3%) in the responder group and in 26 patients (45.6%) in the nonresponder group (P=0.086). FEV1 improvement after LABA/ICS treatment was a significant prognostic factor for fewer acute exacerbations in a multivariate Cox proportional hazard model adjusted for age, sex, FEV1, smoking history, 6 min walk distance, body mass index, exacerbation history in the previous year, and dyspnea scale.Three-month treatment response to LABA/ICS might be a prognostic factor for the occurrence of acute exacerbation in COPD patients.