2 1.2 Current Treatment Options
Current Treatment Options for Asthma
Corticosteroids (ICS) are the controller medication and the first step of choice in managing asthma. ICS is the base drug for any further treatments, but as asthma worsens, different types of drugs are needed to be used in addition to ICS. This is because ICS shows most of its clinical benefits at low to moderate dosage, increasing the dosage of ICS higher as asthma worsens is rarely beneficial while increased risks of side effects come in. High-dose ICS should always be avoided and asthma should try to be managed with the lowest possible dosage of ICS (Agarwal. R, 2015).
As symptoms worsen and monotherapy with ICS is no longer sufficient the addition of Long-acting β-agonist (LABA) is the preferred choice (René Aalbers, 2016). There are other asthma treatment options such as leukotriene receptor antagonists (LTRAs) and long-acting methylxanthines, but monotherapy treatment with them is inferior to monotherapy with ICS, and the combination of them to ICS as a double therapy is inferior to ICS-LABA double therapy. Thus, ICS-LABA double therapy is the best choice as the step-up treatment for managing asthma (Agarwal. R, 2015).
As symptoms further worsen to the point where the increased dosage of ICS-LABA provides little additional effects and increases risks of side effects such as adrenaline suppression, triple therapy is needed. There is a range of different types of drugs that can be used in combination with ICS-LABA but these drugs are either specialized in a certain type of patients, take a long time to take effect, or have side effects such as ototoxicity and cardiac arrhythmia.
Key Takeaways
Treatment for Asthma
- ICS-LABA and a third drug if needed
- lowest possible dosage of ICS as possible
Current Treatment Options for COPD
Initial treatment of mild Chronic obstructive pulmonary disease (COPD) is generally short-acting β2-agonist (SABA) or short-acting antimuscarinic agent (SAMA). More symptomatic patients are treated with LABA or long-acting muscarinic antagonist (LAMA) as the preferred option, double therapy with LABA-LAMA is also an option for high-risk patients.
Key Takeaways
Treatment for COPD
- SABA-SAMA double therapy
- LABA-LAMA double therapy
Current Treatment Options for ACOS
Asthma–COPD overlap syndrome (ACOS) is generally treated with a high-risk COPD or asthma criteria. Inhaled corticosteroids are effective in patients with ACOS with significant benefits in decreasing exacerbations, but once again increased levels of ICS have risks of significant side-effects and must be used with caution. The benefits of LABA-LAMA double therapy is supported for reducing symptoms and decreasing the frequency of exacerbations. On the other hand, the treatment option on the asthma part of ACOS, which is ICS-LABA therapy’s effect and its comparison to the effect of LABA-LAMA for treatment of ACOS still awaits study (Miravitlles et al., 2016).
Limitations and Effectiveness of ICS-LABA-LAMA triple therapy
The effect of LAMA drugs is proven in treating COPD, and it is shown to be also beneficial to be used together with LABA to treat ACOS. LAMA type drugs have an anti-inflammatory effect which contributes to its beneficial effects. Furthermore, LAMA drugs are also shown to improve lung function and increase the time to severe exacerbation. Lastly, treatment with LAMA-type drugs shown little to no side effects. Although with many benefits, LAMA triple therapy’s etiology of the beneficial effects and its effect while used together with ICS are not studied yet. Moreover, physiology outcomes confirm the therapeutic effects of LAMA but ACT scores and CAT scores did not show benefits with respect to healthcare outcomes. This emphasizes an urgent need for a deeper study of LAMA drugs. Triple therapy with LAMA type drugs, which are proven to be effective, conventional, and reduce hospitalization rates in patients with obstructive airway diseases, is already in use even though randomized clinical trials have not previously conducted on patients yet.
References:
Agarwal, R., Dhooria, S., Aggarwal, A. N., Maturu, V. N., Sehgal, I. S., Muthu, V., Prasad, K. T., Yenge, L. B., Singh, N., Behera, D., Jindal, S. K., Gupta, D., Balamugesh, T., Bhalla, A., Chaudhry, D., Chhabra, S. K., Chokhani, R., Chopra, V., Dadhwal, D. S., D’Souza, G., … Varma, S. (2015). Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India : official organ of Indian Chest Society, 32(Suppl 1), S3–S42. https://doi.org/10.4103/0970-2113.154517
Miravitlles, M., Vogelmeier, C., Roche, N., Halpin, D., Cardoso, J., Chuchalin, A. G., . . . Blasi, F. (2016). A review of national guidelines for management of COPD in Europe. European Respiratory Journal, 47(2), 625-637. doi:10.1183/13993003.01170-2015
René Aalbers, Claus Vogelmeier, Piotr Kuna, Achieving asthma control with ICS/LABA: A review of strategies for asthma management and prevention, Respiratory Medicine, Volume 111, 2016, Pages 1-7, ISSN 0954-6111, https://doi.org/10.1016/j.rmed.2015.11.002.