Jenkins Christine
Department of Thoracic Medicine, The George Institute for Global Health and Concord Clinical School, University of Sydney, Sydney, NSW, Australia,
Ther Clin Risk Manag. 2019 Mar 14;15:423-435. doi: 10.2147/TCRM.S177603. eCollection 2019.
Despite the availability of a range of treatment options and management guidelines, a high proportion of adults with asthma remain uncontrolled. The challenge of managing uncontrolled asthma includes providing efficacious treatment while limiting side effects, recognizing situations when a change in asthma therapy is required, and considering patient preferences and satisfaction. In line with the Global Initiative for Asthma report, asthma management is based on a backbone of inhaled corticosteroid (ICS) therapy and use of add-on therapies to achieve disease control. This review considers whether add-on options could be better utilized in clinical practice. A number of long-acting muscarinic antagonists are in development, but tiotropium is the most widely studied for use in asthma. Evidence demonstrating the efficacy of tiotropium as an add-on therapy to at least ICS in adults with symptomatic mild, moderate, and severe asthma is presented from randomized controlled trials and real-world evidence. In addition, the benefit of tiotropium therapy in a wide range of patient phenotypes and disease severities without the need for biomarker assessment is discussed. Additional strategies that complement this approach, such as recognizing and overcoming barriers to adherence, ensuring optimal device use, and education and support to enhance patient-physician communication, are discussed. Physician education can also help raise awareness that additional management options are available for patients with moderate-to-severe asthma who remain uncontrolled on ICS/long-acting β-agonist treatment.
尽管有一系列治疗方案和管理指南，但仍有很大比例的成年哮喘患者病情未得到控制。管理未控制哮喘的挑战包括在限制副作用的同时提供有效的治疗，识别需要改变哮喘治疗方案的情况，以及考虑患者的偏好和满意度。根据全球哮喘防治创议报告，哮喘管理以吸入性糖皮质激素（ICS）治疗为基础，并使用附加疗法来实现疾病控制。本综述探讨了附加疗法在临床实践中是否能得到更好的应用。多种长效毒蕈碱拮抗剂正在研发中，但噻托溴铵是在哮喘治疗中研究最为广泛的。本文从随机对照试验和真实世界证据中呈现了噻托溴铵作为附加疗法用于有症状的轻度、中度和重度成年哮喘患者（至少联合ICS）的疗效证据。此外，还讨论了噻托溴铵治疗在广泛的患者表型和疾病严重程度中的益处，且无需进行生物标志物评估。文中还讨论了补充该方法的其他策略，如识别和克服依从性障碍、确保最佳装置使用以及开展教育和提供支持以加强医患沟通。医生教育也有助于提高认识，即对于在ICS/长效β受体激动剂治疗下仍未得到控制的中重度哮喘患者，还有其他管理选择。
