Patient-Activated, Reliever-Triggered Inhaled Glucocorticoid Strategy- An Overview

Introduction:

Asthma is a chronic condition of the lungs affecting children and adults, particularly in underdeveloped and developing countries. The air passage of the affected individuals becomes narrow and constricted due to the inflammation of the surrounding muscles. Symptoms like asthma, cough, wheezing, chest tightness, and shortness of breath, all of them exacerbating at night or during exertion activities like running, exercise, sports activities, etc can result from this. Undertreated cases often suffer from loss of sleep, tiredness, and inability to concentrate. It decreases an individual’s overall productivity because of missed school or work, reflects on the family's financial status, and ultimately on the community.

A survey conducted in 2019 estimated that about 262 million people were affected by asthma and 4,55,000 deaths were reported. In the United States, more than 25 million people have asthma, of which African Americans, Latinos, and Hispanics were the major proportion and suffered from its most serious complications. This population had a death rate from asthma two to three times higher than Caucasians (white people).

Asthma as a condition cannot be cured completely but can be controlled. Inhaled medications are reported to have a good effect on asthma and help the affected individuals lead an active normal life.

What Are the Treatment Modalities for Asthma?

After an asthma diagnosis, the healthcare provider devises a treatment plan based on the severity of the condition and the symptoms the patient displays. Several treatment modalities are available for controlling asthma and providing the patient with an active life. One group of asthma medications called bronchodilators work by relaxing the muscles surrounding the narrow airway that squeezes them opening these airways. The second group, called steroidal and non-steroidal anti-inflammatories, reduces the swelling inside the airways. Several other treatment modalities, like biologics, leukotriene modifiers, cromolyn sodium, etc., are also available.

What Is Meant by SMART in Asthma Management?

Recent asthma management guidelines update recommends a single maintenance reliever therapy, known as SMART. SMART uses a single inhaler with two medicines; one provides quick relief, and the other is a controller medicine. This medication can be taken either as an emergency medicine in cases of sudden symptoms or as a traditional medicine in addition used to control sudden symptoms. This use is based on the patient's age and the severity and frequency of the asthmatic attacks.

What Is Patient Activated Reliever - Triggered, Inhaled Glucocorticoid Strategy in Asthma?

Ongoing research at Brigham and Women's Hospital's Pulmonary and Critical Care Medicine Division is developing an alternative to inhaled corticosteroid use daily to prevent status asthmaticus (asthmatic attacks). This novel strategy is called the patient-activated reliever-triggered, inhaled corticosteroid strategy (PARTICS). This approach instructs patients to use their inhaled corticosteroid (ICS) concurrent with their reliever inhaler in emergencies to ease symptoms like wheezing or shortness of breath. The approach could effectively control asthma and prevent exacerbations.

The backbone of asthma controller treatment is inhalational glucocorticoids. Earlier, the most commonly recommended strategy for asthma control was the twice daily use of a combination containing a short-acting beta two agonist. Recently the guidelines have been updated, suggesting a single inhaler constituting the combination of an inhalational glucocorticoid and a rapid onset LABA (long-acting beta two agonists) twice a day regularly. The use will help control asthma as well as its exacerbations. However, there is only limited evidence to show the effectiveness of this treatment modality. This presents a barrier to the implementation of the strategy.

What Was the Experiment Conducted to Know the Effectiveness of Patient Activated Reliever-Triggered, Inhaled Corticosteroid Strategy?

12,01 asthmatic patients (adults) were recruited from the American African, Hispanic, and Latin populations. Approximately half the people in the group had fair to poor health with many other co-existing health conditions, 68.8 % were obese, and 20 % were smokers or former smokers. They were selected particularly because of the high rate of morbidity associated with asthma in these populations compared to the Caucasian population. Although most individuals were a broad group of self-identified Black and Latin participants, the population included many different ethnic groups. In addition, there was a majority in this trial, so the results cannot be generalized to men. However, compared to men, women are more prone to asthma and constitute two-thirds of adults with asthma. The patients either used an inhalational corticosteroid or had an asthmatic attack in the previous year. They were randomly grouped, and 600 were assigned to follow the patient-activated reliever-triggered, inhaled corticosteroid strategy, and the rest, 601, were to follow their standard therapy. Both groups had to attend a monthly questionnaire for about 15 months. The number of exacerbations, symptoms, days lost from work, and asthma control. The research team did the trial to determine the more effective treatment strategy.

What Were the Results of the Experiment?

The experiment demonstrated that compared to the control, the intervention group (following the patient activated reliever-triggered inhaled corticosteroid strategy), the rate of exacerbation events was less:

• Intervention group - 0.69

• Control group - 0.82

The rate of missed days was also significantly less for the intervention group than for the control group. However, the occurrence of adverse events was equally distributed in both groups.

Conclusion:

The mechanism by which this strategy works is uncertain; it is believed that it may be because of the early use of inhaled glucocorticoids similar to the SMART (single maintenance reliever therapy). Implementation of this strategy totally, as suggested by the National Asthma Education and Prevention Programme 2020, might produce a result similar to or more effective than the one observed in the PARCTICS (patient-activated reliever-triggered, inhaled corticosteroid strategy) trial. The advantage of single-maintenance reliever therapy is that it offers a single inhaler to control asthma and relieve attacks. However, as discussed, several barriers are present for its implementation and require changing the Patient's current therapy line. The study conducted with a diverse population of African Americans and Latinos with PARCTICS (patient-activated reliever-triggered, inhaled corticosteroid strategy) added to existing therapy led to a marked lowering of the exacerbation risks. Excellent outcomes were observed.