Efectos de la pandemia en una consulta de tabaquismo / Effects of the pandemic on a smoking consultation

Objetivo. Análisis de las diferencias entre pacientes atendidos en la unidad hospitalaria de tabaquismo del H. Doctor Peset de Valencia, antes de la pandemia y con posterioridad, para valorar resultados obtenidos en cuanto a abstinencia tabáquica. Material y método. Estudio retrospectivo observacional analizando las mismas variables en dos periodos temporales: pacientes atendidos por primera vez durante el año previo a la pandemia (enero-diciembre 2019) y entre junio de 2021 y junio de 2022 (postpandemia). Se valoran datos demográficos, comorbilidades, dependencia, tratamiento farmacológico prescrito y éxitos obtenidos. Resultados. Diferencias en el número de pacientes atendidos con una reducción de 645 a 115. Incremento de trastornos psiquiátricos de 16,1% a 30,4%. Entre los tratamientos prescritos hay variación en vareniclina (46% a 13,9%) y en citisina (0 a 27,8%). La tasa de abstinencia a los 12 meses disminuye de 37,6% a 8,7% y el porcentaje de abstinencia entre los que completan el seguimiento pasa de 72% a 15,62%. No hay variación significativa en el resto de las variables estudiadas. Conclusión. El impacto de la pandemia en esta consulta se ha reflejado no solo en el drástico descenso del número de pacientes atendidos, sino también en un notable aumento de la comorbilidad psiquiátrica. Además, preocupa la reducción del porcentaje de pacientes que consiguen deshabituación. (AU)

Objective. Analysis of the differences between patients seen in a hospital smoking cessation unit of the H. Doctor Peset de Valencia before and after the pandemic to evaluate the results obtained regarding smoking abstinence. Material and methods. A retrospective observational study analyzing the same variables in two time periods: patients seen for the first time during the year prior to the pandemic (January-December 2019) and between June 2021 and June 2022 (post-pandemic). Demographic data, comorbidities, dependency, drug treatment prescribed and successes obtained are evaluated. Results. Differences were found in the number of patients seen, with a reduction from 645 to 115 and an increase of psychiatric disorders from 16.1% to 30.45. Among the treatments prescribed, there were variations in varenicline (46% to 13.9%) and in cytisine (0 to 27.8%). Abstinence rate at 12 months decreased from 37.6% to 8.7% and the abstinence percentage among those who completed the follow-up from 72% to 15.62%. There are no significant variations in the rest of the variables studied. Conclusion. The impact of the pandemic in this consultation has not only been reflected in the drastic decrease in the number of patients seen but also on a notable increase in psychiatric comorbidity. In addition, the reduction in the percentage of patients who achieved cessation is of concern. (AU)

Response to Monoclonal Antibodies in Asthma: Definitions, Potential Reasons for Failure, and Therapeutic Options for Suboptimal Response.

Real-life data reveal that more than half of severe asthma patients treated with monoclonal antibodies (mAbs) do not achieve a complete response. Response to mAbs must be assessed holistically, considering all the clinically meaningful therapeutic goals, not only reduction of exacerbations and oral corticosteroids. There are 2 different ways of measuring the response to mAbs. One, qualitative, classifies patients according to the degree of disease control they have achieved, without explaining how much a given patient improves relative to the baseline (pre-mAb) clinical situation; the other, quantitative, scores the changes occurring after treatment. Both methods are complementary and essential to making clinical decisions on whether to continue treatment. The various potential causes of suboptimal response to mAbs include incorrect identification of the specific T2 pathways, comorbidities that reduce the room for improvement, insufficient dose, autoimmune phenomena, infections, change in the initial inflammatory endotype, and adverse events. Once a suboptimal response has been confirmed, a well-structured and multifaceted assessment of the potential causes of failure should be performed, with emphasis on the resulting inflammatory process of the airway after mAb therapy and the presence of chronic or recurrent infection. This investigation should guide the decision on the best therapeutic approach. The present review aims to help clinicians gain insights into how to measure response to mAbs and proceed in cases of suboptimal response.

Cost-effectiveness of benralizumab versus mepolizumab and dupilumab in patients with severe uncontrolled eosinophilic asthma in Spain.

OBJECTIVE: To assess the cost-effectiveness of benralizumab (benra) vs. mepolizumab (mepo) and dupilumab (dupi) for the treatment of patients with severe uncontrolled asthma from the Spanish Health System perspective. METHODS: Exacerbations avoided, quality-adjusted life years (QALYs) gained and costs in a 5-year period were estimated with a Markov model for a cohort of 1,000 patients in which, based on published evidence, 31% of the patients received biologics + oral corticosteroids (OCS) and 69% received only biologics. Efficacy data (exacerbation reduction and OCS elimination) were derived from a matching-adjusted indirect comparison. Published EQ-5D utilities per health state (biologic alone, biologic + OCS, standard of care + OCS, exacerbations, and post-exacerbations) were used for QALY estimation. Utility decrements associated with exacerbation management [-0.1 (OCS or emergency visits), -0.2 (hospitalization)] derived from the literature were applied. Costs (€, 2022) included drug acquisition (ex-factory price), administration and disease management. An expert panel (2 pneumologists and 1 pharmacist) validated all inputs. RESULTS: Benra was more effective (52.21 QALYs) than mepo (51.39 QALYs) and dupi (51.30 QALYs). Benra avoided more exacerbations (2.87 exacerbations) compared to mepo (4.70 exacerbations) and dupi (5.11 exacerbations) for the 5-year horizon. Total costs/patient were €56,093.77 (benra), €59,280.45 (mepo) and €62,991.76 (dupi), resulting in benra dominating (more QALYs with lower costs) vs. mepo and dupi. CONCLUSIONS: Benralizumab can be considered as a dominant treatment alternative vs. other biologic drugs for the treatment of uncontrolled severe eosinophilic asthma patients in Spain.

Response to Monoclonal Antibodies in Asthma: Definitions, Potential Reasons for Failure, and Therapeutic Options for Suboptimal Response

Real-life data reveal that more than half of severe asthma patients treated with monoclonal antibodies (mAbs) do not achieve a complete response. Response to mAbs must be assessed holistically, considering all the clinically meaningful therapeutic goals, not only reduction of exacerbations and oral corticosteroids. There are 2 different ways of measuring the response to mAbs. One, qualitative, classifies patients according to the degree of disease control they have achieved, without explaining how much a given patient improves relative to the baseline (pre-mAb) clinical situation; the other, quantitative, scores the changes occurring after treatment. Both methods are complementary and essential to making clinical decisions on whether to continue treatment. The various potential causes of suboptimal response to mAbs include incorrect identification of the specific T2 pathways, comorbidities that reduce the room for improvement, insufficient dose, autoimmune phenomena, infections, change in the initial inflammatory endotype, and adverse events. Once a suboptimal response has been confirmed, a well-structured and multifaceted assessment of the potential causes of failure should be performed, with emphasis on the resulting inflammatory process of the airway after mAb therapy and the presence of chronic or recurrent infection. This investigation should guide the decision on the best therapeutic approach. The present review aims to help clinicians gain insights into how to measure response to mAbs and proceed in cases of suboptimal response (AU)

Los estudios clínicos en vida real revelan que más de la mitad de los pacientes con asma grave, tratados con anticuerpos monoclonales (mAb), no logran una respuesta completa. La respuesta a los mAbs debe evaluarse de manera integral, considerando todos los objetivos terapéuticos clínicamente significativos y no solo las exacerbaciones o la reducción de corticosteroides orales. Existen dos formas diferentes de medir la respuesta a los mAbs: una, cualitativa, que clasifica a los pacientes según el grado de control de la enfermedad que han logrado, sin explicar cuánto mejora un determinado paciente con respecto a su situación clínica basal (pre-mAb); y la otra, cuantitativa, la cual puntúa los cambios ocurridos después del tratamiento. Ambos métodos son complementarios y claramente esenciales a la hora de tomar decisiones clínicas sobre la continuación del tratamiento con estos fármacos biológicos. Se han descrito varias causas posibles de respuesta subóptima a los mAbs que son: la identificación incorrecta de las vías T2 específicas, las comorbilidades que reducen el margen de mejora, una dosis insuficiente, fenómenos autoinmunes, infecciones, cambio del endotipo inflamatorio inicial y la aparición de efectos adversos. na vez que se ha confirmado una respuesta subóptima, se debe realizar una evaluación bien estructurada y polifacética de estas posibles causas del fracaso, considerando, en particular, el proceso inflamatorio residual de las vías respiratorias tras la terapia con mAb y la presencia de infecciones crónicas o recurrentes. Esta evaluación es la que debe guiar las decisiones sobre el mejor enfoque terapéutico. Esta revisión tiene como objetivo ayudar a los clínicos a obtener un conocimiento más profundo sobre cómo medir la respuesta a los mAbs y cómo proceder con los pacientes que presenten una respuesta subóptima (AU)

Factors Affecting the Success of Step-up Therapy in Patients With Moderate-Severe Asthma: A Real-Life Study.

INTRODUCTION AND OBJECTIVE: Introduction: Clinical practice guidelines recommend regular adjustment of treatment to achieve control of asthma. A step-up approach based on the degree of disease control should be followed. Objective: To perform a real-life analysis of the factors that affect the success or failure of this therapeutic strategy and of the criteria applied by clinicians when applying a step-up approach in a representative sample of patients diagnosed with moderate-severe asthma. MATERIAL AND METHODS: We performed a multicenter retrospective cohort study involving 226 Spanish specialist physicians (98 allergologists, 127 pulmonologists, and 1 family physician). We included 1254 patients (787 women) diagnosed with moderate-severe asthma who underwent step-up therapy during 2016. RESULTS: Step-up was successful in 44% of cases. The factors associated with success were presence of <2 comorbid conditions, lower grade of severity and therapy step before modification, absence of exacerbations during the previous year, fewer daytime/nighttime symptoms, and limitation in activities, as well as type of inhaled corticosteroid/ long-acting ß2-agonist combination after modification, lower body mass index, and higher fractional exhaled nitric oxide. An early increase in the maintenance dose once a lack of control was detected (≤3 months, >3 to ≤6 months, >6 to ≤12 months) was more likely to be successful. CONCLUSION: The factors that determine whether or not this therapeutic strategy manages to control asthma are time since onset of clinical impairment, previous grade of severity, number of comorbid conditions, previous exacerbations, and frequency of symptoms.

Factors Affecting the Success of Step-up Therapy in Patients With Moderate-Severe Asthma: A Real-Life Study

Background: Clinical practice guidelines recommend regular adjustment of treatment to achieve control of asthma. A step-up approachbased on the degree of disease control should be followed.Objective: To perform a real-life analysis of the factors that affect the success or failure of this therapeutic strategy and of the criteriaapplied by clinicians when applying a step-up approach in a representative sample of patients diagnosed with moderate-severe asthma.Material and Methods: We performed a multicenter retrospective cohort study involving 226 Spanish specialist physicians (98 allergologists,127 pulmonologists, and 1 family physician). We included 1254 patients (787 women) diagnosed with moderate-severe asthma whounderwent step-up therapy during 2016.Results: Step-up was successful in 44% of cases. The factors associated with success were presence of <2 comorbid conditions, lower gradeof severity and therapy step before modification, absence of exacerbations during the previous year, fewer daytime/nighttime symptoms,and limitation in activities, as well as type of inhaled corticosteroid/ long-acting β₂-agonist combination after modification, lower bodymass index, and higher fractional exhaled nitric oxide. An early increase in the maintenance dose once a lack of control was detected(≤3 months, >3 to ≤6 months, >6 to ≤12 months) was more likely to be successful.Conclusion: The factors that determine whether or not this therapeutic strategy manages to control asthma are time since onset of clinicalimpairment, previous grade of severity, number of comorbid conditions, previous exacerbations, and frequency of symptoms. (AU)

Antecedentes: Las guías de práctica clínica recomiendan el ajuste del tratamiento hasta alcanzar el control del asma, siguiendo un escaladoprogresivo basado en el grado de control de la enfermedad.Objetivo: Realizar un análisis en vida real de los criterios que utilizan los clínicos para realizar el escalado terapéutico y de los factoresque condicionan el éxito o el fracaso de esta estrategia terapéutica en una muestra representativa de pacientes diagnosticados de asmapersistente moderada y grave.Material y métodos: Estudio multicéntrico retrospectivo de cohorte en el que participaron 226 médicos especialistas españoles (98alergólogos, 127 neumólogos y un médico de atención primaria). Incluimos 1.254 pacientes (787 mujeres) diagnosticados de asmapersistente moderada o grave en los que se realizó un escalado de tratamiento durante 2016.Resultados: El escalado terapéutico fue exitoso en el 44% de los casos. Los factores asociados con el éxito fueron la presencia de <2comorbilidades, menor grado de gravedad y del escalón terapéutico de la terapia antes de la modificación, ausencia de exacerbacionesdurante el año anterior, menos síntomas diurnos/nocturnos y limitación en las actividades ordinarias, así como el tipo de corticosteroideinhalado (ICS) / combinación de β₂-agonista de acción prolongada (LABA) después de la modificación, índice de masa corporal inferiory fracción del óxido nítrico exhalado superior. Un aumento temprano en la dosis de mantenimiento una vez que se detectó una falta decontrol (≤ 3 meses,> 3 a ≤ 6 meses,> 6 a ≤ 12 meses) también se asoció a un aumento de probabilidad de éxito.Conclusión: Los factores que determinan si el escalado terapéutico logra controlar el asma son el tiempo transcurrido desde el inicio deldeterioro clínico, el grado previo de gravedad, el número de afecciones comórbidas, las exacerbaciones previas y la frecuencia de síntomas. (AU)

Factors that determine the loss of control when reducing therapy by steps in the treatment of moderate-severe asthma in standard clinical practice: A multicentre Spanish study. / Factores que condicionan la pérdida de control al reducir escalones terapéuticos en el tratamiento del asma moderada-grave en la práctica clínica habitual: estudio español multicéntrico.

BACKGROUND: Although the clinical practice guidelines recommend continuous adjustment of asthma treatment and reducing the maintenance drugs when achieving control (step-down), there are few studies of standard clinical practice aimed at collecting information on the factors that determine step-down failure. OBJECTIVE: To determine the factors that determine step-down failure in standard clinical practice of patients with moderate-severe asthma controlled by a combination of inhaled glucocorticoids and long-acting beta agonists. METHODS: A multicentre retrospective study included 374 patients with moderate-severe asthma controlled with inhaled glucocorticoids and long-acting beta agonists for whom the physician indicated a step-down in 2016. RESULTS: The step-down failed in 41.7% of the patients. The following factors were related to failure: greater patient age (P=.006), presence of at least 2 comorbidities (P=.016), greater severity level (severe persistent vs. moderate persistent) (P<.001), greater age at diagnosis (>40 years) (P=.045), the higher the therapeutic step before (P=.003) and after the change (P<.001), the shorter the time of improvement/control prior to the change (P=.019), lower FEV1 (P=.001) and a poorer Asthma Control Test score or Asthma Control Questionnaire score before the step-down (P<.001). The logistic regression analysis showed a higher probability of step-down failure in the more elderly patients (OR, 0.983; 95% CI 0.969-0.997) and those with severe asthma compared to those with moderate asthma (OR, 0.537; 95% CI 0.292-0.985), as well as an increased probability of success if the patients had the disease controlled for more than 6 months (OR, 2.253; 95% CI 1.235-4.112). CONCLUSION: In standard clinical practice conditions, step-down fails in a high percentage of patients, and the suggestion is to indicate step-down when the patient has had more than 6 months of disease control.

Asthma, comorbidities, and aggravating circumstances: the GEMA-FORUM II task force

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Actitudes y barreras en el asma inicialmente no controlada en España. Estudio Abanico / Attitudes and barriers uncontrolled asthma in Spain. Abanico study

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