Optimizing asthma management: Role of long-acting muscarinic antagonists.

Patients with asthma who are suboptimally responsive to inhaled corticosteroids (ICS) and long-acting ß2-agonists (LABAs) are frequently exposed to oral corticosteroids and high-dose ICS, which can lead to significant side effects. Long-acting muscarinic antagonists (LAMAs) have demonstrated efficacy and safety in a subset of these patients. This review summarizes the results of key studies using LAMAs in patients with asthma aged 12 years or older. LAMA as an add-on treatment improved lung function and asthma control in patients with uncontrolled asthma across studies. The efficacy of LAMAs as an add-on to ICS was superior to that of placebo and ICS dose escalation and comparable with that of LABAs. LAMA plus ICS plus LABA provided modest improvements in bronchodilation and increased the time to first severe exacerbation versus ICS plus LABA. Single-inhaler triple therapy was associated with decreased health care resource utilization and improved cost-effectiveness versus multiple inhalers. LAMAs were generally well tolerated; asthma exacerbations, bronchitis, and nasopharyngitis were common adverse events with LAMA in combination with ICS alone or ICS plus LABA. Thus, the overall evidence presented in this review supports the use of add-on LAMA treatment as a reasonable option in patients with asthma uncontrolled with ICS plus LABA or ICS alone.

Correlates of household smoking bans in low-income families of children with and without asthma.

Exposure to secondhand smoke (SHS) harms all children's health, especially children with asthma. Yet, children with asthma are as likely to live with smokers as healthy children. Household smoking bans are being advocated to reduce children's harm from SHS. To measure the effect of household smoking bans on child SHS exposure and to examine correlates of strict smoking bans in a low-income, diverse sample, 91 children with asthma were matched to 91 healthy children. All had at least one smoker living in their homes. Nicotine dosimeters, child cotinine assays, and maternal reports quantified child SHS exposures. Maternal reports of household smoking rules, behaviors, and beliefs, and other family characteristics were also gathered. The presence of a strict household smoking ban vastly reduced children's SHS exposures and was associated with fewer cigarettes smoked by the mother and by other family members, the belief that SHS was a personal health risk, having children with asthma, and living in a single-family home. Many children are exposed to high levels of SHS at home. Strict household smoking bans greatly decrease, but do not eliminate children's SHS exposure. Even in disadvantaged families, mutable factors were associated with strict smoking bans. Increased dissemination and use of established public health strategies are needed to reduce children's SHS exposures.

Use of fluticasone in acute symptomatic pulmonary sarcoidosis.

BACKGROUND: Inhaled corticosteroids have been used with variable success in sarcoidosis. The role of the inhaled corticosteroid fluticasone in symptomatic pulmonary patients was studied. METHODS: Twenty-two patients at five institutions who had been given an initial dose of oral corticosteroids within the prior four weeks were enrolled in a randomized double blind trial of inhaled fluticasone. An algorithm for the dosage of prednisone including rules for reducing dose was developed and applied at all centers. RESULTS: Of the 21 patients seen for more than one visit, 10 received fluticasone and 11 placebo. There was no significant difference in the improvement of vital capacity or average daily dose of prednisone for the fluticasone versus placebo. Eight of ten patients taking fluticasone had improvement in cough, while only 6 of 11 patients on placebo had improved cough despite taking oral corticosteroids (p = 0.36, N.S.). The algorithm for decreasing corticosteroid dosage was exactly applied in over 80% of patient visits and oral corticosteroids were used throughout most of the year of treatment. Patients registered higher complaints regarding increased appetite and polyuria when on ten mg or more prednisone a day. There was no clinical difference in the rate of toxicity for the fluticasone versus placebo group. CONCLUSION: A standard approach to tapering oral corticosteroids was followed in over 80% of patient visits. Oral corticosteroids were associated with significant complaints, while inhaled corticosteroids were well tolerated.