Departmental allergy and immunology update

Published on Thursday, September 15, 2022

An udpate from Dr. Utsav Nandi, Associate Director of Research, and Assistant Professor:

The MANDALA trial, which compared the use of short acting beta agonists (SABA - albuterol) to a fixed-dose combination of SABA and inhaled corticosteroids (saba+ICS - albuterol-budesonide) as a rescue medication, included patients who were already receiving inhaled glucocorticoid containing meds at baseline. Their rationale was that albuterol alone did nothing for airway inflammation and thus, may not mitigate the risk for a severe exacerbation.

Their conclusion: “The risk of severe asthma exacerbation was significantly lower with as-needed use of a fixed-dose combination of 180 μg of albuterol and 160 μg of budesonide than with as-needed use of albuterol alone among patients with uncontrolled moderate-to-severe asthma who were receiving a wide range of inhaled glucocorticoid-containing maintenance therapies”.

Interestingly, this is not new. There have now been a few trials looking at this and it is also listed as a treatment modality in the GINA guidelines (p.136). However, GINA notes that there is evidence in preventing severe asthma exacerbation using this strategy only in patients who have not received concomitant systemic steroids.

The latest National Asthma Education and Prevention Program (NAEPP) recommendations also, for the first time, list SABA and ICS combo as a potential rescue strategy.

This trial did not provide much detail on ICS compliance at home, so I'm not sure if those who were not receiving ICS consistently could potentially benefit more. I don’t usually ask patients about their controller medications, but I could see, physiologically, how this may benefit not only those who are on ICS at home, but maybe more so those who aren’t (some ICS better than none?). Yes, that does sound like indication creep, but maybe a reverse creep (if that’s a thing :).

My takeaway is that SABA/ICS combo is a valuable tool to add to our armamentarium in managing moderate to severe asthma exacerbations, especially when these combinations become commercially available.

Speaking of asthma, many patients with severe asthma are also being treated with biologics, particularly anti-IL-5 drugs. While this does not have much to do with our daily ED practice, I did want to let you know that UMMC is part of 2 clinical trials evaluating a new, long-acting IL-5 drug. In case you know anyone (inside or outside the ED) who is interested in being a part of these trials, please reach out to me (unandi@umc.edu or 601-815-2756) and I can discuss it in more detail with them and potentially screen them for enrollment.