哮喘联盟

   摘要
   基本原理：针对采用吸入性糖皮质激素（ICS）单一疗法不能控制哮喘的患者，指南建议在吸入性糖皮质激素中添加长效β受体激动剂（LABA）作为首选升级治疗方案，而非增加吸入性糖皮质激素剂量。然而指南根据的随机对照试验只纳入了<5%的哮喘患者。因此需要现实世界数据补充准入标准严格的随机试验结果。
   目的：旨在比较增加不同种类吸入性糖皮质激素剂量与添加长效β受体激动剂的升级治疗的效果。
   方法：我们进行了回顾性配对队列研究，采用了大量初级保健数据来比较使用小颗粒和标准颗粒可吸入糖皮质激素与添加LABA的哮喘升级治疗对于12～80岁患者的疗效。我们调查了哮喘控制和严重急性发作的综合结果。
   测量和主要结果：增加吸入性糖皮质激素剂量和添加LABA两组的 1年以上哮喘控制率和严重急性发作率差别不大。在小颗粒吸入糖皮质激素组中（n=3036每队列），增加吸入性糖皮质激素剂量相比添加LABA达到哮喘控制水平的校正比值比为0.99（95% CI，0.88-1.12），严重急性发作校正风险比为1.04 (0.91-1.20)。在标准颗粒吸入糖皮质激素组中（n=809每队列），达到哮喘控制水平的校正比值比为0.85 (0.67-1.07) 严重急性发作校正风险比为1.18 (0.92-1.54)。研究结果未受到烟雾状态的影响。
   结果：在应用于广大初级保健群体时，采用增加剂量的小颗粒和标准颗粒可吸入糖皮质激素与添加LABA的抗炎治疗同样有效，研究结果对患者与医师同样重要。在拟定治疗建议时，现实世界人群和结果都需纳入考虑。
 

（苏欣 审校）
Ann Am Thorac Soc. 2015 Mar 10. [Epub ahead of print]
 

Increased Dose of Inhaled Corticosteroid vs. Add-On Long-Acting Beta-Agonist for Step-Up Therapy in Asthma.
 

Israel E1, Roche N, Martin RJ, Colice G, Dorinsky PM, Postma DS, Guilbert TW, van Aalderen WM, Grigg J,Hillyer EV, Burden A, von Ziegenweidt J, Thomas V, Price DB.

Author information
 

ABSTRACT
RATIONALE:Guidelines advocate adding long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) as the preferred step-up therapy to increasing inhaled corticosteroid dose for patients with uncontrolled asthma on inhaled corticosteroid monotherapy. However, <5% of patients with asthmaqualify for the randomized controlled trials on which guidelines are based. Thus, real-world data are needed to complement results of randomized trials with narrow entry criteria.
OBJECTIVES:To compare the effectiveness of stepping up asthma therapy with an increased dose of different types of inhaled corticosteroid as compared with add-on LABA.
METHODS:We performed a historical matched cohort study utilizing large primary care databases to compare asthma step-up therapy with small- and standard size-particle inhaled corticosteroid vs. added LABA for patients 12-80 years old. As outcomes, we examined a composite of asthma control and rates of severe exacerbations.
MEASUREMENTS AND MAIN RESULTS:The odds of asthma control and rates of severe exacerbations over 1 outcome year were comparable with increased inhaled corticosteroid dose vs. added LABA. The adjusted odds ratios (95% CI) for achieving asthma control with increased inhaled corticosteroid dose vs inhaled corticosteroid/LABA were 0.99 (0.88-1.12) for small-particle inhaled corticosteroid (n=3036 per cohort) and 0.85 (0.67-1.07) for standard size-particle inhaled corticosteroid (n=809 per cohort). The adjusted rate ratios (95% CI) for severe exacerbations, compared with inhaled corticosteroid/LABA combination inhaler, were 1.04 (0.91-1.20) and 1.18 (0.92-1.54), respectively. The results were not affected by smoking status.
CONCLUSIONS:When applied to a broad primary care population, anti-inflammatory therapy utilizing increased doses of small- or standard size-particle inhaled corticosteroid is as effective as adding LABA, as measured by outcomes important to both patients and providers. Real-world populations and outcomes need to be taken into consideration when formulating treatment recommendations.
 

Ann Am Thorac Soc. 2015 Mar 10. [Epub ahead of print]