1. Provision of an inhaled glucocorticoid and instruction on its use led to a significantly lower rate of severe asthma exacerbations among Black and Latinx adults with asthma.
2. Provision of an inhaled glucocorticoid and instruction on its use increased monthly asthma control.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Black and Latinx populations in the United States bear disproportionate asthma morbidity and mortality. Asthma-related emergency department visits and hospitalizations are higher among Black and Latinx persons than among White persons. Mortality from asthma is also twice as high among Black and Latinx persons compared to White persons. While current recommendations include the use of inhaled glucocorticoids for asthma-controller therapy, there is a gap in knowledge as to understanding the effectiveness of this strategy among Black and Latinx patients, as few trials have included substantial proportions of these populations. This study found that providing an as-needed glucocorticoid inhaler and one-time instruction on its use significantly decreased severe asthma exacerbations among Black and Latinx adults with asthma. This study was limited by being open-label and the possibility of a placebo effect, as well as the study population including many different ethnic groups and women being overrepresented in this trial. Nevertheless, these study’s findings are significant, as they demonstrate that the provision of inhaled glucocorticoids with instruction for use significantly reduced the risk of severe asthma exacerbations among Black and Latinx patients with moderate to severe asthma.
Click to read the study in NEJM
Relevant Reading: Biologic Therapies for Severe Asthma
In-Depth [open-label randomized trial]: This pragmatic, open-label trial randomly assigned Black and Latinx patients with moderate-to-severe asthma to receive either patient-activated reliever-triggered inhaled glucocorticoids plus usual care or to continue their usual care. There were 1201 adults (603 Black and 598 Latinx) in the trial, with 600 assigned to the intervention group and 601 to the usual-care group. Patients who were aged 18 to 75 with clinician-diagnosed asthma and self-identified as Black or Latinx were included in the study. Patients who were taking regular systemic glucocorticoids were excluded from the study. The primary outcome was the annualized rate of severe asthma exacerbations. Outcomes in the primary analysis were assessed via Andersen-Gill adaption of the time-to-event Cox proportional-hazards model with stratification according to race and ethnic group and adjustment for baseline characteristics. Based on the analysis, the annualized rate of severe asthma exacerbations was 0.69 (95% confidence interval [CI], 0.61 to 0.78) in the inhaled glucocorticoid group and 0.82 (95% CI, 0.73 to 0.92) in the usual-care group. To measure monthly asthma control, the study utilized the Asthma Control Test (ACT), with a range from 5 (poor) to 25 (complete control). The study found that ACT scores increased by 3.4 points (95% CI, 3.1 to 3.6) in the intervention group and 2.5 points (95% CI, 2.3 to 2.8) in the usual-care group. Additionally, to quantify the quality of life, the study utilized the Asthma Symptom Utility Index (ASUI, range of 0 to 1 with lower scores indicating greater impairment and lower quality). The results demonstrate that the ASUI scores for the intervention group increased by 0.12 points (95% CI, 0.11 to 0.13) compared to increasing by 0.08 points in the usual-care group (95% CI, 0.07 to 0.09). Overall, this study demonstrated that instruction and provision of reliever-triggered inhaled glucocorticoids among Black and Latinx populations with moderate-to-severe asthma can reduce the risk of severe asthma exacerbations, providing a new strategy to reduce disparities in asthma morbidity.
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