In the UK, most individuals with
asthma are well aware of the possibility to use an inhaler that contains a
combination of corticosteroids and so-called LABA. In fact, in the UK the
treatment (which is commonly called SMART) appears to have been widely
available for adults for nearly ten years. Yet, two trials that were recently
published in The Lancet Respiratory
Medicine recently appear to have met some resistance in the US, with some
sources claiming that recommending the use of SMART inhalers would go against
national and international medical guidelines, that clinicians’ perceptions of
the efficacy of SMART are not the same as patients perceptions and that the
promotion of SMART inhalers reflects financial interests rather than a concern
for patients well-being. In this blog post, we consider whether there is any
foundation behind those statements and whether the findings from the two
studies warrant a serious consideration of SMART treatments.
The first study, conducted by
Patel et al, was a 24 week trial that included a total of 301 patients. The
participants, who were between the ages of 16 and 65 were randomly put into
groups that either used SMART inhalers or used standard inhalers. The key
findings indicate that individuals in the SMART group had fewer severe asthma
exacerbations, leading the researchers to conclude that SMART is a particularly
suitable treatment for adults that are at risk of having severe asthma
exacerbations.
In addition to standardising the
treatments so that they were comparable between the groups, the researchers
also used an electronic device to ensure that the measurement of actuations was
more precise than it had been in past studies. This study also differed from
past studies, as the researchers did not use dry powdered inhaler and as it was
the first study that had not received funding from a pharmaceutical company.
The second study, conducted by
Papi et al, was a double blind trial that was conducted between a total of 14
European countries (183 centres) over the course of 48 weeks. The 1714
participants, who were over the age of 18, were randomly put into groups that
either used a combination of corticosteroids and LABA or only relied on LABA.
After controlling for factors such as lung function, symptoms scores and asthma
exacerbation, the findings suggested that the latter group had severe
exacerbations earlier than the former group. Moreover, individuals in the
former group also had fewer mild asthma exacerbations. Based on this the
researchers concluded that the using a combination of corticosteroids and LABA
would be useful for patients with moderate to severe asthma.
Given that this trial controlled
for many aspects that previous studies did not address sufficiently, it is
unlikely that the findings from this large-scale trial are random. The sheer
size of the trial, in combination with the blind design, makes it challenging
to question the findings.
It is clear that both of the
aforementioned trials are robust and unique in many ways. However, despite the
fact that these studies corroborate findings of past trials and testimonies of
clinicians, it also appears that patients’ perception of their symptoms
improving or being better controlled as a result of using SMART inhalers is not
always a given. This of course, should not be taken lightly. However, some
likely explanations for this incongruence could be attributed to variations in
diagnosis severity, triggers and medication compliance.
To our knowledge there are no
studies to address this, but it does seem like a feasible explanation for the
incongruence between clinicians and some patients’ perceptions. We believe that
rather than considering negative patient testimonies as noise, it would be
valuable to understand the difference between patients who find SMART useful
and patients who do not. This of course, is less extreme than suggesting that
SMART treatments are breaching medical guidelines.
In conclusion, we find it
abundantly clear that the two studies are extremely valuable in further
supporting the use of SMART inhalers. We see little support for the argument of
financial motivation, especially when considering the Patel et al trial and
hope that future research efforts are put into optimising the use of SMART
inhalers for relevant patient groups.