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ERS 2023 International Congress Asthma Highlights

The European Respiratory Society (ERS) international congress took place 9–13 September 2023 in Milan, Italy. The congress featured scientific sessions on a broad range of respiratory fields. Here we provide some highlights from the congress that focus on the insights and advances in the field of asthma.

Please click on the tabs below to access the session summaries for each topic.

Global, Regional, and National Trends in Incidence of Asthma: Findings From the Global Burden of Disease Study 2019

Xing Y, et al | Abstract no PA2074

Objective:

To determine the geographical variation of asthma incidence over the past 3 decades to facilitate the initiation of more targeted strategies for asthma prevention.

Methods:

  • Detailed information on asthma during the last 30 years from a total of 204 countries and territories was collected from the Global Burden of Disease Study 2019.
  • Age-standardised incidence rate (ASR) and the number of incident cases were calculated to reflect the global pattern of asthma incidence.
  • Temporal trends were quantified by average annual percent change (AAPC), using a join-point regression model.

Results:

  • The overall ASR decreased from 1990 to 2019, with an AAPC of −0.41 (95% CI, −0.59 to −0.23).
  • New asthma cases increased in most parts of the world, with the most pronounced increase in Western Sub-Saharan Africa (AAPC = 2.51; 95% CI, 2.38–2.64), followed by Central Sub-Saharan Africa.
  • The absolute number of new asthma cases also significantly increased worldwide (AAPC = 0.53; 95% CI, 0.37–0.70) and most of the new asthma cases were reported in India.
  • When classifying the geographical regions by socio-demographic index (SDI), more new cases were found in low-SDI regions (AAPC = 2.24; 95% CI, 2.08–2.40).
  • The most remarkable increase was observed in Qatar (AAPC = 5.68; 95% CI, 5.38–5.97), while the greatest decrease was observed in Japan (AAPC = −2.50; 95% CI, −2.67 to −2.32).

Key takeaways

Despite a decreasing trend of ASR on a global scale, a remarkable increase in new asthma cases was observed in countries and regions with low SDI. There is a need for geographically-specific allocation of healthcare resources to forestall the increasing burden of asthma.

Characteristics of Patients With Asthma Using Single Inhaler Triple Therapy in the USA

Noorduyn SG, et al | Abstract no PA4122 (GSK ID: 217417)

Objective:

To assess patient characteristics of those who initiated SITT with FF/UMEC/VI, following treatment with dual therapy ICS and LABA in routine practice.

Methods:

  • A longitudinal cohort of patients with asthma was identified in a US Optum administrative claims database
  • Patients aged ≥18 years with 2 years of continuous enrolment who initiated inhaled SITT during September 2020–March 2021, following treatment with ICS/LABA, were included
  • Patients were stratified by the initial dose of FF/UMEC/VI (SITT100 or SITT200)
  • Baseline resource use was reported as annual rates and proportions

Results:

  • This study included 666 patients. Mean age was 57 years (65% female; mean comorbidity score = 1.6) for SITT100 and 62 years (69% female; mean comorbidity score = 1.8) for SITT200
  • More patients who initiated SITT200 were treated with LAMA monotherapy (7% vs 3%) and OCS (61% vs 57%) than with SITT100, prior to FF/UMEC/VI
  • All-cause and asthma-specific resource use was similar across both groups before SITT initiation

Key takeaways

Differences in baseline clinical characteristics were noted between SITT100 and SITT200 groups, with older patients and patients with more severe symptoms initiating treatment with high-dose FF/UMEC/VI.

Uncontrolled Asthma Associates Age-Dependently With Biomarkers and Comorbidities in Adult-Onset Asthma

Warm K, et al | Abstract no PA2064

Objective:

To assess the association between uncontrolled adult-onset asthma and clinical biomarkers as well as comorbidities in middle-aged and elderly patients.

Methods:

  • A population-based adult-onset asthma cohort from 2019 to 2020 (N=227) underwent a structured interview, an ACT, spirometry, a skin prick test, blood sampling and measurement of FeNO
  • Analyses were performed among all included as well as separately in middle-aged (age 37–64 years; n=120) and elderly (age ≥65 years; n=107) patients

Results:

  • Uncontrolled asthma (ACT score ≤19) was associated with a blood neutrophil count ≥5 cells/µL, BMI ≥30 kg/m2 and comorbidities among all patients
  • Reflux, malignancy and IHD were more prevalent among the elderly patients than among middle-aged patients, while allergic rhinitis was more prevalent in middle-aged patients
  • BMI ≥30 kg/m2 (OR=3.04), blood eosinophil count ≥0.3 cells/µL (OR=3.17), blood neutrophil count ≥5 cells/µL (OR=4.39) and allergic rhinitis (OR=5.10) were associated with uncontrolled asthma in middle-aged patients after adjustment for sex and smoking
  • Chronic rhinitis (OR=4.08), IHD (OR=3.59), malignancy (OR=3.10) and depression/anxiety (OR=16.31) were associated with uncontrolled asthma in the elderly patients

Key takeaways

Clinical biomarkers, including eosinophils and neutrophils, in blood were associated with uncontrolled asthma among middle-aged patients with adult-onset asthma, while comorbidities were associated with uncontrolled asthma in elderly patients.

Treatable Traits in Asthmatic Children

Vocos M, et al | Abstract no PA2744

Objective:

To evaluate whether different treatable traits (TTs) were associated with specific markers, and if the prevalence of TTs varied between children with severe asthma (SA) and moderate asthma (MA).

Methods:

  • The study included children aged 6–18 years from 3 prospective observational studies
  • Instruments that were assumed to be markers for TTs of interest included:
    • Anthropometry (overweight and obesity)
    • FeNO (Th2 inflammation)
    • Basal and post-bronchodilator spirometry (airflow limitation and bronchodilator reversibility)
    • Pediatric Sleep Questionnaire (sleep-disordered breathing [SDB])
    • Prevalence of these TTs was estimated and compared between SA and MA

Results:

  • Baseline data were collected for 163 children (median age = 11 years; 77% of children had SA)
  • Only 25% of children did not have a TT, 39% had 1 TT and the rest had 2–5 TTs
  • Elevated Th2 airway inflammation (42%), SDB (36%) and airflow limitation (29%) were the most frequent TTs
  • Compared with that in patients with MA, SDB was more frequent in patients with SA
  • Between patients with SA and MA, there was no difference in the pulmonary TTs (Th2 inflammation, airflow limitation and bronchodilator reversibility) and extrapulmonary TTs (overweight and obesity and SDB)

Key takeaways

Pulmonary and extrapulmonary TTs are frequent in children with SA and MA.

Baseline Characteristics Impact on Asthma Exacerbation Risk: Individual Patient Trial Data Analysis

Paggiaro P, et al | Abstract no PA3621

Objective:

To characterise the exacerbation risk (ExR) in moderate-severe asthma.

Methods:

  • Individual patient data (N=6722) from 9 randomised clinical trials were used to build a parametric hazard model of time to first exacerbation, considering symptom control (ACQ-5) and baseline clinical/demographic characteristics, e.g. BMI, exacerbation history and smoking status
  • Model validation used standard goodness-of-fit, graphical and statistical criteria

Results:

  • BMI, ACQ-5, previous exacerbation history, FEV1 % predicted, sex and smoking were risk factors for ≥1 exacerbation (p<0.01)
  • Cumulative exacerbation frequency was lower in patients with well and partially controlled symptoms at baseline than in patients with poorly controlled symptoms (p<0.01)
  • Non-smoking male patients had a significantly lower risk (p<0.01) than smokers and female patients

Key takeaways

This drug–disease modelling approach assessed the contribution of patient-specific factors and treatment choices to ExR in moderate-severe asthma. Symptom control, BMI, FEV1 % pred, exacerbation history and sex contributed to ExR, irrespective of treatment.

Risk Factors for Asthma Exacerbations in Adult-Onset Asthma: An Analysis of GINA Report

Nordman L, et al | Abstract no PA3054

Objective:

To evaluate the prevalence of risk factors for exacerbations listed in the GINA 2022 report and association of these risk factors with exacerbations in patients with adult-onset asthma.

Methods:

  • In the present Seinäjoki study, a total of 203 patients with adult-onset asthma were followed-up for 12 years
  • Exacerbation risk factors were based on the GINA 2022 report
  • Data were available for 17 of the 21 risk factors
  • Exacerbation was defined as:
    • An unplanned visit for asthma management
    • Initiation of an OCS course
    • Hospitalisation

Results:

  • On average, 3.8 asthma exacerbation risk factors were observed. Four patients (2.0%) had none of the risk factors    
  • Most common risk factors were poor adherence at <80% (99/181, 54.7%), chronic rhinosinusitis (110/203, 54.2%) and smoking (107/203, 52.7%)
  • OCS use and number of exacerbations increased with higher risk factor scores
  • GERD was a significant risk for exacerbations (OR, 4.5; 95% CI, 1.5–14.0; p=0.009) after adjusting for gender, pack-years and BMI

Key takeaways

In patients with adult-onset asthma exacerbations, risk factors are common and the value of identifying a single risk factor may be low. Patients with multiple risk factors and/or GERD should be recognised as having risk for exacerbations in clinical practice.

Non-T2 Asthma, the Unmet Need: Molecular Phenotyping to Identify Pathways For Patient Benefit. Are we Getting any Closer?

Costello R | Presentation ID 3222

Objective:

To review the clinical, immunological and physiological features of T2 low asthma.

Highlights:

  • IT2 low asthma is characterised by the absence of T2 inflammation
  • Prevalence of T2 low asthma: 40–50%
  • Exposure to corticosteroids impacts T2 status
  • Significant association of T2 low asthma with higher dose of ICS was reported (OR, 1.03 per change in mg FP received/month; 95% CI, 1.00–1.05; p=0.011)
  • Exposure to OCS increased the chances of T2 low asthma (OR, 1.44 per course of OCS; 95% CI, 1.07–1.96; p=0.018)
  • Between patients with T2-low and T2-high asthma, there was no difference in the cytokine and transcription factor levels
  • Asthma is influenced by co-existing clinical conditions: the higher the number of comorbidities, the lower the ACT score

Key takeaways

  • Treating inflammation is important to treat T2 asthma
  • Little mechanistic evidence to support the concept of T2 low asthma as an independent condition
  • Combined effects of corticosteroid treatment along with the non-specific nature of asthma symptoms may be contributing factors of T2 low asthma

Exploring Technology Preferences and Reliever Inhaler Use in Adults With Asthma – Survey Results With Behavioural Segmentation Analysis
    

Bennett-Steele N, et al | Abstract no OA3176

Objective:

To identify trends in reliever-inhaler use, technology use and other self-management behaviours.

Methods:

  • From December 2022 to March 2023, Asthma + Lung UK ran an online survey, receiving 10,500 responses from people with asthma to questions about reliever inhaler use and the use of technology to manage their asthma
  • The responses to both sets of questions were then clustered against demographic data. The trends were compared with the statistical personas created in our behavioural study

Results:

  • During this survey it was observed that 15% of respondents reported using technology at some point, with the most common being a digital peak flow meter
  • 62% of those who currently use technology did not think that it has made a difference to their asthma management
    • Reliever over-users were found to be over-represented in the technology-using group (80% vs 72%)
  • These trends matched with the profile of reliever overuse from one previous behavioural study, which found an association between the overuse of reliever inhalers, frequent monitoring and higher levels of anxiety

Key takeaways

Use of technology to manage asthma is low but increasing, and these data highlight a proportion of the population that could become hypervigilant or anxious if recommended digital monitoring tools. This insight could be used to better match populations with the most suitable support tool.

Validation of an EMR Derived Algorithm to Identify Moderate Asthma Exacerbations in the UK

Rothnie KJ, et al | Abstract no PA3024 (GSK ID: 214485)

Objective:

To investigate the utility of UK primary care EMR data to identify moderate asthma exacerbations using the extension of the Salford Lung Study (Ex-SLS) asthma cohort.

Methods:

  • This was a retrospective cohort study of previous patients of the Salford Lung Study (SLS) pragmatic randomised controlled effectiveness trial, augmented via linkage to EMRs and patient-completed asthma questionnaires, including self-reported moderate exacerbations
  • The following EMR events were considered potential moderate exacerbations (main algorithm):
    • Asthma exacerbation medical code
    • Decreased lung function, or respiratory symptoms and respiratory medication use within ± 7 days
  • This study also assessed 3 alternative algorithms: Broader diagnostic codes, extended medication period and alternative clinical findings (heart rate [>120 beats/min], respiratory rate [>30 breaths/min], oxygen saturation [>90%] and elevated blood eosinophil [EOS; ≥6% EOS or absolute count ≥150/mL])
  • The validity of EMR-derived vs self-reported moderate exacerbations was assessed

Results:

  • A total of 420 of 485 patients reported having a moderate exacerbation in the prior year
  • The Ex-SLS patient questionnaire showed that 86.6% patients, irrespective of treatment class, self-reported the experience of a moderate exacerbation (0 exacerbation: 13.4%; 1–3 exacerbations: 48.5%; ≥4 exacerbations: 38.1%)
  • As per the main algorithm, 15.5% and 5.2% patients, from the EMR data, reportedly experienced 1 or ≥2 moderate exacerbations, respectively
  • The alternative clinical findings algorithm identified a higher proportion of patients, i.e. 28.9% and 18.6% reportedly experiencing 1 and ≥2 moderate exacerbations, respectively
  • Sensitivity and specificity of the main algorithm was 22.6% and 100%, respectively. However, the sensitivity and specificity of the alternative clinical findings algorithm was 52.4% and 84.6%, respectively
  • Findings of the broader codes and extended medication period algorithms were similar to that of the main algorithm

Key takeaways

This study demonstrated the difficulty in identifying moderate asthma exacerbations in EMR data. Improved structured recording of these events in primary care may improve research and clinical care.

Sensitivity and Specificity of the 2022 European Respiratory Society (ERS) Guidelines for the Diagnosis of Asthma in Adults

Simpson A, et al | Abstract no PA3642

Objective:

To determine the sensitivity and specificity of the ERS algorithm along with each of the 4 pathwaysa in RADicA, a prospective study of diagnostic methods for untreated people with symptoms of asthma referred from primary care.

aThe 4 pathways proposed by ERS guidelines to confirm asthma diagnosis are (a) FEV1/FVC <75% predicted and BDR ≥12% and ≥200 mL, (b) FeNO ≥50 ppb, (c) PEFv ≥20%, and (d) methacholine BCT-PD20 <200 µg.

Methods:

  • The following were considered for asthma diagnosis by a panel of asthma specialists (reference standard):
    • Allergy testing
    • Blood eosinophil count
    • Bronchial challenge test (BCT)
    • Bronchodilator reversibility (BDR)
    • Clinical history
    • Physical examination
    • Peak exploratory flow variability (PEFv)
    • Spirometry
    • Response to 8 weeks of ICS therapy
  • Each participant was asked to go through each of the 4 pathways individually to calculate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of each pathway relative to the reference standard

Results:

  • Out of the 143 adults, 118 exhibited a definitive diagnostic outcome (mean ± SD age = 36 ± 12 years); 59% had asthma
  • The highest sensitivity was exhibited by the algorithm (81%), followed by BCT (62%)
  • Spirometry and BDR along with methacholine BCT exhibited 100% specificity and PPV
  • The NPV was higher with respect to the algorithm (76%), followed by BCT (69%)
  • Altogether, 1 in 6 adults (17%) received a different diagnosis when compared with the diagnosis by the specialist panel, 13 (11%) with asthma were missed and 7 (6%) were wrongly diagnosed with asthma

Key takeaways

  • The diagnostic tests for asthma, as proposed by the ERS guidelines, provide poor sensitivity but good specificity, albeit the ERS algorithm provides a reasonable level of sensitivity and specificity
  • Diagnosis can be improved by adjusting cutoff values for individual tests and/or adjusting the sequence.

Albuterol–Budesonide Asthma Rescue Inhaler: Patterns of As-Needed Use

Papi A, et al | Abstract no PA5292

Objective:

To explore use patterns of as-needed albuterol–budesonide (ABD) 180/160 μg and albuterol in the MANDALA study.

Methods:

  • Patterns of use of an investigational product (IP) were evaluated in patients aged ≥12 years randomised to as-needed ABD 180/160 μg (n=1013) or albuterol 180 μg (n=1014) (administered as 2 inhalations of 90/80 μg and 90 μg, respectively)
  • IP use was documented in an eDiary

Results:

  • ABD and albuterol use patterns were similar. Mean percentage of days with IP use are as follows:
    • 0 to ≤2 inhalations on 50–54% of days
    • ≤4 inhalations on 85% of days
    • >8 inhalations on <2% of days
  • In the ABD and albuterol groups,
    • 5.0% of patients in each group used ≥8 inhalations on ≥7 consecutive days
    • 2.2% and 2.3%, respectively, used 12 inhalations (maximum per protocol) on ≥2 consecutive days
    • 0.4% and 0.5%, respectively, used >12 inhalations on ≥2 consecutive days
  • AE frequency was comparable between treatment groups, overall and with increasing mean daily IP use
  • The small percentage of patients using a mean of ≥6 inhalations/day of ABD (<5%) had no clinically important increase in AEs when compared with those using albuterol

Key takeaways

Similar use patterns were observed between treatment groups, indicating patients use albuterol–budesonide rescue in the same manner as their SABA. High daily use was uncommon. Albuterol–budesonide was well tolerated.

Impact of Extrafine Formulation Single-Inhaler Triple Therapy on Lung Function After Three Months of Treatment in Patients With Asthma and Concomitant COPD: The TriMaximize Study

Koczulla R, et al | Abstract no PA2374

Greulich T, et al | Abstract no PA2377

Timmermann H, et al | Abstract no PA2378

Gessner C, et al | Abstract no PA2379

Objective:

To provide evidence for characteristics, therapy pathways, asthma control and HRQoL of patients having moderate-to-severe asthma prescribed efSITT in real-world clinical practice.

Methods:

  • This is a multicentre, multinational, prospective, observational study investigating the impact of efSITT in patients with moderate-to-severe asthma who were prescribed efSITT (consisting of BDP/FORM/GLY) for 1–3 years in real-world clinical practice
  • Present interim analyses include patients from Germany, UK, Austria and Denmark after 3 months of efSITT treatment (N=280 to 328)a
  • The following parameters were measured:
    • Changes in HRQoL using the Mini AQLQ
    • Changes in asthma control using the ACT
    • Changes in lung function using FEV1, PEF, FVC and sRaw
  • Patients with asthma having concomitant COPD (n=82) were compared with remaining patients with asthma irrespective of other comorbidities (n=235) for level of asthma control

aData from 4 analyses are presented here.    

Results:

  • Patient characteristics:
    • Prior treatment: ICS/LABA = 76–79.7%; ICS/LABA/LAMA = 20.3–24%
    • At baseline:
      • Mean Mini AQLQ score = 4.1 points
      • Mean ACT score = 14.4–14.7 points in patients with asthma and 13.1 points in patients with concomitant COPD
      • Mean FEV1 score = 1.93 L overall, 1.94 L for patients with prior ICS/LABA and 1.89 L for patients with prior ICS/LABA/LAMA
  • Mean change in Mini AQLQ score from baseline after 3 months of treatment
    • Overall population: 0.7 points (p<0.0001)
    • Patients with prior ICS/LABA treatment: 0.9 points (p<0.0001)
    • Both results exceeded MCID of 0.5 points
  • Improvement in ACT score from baseline after 3 months of treatment
    • Overall population: 3.3 points (p<0.0001)
    • Patients with prior ICS/LABA treatment: 3.7 points (p<0.0001)
    • Patients in the asthma only group: 2.9 points (p<0.0001)
    • Patients in concomitant COPD group: 4.4 points (p<0.0001)
  • Mean change in lung function parameters and sRaw from baseline at 3 months of treatment among all patients, patients with prior ICS/LABA and patients with prior ICS/LABA/LAMA, respectively
    • FEV1 (mL): 141 (p<0.0001), 154 (p<0.0001) and 90 (p=0.0328)
    • PEF (mL/s): 245 (p=0.0004), 264 (p=0.0022) and 186 (p=0.0534)
    • FVC (mL): 178 (p<0.0001), 180 (p<0.0001) and 173 (p=0.0036)
    • sRaw (kPa/s): −0.25 (p=0.0048), −0.27 (p=0.0065) and −0.14 (p=0.4288)

Key takeaways

  • In patients with moderate-to-severe asthma, a significant improvement in asthma control, lung function, sRaw and HRQoL was observed after 3 months of switching treatment from ICS/LABA or ICS/LABA/LAMA to efSITT
  • In patients with concomitant COPD, evidence for improvement in asthma control was shown

Patients' Knowledge, Perspectives and Attitudes Towards Treatment Goals and Clinical Remission in Severe Asthma

Zhang S, et al | Abstract no PA1895 (GSK ID: 214851)

Objective:

To study patients with asthma and their perspective on current treatment goals, knowledge and perception of clinical remission (CR).

Methods:

  • A survey of an international online community of 125 patients with moderate-to-severe asthma across 6 countries (France, Germany, Italy, Spain, Japan, USA) was conducted
  • An online qualitative-focused survey was employed to drive response and generate feedback

Results:

  • The following were the most prioritised treatment goals:
    • Avoiding lung deterioration = 76%
    • Avoiding hospitalisation = 73%
    • Avoiding asthma attacks = 73%
  • A total of 46% of patients showed a positive sentiment toward OCS; 24% of patients expressed concerns with adverse effects
  • When shown a definition of CR, 85% of patients agreed it to being an appealing treatment goal; 62% agreed it was realistic
  • There was a lack of consensus of what patients could change in their journey with asthma to make remission more achievable, such as access to more information about the treatment and goals (39%) or choosing alternative treatments in case of slow efficacy (37%)

Key takeaways

The study indicated clinical remission as an appealing treatment goal for patients with asthma, therefore, highlighting the opportunity to help inform and guide patients on clinical remission and increase proactivity in goal setting.

SHAMAL: Reduction of Maintenance Inhaled Corticosteroids in Patients With Severe Eosinophilic Asthma Treated With Benralizumab: A Randomised Phase 4 Study

Jackson D, et al | Presentation ID PA798

Objective:

To assess the ability of benralizumab to permit a progressive reduction from high dose ICS/LABA (BUD/FORM) down to anti-inflammatory reliever (AIR) whilst maintaining control in patients with SEA who were well controlled on benralizumab.

Methods:

  • In total, 168 patients controlled on benralizumab were randomised 3:1 to tapering high-dose ICS/LABA (n=125) or stable high-dose ICS/LABA (n=43)
    • High-dose ICS/LABA was tapered to medium dose, low dose or prn
  • Primary endpoint: Percentage of patients reducing ICS/LABA dose at the end of reduction period (Week 32)
  • Secondary endpoints (during the study period): Change in total ICS dose, annualised asthma exacerbation rates, PROs and change from baseline in pre-bronchodilator FEV1 and FeNO

Results:

  • Number of patients with reduced ICS/LABA dose = 110
    • Number of patients tapered to ICS/LABA AIR only = 72
    • Number of patients reduced to medium dose = 18
    • Number of patients reduced to low dose = 20
  • Mean ± SE change in the ACQ-5 score from baseline at Week 32 = 0.16 ± 0.04
  • Patients in the tapering arm reported using lesser ICS by 73% when compared with patients in the stable dosing arm
  • Patients in the ICS/LABA prn group experienced a reduction in mean change in FEV1 from baseline of more than 100 mL
  • During the taper period, no exacerbations and meaningful changes in symptom control were reported amongst the 110 patients who received reduced ICS/LABA dose)

Key takeaways

Benralizumab enabled the majority of patients with SEA to maintain disease control and remain exacerbation free, despite a reduction in background therapy to AIR only. However, patients in the ICS/LABA prn group did experience a reduction in FEV1 of more than 100 mL.

Aiming for Remission in Asthma: Is This a Useful Treatment Goal?

Virchow JC, et al | Presentation ID 3113

Highlights:

  • To date, treatment of asthma is considered based on severity and not according to the pathology
  • The target for asthma treatment should be ‘remission’
  • Future treatment options for asthma must consider moving from symptom control to symptom prevention and long-term therapeutic benefits
  • Concept of remission does not mean ‘cure’, and it is independent of the current treatment status
  • Four important criteria are proposed for asthma remission: Stability in the lung function, no requirement for systemic corticosteroids as part of asthma treatment, sustaining the absence of asthma symptoms and sustaining the absence of asthma exacerbations
  • Asthma remission could be achieved by considering the disease-modifying anti-asthmatic drugs (DMAADs)
    • Biologics, allergen immunotherapy, ICS, LTRAs, ICS ± LAMA, ICS ± LABA (in the 21st century)
    • Preventive medications and individual treatment options, collateral efficacy (effect on comorbidities) and safety of medications
  • Aiming for asthma remission needs simplification—a concise ‘A2BCD’ guide as follows:
    • Diagnosis – A = Assess: Diagnosis and phenotype; A = Assess: Control and risk
    • Treatment – B = Basics; C = Comorbidities; D = DMAADs
  • Additionally, asthma remodelling could be prevented, treated or reversed
  • Clinical remission could be defined as either partial or complete based on the 4 proposed criteria. Biological remission could consider eosinophils and FeNO levels. Both concepts could influence the prognosis of asthma

Key takeaways

  • We need to move from symptom control to long-term symptom prevention
  • Remission does not mean cure: clinical remission is a treatment goal and is independent of current treatment and disease severity
  • Treatment goal remission: reduction of symptoms and exacerbations, minimal side effects, no OCS

Trends in Inhaler Use and Associated Carbon Footprint: A Sales Data-Based Study in Europe
    

Vartiainen V, et al | Abstract no PA2381

Objective:

To describe the trends of pMDI and DPI use and associated carbon footprint in Europe.

Methods:

  • Between 2011 and 2021, DPI and pMDI sales statistics in European countries (Germany, France, Spain, Italy, Poland, Norway, Sweden, Finland, Denmark and UK) were obtained from IQVIA MIDAS Quarterly 2022
  • The Medical and Chemicals Technical Options Committee’s 2018 assessment report was used to calculate the carbon footprint

Results:

  • The carbon footprint of inhalation therapy increased from 3.37 to 3.89 Mt CO2e over this period owing to a 40% rise in the number of sold pMDI doses and a 10% drop in DPIs
  • Using DPIs instead of pMDIs would have resulted in 92% fewer emissions
  • In 2021, SABA-related emissions were 1.64 Mt CO2e (41% of total emissions), with pMDIs accounting for 94%
  • In 2021, UK was the biggest source of pMDI-related emissions, accounting for 1.24 Mt CO2e (31% of total emissions)

Key takeaways

  • In many European countries, the carbon footprint of inhaler therapy has increased owing to an increased use of pMDI and low use of DPI
  • This study suggested that an increased focus on guideline-based control therapy, as well as prioritising DPIs when clinically relevant, can improve patient outcomes while reducing greenhouse gas emissions due to SABA overuse

Socioeconomic Disparities in the Carbon Footprint of Asthma Care in the UK: Results from SABINA CARBON

Maslova E, et al | Abstract no PA2382

Objective:

To describe asthma care–related greenhouse gas (GHG) emissions by socioeconomic status (SES) in the UK.

Methods:

  • Inclusion data: Patients with asthma (≥12 years) in the Clinical Practice Research Datalink (2008–2019) with linked SES data from the Index of Multiple Deprivation (IMD)
  • For medicines, HCRU and exacerbations, 1-year per capita GHG emissions were calculated
  • Asthma severity was based on 2016 BTS treatment steps

Results:

  • Overall per capita GHG emissions were reported among patients with higher IMD scores and at higher BTS steps
  • Most of this disparity was due to higher SABA-related per capita GHG emissions
  • The per capita GHG emissions increased with higher IMD scores owing to ED visits, inpatient hospitalisations and OCS-treated exacerbations

Key takeaways

  • Carbon footprint of asthma care increased with higher socioeconomic deprivation
  • Improving quality in highly deprived areas can help address health inequities and improve patient outcomes while reducing the carbon footprint of asthma care

Switching Inhaler Treatment From pMDI to DPI in Real-World; Reduction of Carbon Footprint

Janson C, et al | Abstract no PA2385

Objective:

To perform a post hoc analysis on clinical outcomes data from a 12-week real-world, non-interventional, single-arm study that includes patients who switched from pMDI to DPI.

Methods:

  • Patients: Adults with asthma, COPD or ACO who switched treatment from pMDI to DPI (BUD/FORM Easyhaler) according to the treating physician and local guidelines
  • Clinical endpoints: ACT, CAT and lung function tests (FEV1)
  • Range of CO2e in kilograms for a single dose as reported in the Montreal Protocol 2 was used and as a conservative estimate, for a lower range for BUD/FORM Easyhaler, the average estimate was reported (0.004 kg CO2e)

Results:

  • Total number of patients: 253
  • Clinical improvement was observed among all patients after the switch (baseline to 12 weeks)
    • Mean ACT score: Asthma = 13.3–21.0 (p<0.001); ACO = 12.3–19.1 (p<0.001)
    • Mean CAT score: COPD = 23.5–16.8 (p<0.001); ACO = 25.1–16.8 (p<0.001)
    • Mean FEV1 % predicted: Asthma = 76.7–87.1 (p<0.001); COPD = 51.3–58.8 (p<0.001); ACO = 60.9–63.6 (p=0.18)
  • Range of estimated CO2e emissions per year was (90–97%) lower for BUD/FORM Easyhaler (2.9–14.6 kg CO2e emissions/year) than for pMDI (91–137 kg CO2e emissions/year), assuming twice-daily dosing for both the inhalers

Key takeaways

  • The study suggested that switching from a pMDI to DPI may enhance disease control among patients with asthma, COPD and ACO
  • Switching from a pMDI to DPI may have a positive environmental impact with reduced carbon footprint

Related materials

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ATS 2023 International Congress Asthma Highlights

The ATS 2023 international conference took place between May 19–24, 2023 in Washington DC, USA…

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JRS 2023: The impact of not well controlled versus well controlled asthma on patients’ daily lives in Japan

The 63rd Annual Meeting of the Japanese Respiratory Society took place 28–30 April 2023 in Tokyo, Japan…

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CHEST 2023: Reduction of asthma exacerbations following initiation of single-inhaler triple therapy in US clinical care

The CHEST 2023 Annual Meeting took place October 8–11, 2023 in Honolulu, Hawai’i, United States…

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Footnotes

Abstracts presented at ERS 2023 are published in the European Respiratory Journal in November 2023, available from: https://erj.ersjournals.com/.

Abbreviations

AAPC, average annual percent change; ABD, albuterol–budesonide; ACO, asthma COPD Overlap; ACQ-5, Asthma Control Questionnaire-5; ACT, Asthma Control Test; AE, adverse event; AIR, anti-inflammatory reliever; AQLQ, Asthma Quality of Life Questionnaire; ASR, age-standardised incidence rate; BCT, bronchial challenge test; BDR, bronchodilator reversibility; BDP, beclometasone dipropionate; BMI, body mass index; BTS, British Thoracic Society; BUD, budesonide; CARBON, healthCARe-Based carbON cost of treatment; CAT, COPD Assessment Test; CI, confidence interval; CO2e, carbon dioxide equivalent; COPD, chronic obstructive pulmonary disease; CR, clinical remission; DMAAD, disease-modifying anti-asthmatic drugs; DPI, dry-powder inhaler; ED, emergency department; EMR, electronic medical record; efSITT, extrafine formulation single-inhaler triple therapy; EOS, eosinophil; ERS, European Respiratory Society; ExR, exacerbation risk; FeNO, fractional exhaled nitric oxide; FEV1, forced expiratory volume in 1 second; FF, fluticasone furoate; FORM, formoterol; FP, fluticasone propionate; FVC, forced vital capacity; GERD, gastroesophageal reflux disease; GHG, greenhouse gases; GINA, Global Initiative for Asthma; GLY, glycopyrronium; HCRU, healthcare resource utilisation; HRQoL, health-related quality of life; ICS, inhaled corticosteroid; IHD, ischaemic heart disease; IMD, Index of Multiple Deprivation; IP, investigational product; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; LTRA, leukotriene receptor antagonist; MA, moderate asthma; MCID, minimal clinically important difference; NPV, negative predictive value; OCS, oral corticosteroid; OR, odds ratio; PEF, peak expiratory flow; PEFv, peak expiratory flow variability; PD, provocative dose; prn, as needed; pMDI, pressurised metered-dose inhaler; ppb, parts per billion; PPV, positive predictive value; PRO, patient-reported outcome; RADicA, Rapid Access Diagnostics for Asthma; SA, severe asthma; SABA, short-acting β2-agonist; SABINA, SABA Use IN Asthma. SD, standard deviation; SE, standard error; SEA, severe eosinophilic asthma; SES, socioeconomic status; SD, standard deviation; SDB, sleep-disordered breathing; SDI, socio-demographic index; SITT, single-inhaler triple therapy; SLS, Salford Lung Study; sRaw, specific airway resistance; T2, type 2; Th2, T helper type 2; TT, treatable traits.

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NX-GBL-FVU-WCNT-230013 | Date of preparation: October 2023