Journal article

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Mometasone or Tiotropium in Mild Asthma with a Low Sputum Eosinophil Level

Author(s): Lazarus SC, Krishnan JA, King TS et al.

N Engl J Med. 2019 May 19

Airway diseases
General respiratory patient care

Digest Author(s): Stylianos Loukides, e-Learning Director / 21 May, 2019

In many patients with mild, persistent asthma, eosinophilic inflammation is absent. The proper treatment for these patients remains controversial. In the current 42-week, double-blind, crossover trial 295 patients received either mometasone, tiotropium or placebo. The patients were further categorized according to the sputum eosinophil level (<2% or ≥2%). The primary outcome was the response to mometasone as compared with placebo and to tiotropium as compared with placebo among patients with a low sputum eosinophil level who had a prespecified differential response to one of the trial agents. The response was determined by a multidimensional approach consisting of incorporated treatment failure, asthma control days, and the forced expiratory volume in 1 second. A total of 73% of the patients had a low eosinophil level. Interestingly in patients with low sputum eosinophilic count no significant difference was observed between the response to mometasone or tiotropium, as compared with placebo. Among patients with a high eosinophil level, the response to mometasone was significantly better than the response to placebo but the response to tiotropium was not. Summarizing the above results, the majority of patients with mild, persistent asthma had a low sputum eosinophil level and had no significant difference in their response to either mometasone or tiotropium as compared with placebo.

Comment

Considering the recently published GINA guidelines, treatment for step 1 and 2 is based to as needed intervention containing ICS [budesonide] and LABA [formoterol]. The current study raised a significant challenging issue. Do we need to treat patients with ICS if a T2 low process exists? If not then LAMA represents the ideal treatment option? This is a single study lasting 42 weeks with some reasonable data but which needs further detailed assessment in order to apply them in clinical practice. At the moment we can keep the simplicity that GINA guidelines introduced in their latest version and to keep in your minds that performing sputum induction in daily clinical practice remains a time-dependent procedure.