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      Inhaled Combined Budesonide–Formoterol as Needed in Mild Asthma

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          Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study.

          For most patients, asthma is not controlled as defined by guidelines; whether this is achievable has not been prospectively studied. A 1-year, randomized, stratified, double-blind, parallel-group study of 3,421 patients with uncontrolled asthma compared fluticasone propionate and salmeterol/fluticasone in achieving two rigorous, composite, guideline-based measures of control: totally and well-controlled asthma. Treatment was stepped-up until total control was achieved (or maximum 500 microg corticosteroid twice a day). Significantly more patients in each stratum (previously corticosteroid-free, low- and moderate-dose corticosteroid users) achieved control with salmeterol/fluticasone than fluticasone. Total control was achieved across all strata: 520 (31%) versus 326 (19%) patients after dose escalation (p < 0.001) and 690 (41%) versus 468 (28%) at 1 year for salmeterol/fluticasone and fluticasone, respectively. Asthma became well controlled in 1,071 (63%) versus 846 (50%) after dose escalation (p < 0.001) and 1,204 (71%) versus 988 (59%) at 1 year. Control was achieved more rapidly and at a lower corticosteroid dose with salmeterol/fluticasone versus fluticasone. Across all strata, 68% and 76% of the patients receiving salmeterol/fluticasone and fluticasone, respectively, were on the highest dose at the end of treatment. Exacerbation rates (0.07-0.27 per patient per year) and improvement in health status were significantly better with salmeterol/fluticasone. This study confirms that the goal of guideline-derived asthma control was achieved in a majority of the patients.
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            Compliance, adherence, and concordance: implications for asthma treatment.

             Rob Horne (2006)
            Good-quality outcomes in asthma hinge not just on the availability of medications but also on their appropriate use by patients: optimal "self-management." In asthma, low rates of adherence to prophylactic (preventer) medication are associated with higher rates of hospitalization and death. Many patients choose not to take their medication because they perceive it to be unnecessary or because they are concerned about potential adverse effects. Approximately one third of asthma patients have strong concerns about adverse effects from inhaled corticosteroids (ICS). These concerns are not just related to the experience of local symptoms attributed to ICS side effects, but also include more abstract concerns about the future, arising from the belief that regular use of ICS will result in adverse long-term effects or dependence. We need more effective ways of eliciting and addressing patients' concerns about ICS. The development of ICS options with an improved safety profile remains a key objective. However, the ideal solution is not just pharmacologic. We also need more effective ways of communicating the relative benefits and risks to patients in order to facilitate informed adherence. Clinicians must be prepared to work in an ongoing partnership with patients to ensure that they are offered a clear rationale as to why ICS are necessary and to address their concerns about potential adverse effects. This approach, based on a detailed examination of patients' perspectives on asthma and its treatment, and an open, nonjudgmental manner on the part of the clinician, is consistent with the idea of concordance.
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              Asthma control and management in 8,000 European patients: the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey

              Background: Asthma is one of the most common chronic diseases in the world, and previous studies have reported low levels of control. Recent developments in the availability and use of online sources of information about asthma might add to patients’ knowledge and help improve control. Aims: To investigate whether asthma control has improved by assessing levels of symptoms, exacerbations and Global Initiative for Asthma-defined control in a real-life population of patients who use the Internet and social media, as well as evaluate patient perception of control and attitudes to asthma. Methods: Online surveys were conducted among 8,000 patients with asthma (aged 18–50 years, ⩾2 prescriptions in the previous 2 years, use of social media) from 11 European countries. Results: Levels of asthma control were low: 45% of respondents had uncontrolled asthma. Acute exacerbations were common: 44% of respondents reported having used oral steroids for asthma in the previous 12 months, 24% had visited an emergency department and 12% had been hospitalised. More than 80% of respondents (overall, and among those with a history of exacerbations) considered their asthma to be controlled. Of those who had an exacerbation requiring oral steroids, 75% regarded their asthma as not serious. Conclusions: Asthma control in Europe remains poor; symptoms and exacerbations are common. Many patients regard their asthma as controlled and not serious despite experiencing symptoms and exacerbations. There is a need to assess patients’ control, risk and inhaler technique, and to ensure that patients are prescribed, and take, appropriate treatments.
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                Author and article information

                Affiliations
                [1 ]From the Firestone Institute for Respiratory Health, St. Joseph’s Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) — both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.);...
                Journal
                New England Journal of Medicine
                N Engl J Med
                New England Journal of Medicine (NEJM/MMS)
                0028-4793
                1533-4406
                May 17 2018
                May 17 2018
                : 378
                : 20
                : 1865-1876
                10.1056/NEJMoa1715274
                © 2018
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