Skip to main content

Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma.

Publication ,  Journal Article
Wechsler, ME; Szefler, SJ; Ortega, VE; Pongracic, JA; Chinchilli, V; Lima, JJ; Krishnan, JA; Kunselman, SJ; Mauger, D; Bleecker, ER; Benson, M ...
Published in: N Engl J Med
September 26, 2019

BACKGROUND: Morbidity from asthma is disproportionately higher among black patients than among white patients, and black patients constitute the minority of participants in trials informing treatment. Data indicate that patients with inadequately controlled asthma benefit more from addition of a long-acting beta-agonist (LABA) than from increased glucocorticoids; however, these data may not be informative for treatment in black patients. METHODS: We conducted two prospective, randomized, double-blind trials: one involving children and the other involving adolescents and adults. In both trials, the patients had at least one grandparent who identified as black and had asthma that was inadequately controlled with low-dose inhaled glucocorticoids. We compared combinations of therapy, which included the addition of a LABA (salmeterol) to an inhaled glucocorticoid (fluticasone propionate), a step-up to double to quintuple the dose of fluticasone, or both. The treatments were compared with the use of a composite measure that evaluated asthma exacerbations, asthma-control days, and lung function; data were stratified according to genotypic African ancestry. RESULTS: When quintupling the dose of fluticasone (to 250 μg twice a day) was compared with adding salmeterol (50 μg twice a day) and doubling the fluticasone (to 100 μg twice a day), a superior response occurred in 46% of the children with quintupling the fluticasone and in 46% of the children with doubling the fluticasone and adding salmeterol (P = 0.99). In contrast, more adolescents and adults had a superior response to added salmeterol than to an increase in fluticasone (salmeterol-low-dose fluticasone vs. medium-dose fluticasone, 49% vs. 28% [P = 0.003]; salmeterol-medium-dose fluticasone vs. high-dose fluticasone, 49% vs. 31% [P = 0.02]). Neither the degree of African ancestry nor baseline biomarkers predicted a superior response to specific treatments. The increased dose of inhaled glucocorticoids was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years of age. CONCLUSIONS: In contrast to black adolescents and adults, almost half the black children with poorly controlled asthma had a superior response to an increase in the dose of an inhaled glucocorticoid and almost half had a superior response to the addition of a LABA. (Funded by the National Heart, Lung, and Blood Institute; BARD ClinicalTrials.gov number, NCT01967173.).

Duke Scholars

Altmetric Attention Stats
Dimensions Citation Stats

Published In

N Engl J Med

DOI

EISSN

1533-4406

Publication Date

September 26, 2019

Volume

381

Issue

13

Start / End Page

1227 / 1239

Location

United States

Related Subject Headings

  • Salmeterol Xinafoate
  • Prospective Studies
  • Male
  • Humans
  • Glucocorticoids
  • General & Internal Medicine
  • Fluticasone
  • Female
  • Drug Combinations
  • Double-Blind Method
 

Citation

APA
Chicago
ICMJE
MLA
NLM
Wechsler, M. E., Szefler, S. J., Ortega, V. E., Pongracic, J. A., Chinchilli, V., Lima, J. J., … NHLBI AsthmaNet, . (2019). Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma. N Engl J Med, 381(13), 1227–1239. https://doi.org/10.1056/NEJMoa1905560
Wechsler, Michael E., Stanley J. Szefler, Victor E. Ortega, Jacqueline A. Pongracic, Vernon Chinchilli, John J. Lima, Jerry A. Krishnan, et al. “Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma.N Engl J Med 381, no. 13 (September 26, 2019): 1227–39. https://doi.org/10.1056/NEJMoa1905560.
Wechsler ME, Szefler SJ, Ortega VE, Pongracic JA, Chinchilli V, Lima JJ, et al. Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma. N Engl J Med. 2019 Sep 26;381(13):1227–39.
Wechsler, Michael E., et al. “Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma.N Engl J Med, vol. 381, no. 13, Sept. 2019, pp. 1227–39. Pubmed, doi:10.1056/NEJMoa1905560.
Wechsler ME, Szefler SJ, Ortega VE, Pongracic JA, Chinchilli V, Lima JJ, Krishnan JA, Kunselman SJ, Mauger D, Bleecker ER, Bacharier LB, Beigelman A, Benson M, Blake KV, Cabana MD, Cardet J-C, Castro M, Chmiel JF, Covar R, Denlinger L, DiMango E, Fitzpatrick AM, Gentile D, Grossman N, Holguin F, Jackson DJ, Kumar H, Kraft M, LaForce CF, Lang J, Lazarus SC, Lemanske RF, Long D, Lugogo N, Martinez F, Meyers DA, Moore WC, Moy J, Naureckas E, Olin JT, Peters SP, Phipatanakul W, Que L, Raissy H, Robison RG, Ross K, Sheehan W, Smith LJ, Solway J, Sorkness CA, Sullivan-Vedder L, Wenzel S, White S, Israel E, NHLBI AsthmaNet. Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma. N Engl J Med. 2019 Sep 26;381(13):1227–1239.

Published In

N Engl J Med

DOI

EISSN

1533-4406

Publication Date

September 26, 2019

Volume

381

Issue

13

Start / End Page

1227 / 1239

Location

United States

Related Subject Headings

  • Salmeterol Xinafoate
  • Prospective Studies
  • Male
  • Humans
  • Glucocorticoids
  • General & Internal Medicine
  • Fluticasone
  • Female
  • Drug Combinations
  • Double-Blind Method