World Asthma Day
The theme for World Asthma Day on 3 May 2011, organized by the Global Initiative for Asthma (GINA), was “You can control your asthma”. Asthma is a disease whose prevalence remains high, and impacts significantly on the lives of many people across the world. High rates of avoidable asthma hospital admission continue to point to the dangers of under-treated asthma, which impact on healthcare services in many countries. Cochrane Reviews of asthma therapy have made a number of important contributions to the evidence-base for decision-making in asthma, where maintaining asthma control remains the main goal of treatment. The asthma reviews cover assessments of the benefits and harms of treatments used across the treatment pathway from initial maintenance therapy with regular inhaled steroids or alternative options, to the introduction of additive therapies such long-acting beta-agonists, leukotriene receptor antagonists, and new therapies such as anti-immunoglobulin E. The reviews have also highlighted the importance of education and self-management to both children and adults. This special collection was first published in April 2010, and has since been updated in May 2011 for World Asthma Day.
Pharmacotherapy: inhaled steroids and alternative maintenance treatments
Inhaled corticosteroids versus sodium cromoglycate in children and adults with asthma
Inhaled corticosteroids (ICS) and sodium cromoglycate have become established as effective controller medications for children and adults with asthma, but their relative efficacy is not clear. This review compares the relative effectiveness and adverse effects of ICS and sodium cromoglycate among children and adults with chronic asthma.
Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children
Anti-leukotrienes agents are currently being studied as alternative first-line agents to ICS in mild to moderate chronic asthma. This review compares the safety and efficacy of anti-leukotriene agents with inhaled glucocorticoids and to determine the dose-equivalence of anti-leukotrienes to daily dose of inhaled glucocorticoids.
High dose versus low dose inhaled corticosteroid as initial starting dose for asthma in adults and children
ICS form the basis of maintenance therapy in asthma and their efficacy is well established. However, the optimal starting dose of ICS is not clearly established. Recent reviews demonstrate a relatively flat efficacy curve for ICS and increasing side effects with increasing ICS doses. High doses are frequently prescribed and there are now reports of significant side effects occurring with high dose ICS use. These issues demonstrate the need to establish the optimal starting dose of ICS in asthma. This review aims to establish the optimal starting dose of ICS by evaluating the efficacy of initial high dose ICS with low dose ICS in subjects with asthma, not currently on ICS.
Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children
Written action plans providing guidance in the early treatment of asthma exacerbations have traditionally advocated doubling of ICS as one of the first steps in treatment. This review compares the clinical effectiveness of increasing the dose of ICS versus keeping the usual maintenance dose as part of a patient-initiated action plan at the onset of asthma exacerbations.
Fluticasone versus placebo for chronic asthma in adults and children
Inhaled fluticasone propionate is a relatively new ICS for the treatment of asthma. This review assessed efficacy and safety outcomes in studies that compared fluticasone propionate to placebo for treatment of chronic asthma.
Fluticasone versus beclomethasone or budesonide for chronic asthma in adults and children
Beclomethasone dipropionate and budesonide are commonly prescribed ICS for the treatment of asthma. Fluticasone propionate is newer agent with greater potency in in-vitro assays. This review compares the efficacy and safety of fluticasone to beclomethasone or budesonide in the treatment of chronic asthma.
Ciclesonide versus placebo for chronic asthma in adults and children
ICS are an integral part of asthma management, and act as an anti-inflammatory agent in the airways of the lung. These agents confer significant benefit in terms of symptom management and improvement in lung function, but may also cause harm in terms of local and systemic side-effects. Ciclesonide is a novel steroid that has efficient distribution and release properties that mean it can be taken once daily, making it potentially useful in ongoing asthma management. This review assesses the efficacy of inhaled ciclesonide in adults and children with chronic asthma.
Beclomethasone versus placebo for chronic asthma
Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti-inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane-134a (HFA) propellant which is free from chlorofluorocarbon (CFC). This review compared the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma.
Regular treatment with salmeterol for chronic asthma: serious adverse events
Epidemiological evidence has suggested a link between beta-agonists and increases in asthma mortality. There has been much debate about possible causal links for this association, and whether regular (daily) long-acting beta2-agonists are safe. This review assesses the risk of fatal and non-fatal serious adverse events in trials that randomised patients with chronic asthma to regular salmeterol versus placebo or regular short-acting beta2-agonists.
Regular treatment with formoterol for chronic asthma: serious adverse events
Epidemiological evidence has suggested a link between beta-agonists and increases in asthma mortality. There has been much debate about possible causal links for this association, and whether regular (daily) long-acting beta2-agonists are safe. This review assesses the risk of fatal and non-fatal serious adverse events in trials that randomised patients with chronic asthma to regular formoterol versus placebo or regular short-acting beta2-agonists.
Oral xanthines as maintenance treatment for asthma in children
Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti-inflammatory effects. The current role of xanthines in the long-term treatment of childhood asthma needs to be reassessed. This review aims to determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma.
Pharmacotherapy: adding treatments to inhaled steroids
Anti-IgE for chronic asthma in adults and children
Omalizumab is a recombinant humanised monoclonal antibody directed against immunoglobulin E (anti-IgE) to inhibit the immune system's response to allergen exposure. Omalizumab is directed against the binding site of IgE for its high affinity Fc receptor. It prevents free serum IgE from attaching to mast cells and other effector cells and prevents IgE mediated inflammatory changes. This review aims to determine the efficacy of anti-IgE compared with placebo in patients with allergic asthma.
Regular treatment with salmeterol and inhaled steroids for chronic asthma: serious adverse events
Epidemiological evidence has suggested a link between beta2-agonists and increased asthma mortality. There has been much debate about possible causal links for this association, and whether regular (daily) long-acting beta2-agonists are safe. This review assesses the risk of fatal and non-fatal serious adverse events in trials that randomised patients with chronic asthma to regular salmeterol with ICS versus the same dose of ICS alone.
Regular treatment with formoterol and inhaled steroids for chronic asthma: serious adverse events
Epidemiological evidence has suggested a link between beta2-agonists and increases in asthma mortality. There has been much debate about possible causal links for this association, and whether regular (daily) long-acting beta2-agonists are safe when used alone or in conjunction with ICS. This review assesses the risk of fatal and non-fatal serious adverse events in trials that randomised patients with chronic asthma to regular formoterol with ICS versus the same dose of ICS alone.
Link to Journal Club Article Regular treatment with formoterol and an inhaled corticosteroid versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma: serious adverse events
An increase in serious adverse events with both regular formoterol and regular salmeterol in chronic asthma has been demonstrated in comparison with placebo in previous Cochrane reviews. This increase was significant in trials that did not randomise participants to an ICS, but less certain in the smaller numbers of participants in trials that included an ICS in the randomised treatment regimen. This review compares the risks of mortality and non-fatal serious adverse events in trials which have randomised patients with chronic asthma to regular formoterol versus regular salmeterol, when each are used with an ICS as part of the randomised treatment.
Combination formoterol and inhaled steroid versus beta2-agonist as relief medication for chronic asthma in adults and children
Formoterol has a fast onset of action and can therefore be used to relieve symptoms of asthma. A combination inhaler can deliver formoterol with different doses of ICS; when used as a reliever both drugs will be delivered more frequently when asthma symptoms increase. This has the potential to treat both bronchoconstriction and inflammation in the early stages of exacerbations. This review assesses the efficacy and safety of combined inhalers containing both formoterol and an ICS when used for reliever therapy in adults and children with chronic asthma.
Combination formoterol and budesonide as maintenance and reliever therapy versus inhaled steroid maintenance for chronic asthma in adults and children
Traditionally inhaled treatment for asthma has been considered as preventer and reliever therapy. The combination of formoterol and budesonide in a single inhaler introduces the possibility of using a single inhaler for both prevention and relief of symptoms (single inhaler therapy). This review compares formoterol and corticosteroid in single inhaler for maintenance and relief of symptoms with ICS for maintenance and a separate reliever inhaler.
Combination fluticasone and salmeterol versus fixed dose combination budesonide and formoterol for chronic asthma in adults and children
Combination therapies are frequently recommended as maintenance therapy for people with asthma, whose disease is not adequately controlled with inhaled steroids. Fluticasone/salmeterol (FP/SAL) and budesonide/formoterol (BUD/F) have been assessed against their respective monocomponents, but there is a need to compare these two therapies on a head-to-head basis. This review aims to estimate the relative effects of FP/SAL and BUD/F in terms of asthma control, safety and lung function.
Addition of long-acting beta-agonists to inhaled corticosteroids for chronic asthma in children
Long-acting beta2-agonists (LABA) in combination with ICS are increasingly prescribed in asthmatic children. This review compares the safety and benefit of adding LABA to ICS with the same or an increased dose of ICS in children with persistent asthma.
Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma
In asthmatic patients inadequately controlled on ICS and/or those with moderate persistent asthma, two main options are recommended: the combination of a long-acting inhaled beta2-agonist (LABA) with ICS or use of a higher dose of ICS. This review aims to determine, in asthmatic patients, the effect of the combination of LABA and ICS compares to a higher dose of ICS on the incidence of asthma exacerbations, on pulmonary function and on other measures of asthma control and to look for characteristics associated with greater benefit for either treatment option.
Addition of long-acting beta2-agonists to inhaled steroids as first line therapy for persistent asthma in steroid-naive adults and children
In asthmatic patients inadequately controlled on ICS and/or those with moderate persistent asthma, two main options are recommended: the combination of a LABA with ICS or use of a higher dose of ICS. This review aims to determine, in asthmatic patients, the effect of the combination of LABA and ICS compares to a higher dose of ICS on the incidence of asthma exacerbations, on pulmonary function and on other measures of asthma control and to look for characteristics associated with greater benefit for either treatment option.
Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma
Anti-leukotriene agents are being considered as 'add-on' therapy to ICS, in chronic asthma. This review examines the safety and efficacy of daily anti-leukotriene plus ICS compared to ICS alone, and determine the corticosteroid-sparing effect of anti-leukotriene when added to ICS in chronic asthma.
Behavioural interventions: education, self-management, & environment
Written action plans for asthma in children
While all asthma consensus statements recommend the use of written action plan as a central part of asthma management, a recent systematic review of randomised trials highlighted the paucity of trials where the only difference between groups was the provision or not of a written action plan. This review evaluates the independent effect of providing versus not providing a written action plan in children and adolescents with asthma, and compared the effect of different written action plans.
Self-management education and regular practitioner review for adults with asthma
A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. This review assesses the effects of asthma self-management programmes, when coupled with regular health practitioner review, on health outcomes in adults with asthma.
Culture-specific programs for children and adults from minority groups who have asthma
People with asthma who come from minority groups have poorer asthma outcomes and more asthma-related visits to Emergency Departments. Various programmes are used to educate and empower people with asthma and these have previously been shown to improve certain asthma outcomes. This review aims to determine whether culture-specific asthma programmes, in comparison to generic asthma education programmes or usual care, improve asthma-related outcomes in children and adults with asthma who belong to minority groups.
Psychological interventions for children with asthma
Asthma is a chronic disease of inflammation and smooth muscle dysfunction, including bronchoconstriction. These symptoms are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. Psychological factors may influence the symptoms and management of asthma in children in many ways, for example, evidence suggests that emotional stress can either precipitate or exacerbate both acute and chronic asthma. This review assesses the efficacy of psychological interventions in improving health and behavioural outcomes for children with asthma.
Psychological interventions for adults with asthma
Many people have asthma, and for some their symptoms may be triggered by psychological factors. In addition, compliance with medical therapy may have a psychological dimension. Therefore, psychological interventions aim to reduce the burden of symptoms and improve management of the disease. This review assesses the effectiveness of psychological interventions for adults with asthma.
House dust mite control measures for asthma
The major allergen in house dust comes from mites. Chemical, physical, and combined methods of reducing mite allergen levels are intended to reduce asthma symptoms in people who are sensitive to house dust mites. This review assesses the effects of reducing exposure to house dust mite antigens in the homes of people with mite-sensitive asthma.
Telehealthcare for asthma
Healthcare systems internationally need to consider new models of care to cater for the increasing numbers of people with asthma. Telehealthcare interventions are increasingly being seen by policymakers as a potential means of delivering asthma care. We defined telehealthcare as being healthcare delivered from a distance, facilitated electronically and involving the exchange of information through the personalised interaction between a healthcare professional using their skills and judgement and the patient providing information. This review assesses the effectiveness of telehealthcare interventions in people with asthma.
Image credit: Jim Varney/Science Photo Library, C002/044
Date published: 13 April 2010; updated 11 May 2011 with two new reviews.
Contact: Cochrane Editorial Unit (editorial-unit@cochrane.org)
