Landmark study “a gamechanger” for asthma sufferers worldwide

TVNZ's 1 News interviewed Professor Beasley about the research, which showed a combination inhaler could more than halve the risk of severe asthma exacerbations.

New findings from a landmark New Zealand-led study have provided the missing evidence needed to potentially change the way doctors treat the world’s most common form of respiratory illness.

Around 10-15% of the world’s adult population suffer from asthma. The prevalence is high in New Zealand with one in every six adults living with the disease daily. Now a new international study conducted by the Medical Research Institute of New Zealand (MRINZ), including hundreds of New Zealand patients with mild asthma, has found that a more simplified, single combination inhaler treatment more than halves the risk of severe asthma attacks compared to commonly prescribed asthma treatments.

“The findings from this study are exciting and have the potential to be a gamechanger in the way doctors treat mild asthma,” says study author and MRINZ Director Professor Richard Beasley.

“The results provide new evidence supporting recent major changes in the management approach recommended in international asthma treatment guidelines.”

Currently, most adults with mild asthma are given two different inhaler medications; a preventer (an inhaled corticosteroid) taken twice daily to keep symptoms at bay and a separate reliever (an inhaled bronchodilator) taken whenever needed to relieve asthma symptoms such as wheezing. This practice is currently recommended by international and New Zealand asthma treatment guidelines. However, in reality, many doctors are reluctant to prescribe regular preventer inhalers, and patients are not likely to use them regularly if their asthma symptoms are infrequent. As a result, most patients with mild asthma end up just using a reliever inhaler such as salbutamol, and no preventer inhaler on a regular basis.

This new study, published in the prestigious New England Journal of Medicine and presented at the American Thoracic Society Annual Scientific Meeting in Dallas today, shows that the use of a combined preventer and reliever in one inhaler, which is taken only when needed to relieve symptoms, reduces the risk of an asthma attack by around half compared with a reliever inhaler alone. It also shows that using this combined preventer-reliever inhaler when needed is better at reducing the risk of a severe asthma attack than using a separate preventer inhaler taken twice daily.

The randomised controlled trial involved 675 adults from New Zealand, Australia, the UK, and Italy who were taking only a reliever medication before they started the study. Most patients (82%) came from New Zealand. They were randomly assigned into one of three groups. One third were asked to use the reliever inhaler salbutamol (Ventolin) for 12 months whenever they had symptoms; one third were asked to use both the preventer inhaler budesonide (Pulmicort) twice daily as well as a separate salbutamol (Ventolin) inhaler whenever they had symptoms; and the final group were asked to use a single combined preventer-reliever inhaler containing both budesonide and formoterol (Symbicort) whenever they had symptoms. The study showed that the risk of an asthma attack was reduced by about half in the preventer-reliever group compared with the reliever inhaler group. The most striking finding was that in the combined preventer-reliever inhaler group the risk of severe asthma attacks was reduced by 60% compared to the group that used just the reliever inhaler when they had symptoms, and by 56% compared to the group using the preventer inhaler every day on top of the reliever inhaler for symptom relief.

“The trial shows for the first time that when patients take just a single combined preventer-reliever inhaler whenever needed to relieve symptoms, they do a lot better than the current recommended treatment of a regular preventer inhaler taken twice daily plus a reliever inhaler whenever needed to relieve symptoms,” says Professor Beasley.

“The greater benefit was achieved despite exposure to less than half the amount of inhaled corticosteroid preventer medication because the inhaled corticosteroid works better when taken as needed in mild asthma.”

“This novel approach simplifies treatment as it doesn’t require patients to take a preventer inhaler twice daily even when they have no symptoms,” he says. “It also addresses two key problems in asthma management; the reluctance of doctors to prescribe regular preventer inhaler therapy and the reluctance of patients to use it when they feel well. With a combined preventer-reliever inhaler, patients have more personal and immediate control over their asthma management. This takes advantage of the patient’s natural behaviour to take a reliever only when they are experiencing symptoms.”

“Professor Beasley and his team should be congratulated on this great piece of work,” says Dr Stuart Jones, Medical Director of the NZ Asthma and Respiratory Foundation and Middlemore Hospital Respiratory Physician.

“For those with mild asthma, implementation of the study’s findings will lead to a reduction in exacerbations, which means less time feeling unwell and more time doing what you enjoy in life, all while using inhaled steroids sparingly.”

Professor Beasley says we are now getting close to asthma treatment being the use of a single preventer-reliever inhaler for nearly all patients across the spectrum of asthma severity. In mild asthma, patients would simply take this combined preventer-reliever inhaler when they have symptoms with no requirement for other inhalers. In moderate to severe asthma, patients would take the combined preventer-reliever inhaler daily both as a regular maintenance medication and also as a reliever when needed.