Am J Respir Crit Care Med:哮喘患者吸入激素治疗依从性或可改善

2013-01-06 Am J Respir Crit Care Med 网络 士心

  对吸入糖皮质激素治疗(ICS)的不依从,是难治性哮喘控制不良的一个主要因素,但是要确定那些患者对吸入糖皮质激素治疗具有不依从性,目前仍是一个具有挑战性的难题。为了确定在直接观察下的吸入糖皮质激素治疗(DOICS)后,使用呼出气一氧化氮分数(FeNO)抑制状况作为一个对吸入糖皮质激素治疗依从性测试的可能性,来自于英国北爱尔兰贝尔法斯特市贝尔法斯特皇后大学感染与免疫中心的Diarmuid&nbsp

  对吸入糖皮质激素治疗(ICS)的不依从,是难治性哮喘控制不良的一个主要因素,但是要确定那些患者对吸入糖皮质激素治疗具有不依从性,目前仍是一个具有挑战性的难题。为了确定在直接观察下的吸入糖皮质激素治疗(DOICS)后,使用呼出气一氧化氮分数(FeNO)抑制状况作为一个对吸入糖皮质激素治疗依从性测试的可能性,来自于英国北爱尔兰贝尔法斯特市贝尔法斯特皇后大学感染与免疫中心的Diarmuid M. McNicholl博士及其同事进行了一项研究,研究结果发表于2012年12月1日出版的《美国呼吸与危重症医学》( Am. J. Respir. Crit. Care Med)杂志上。研究结果显示:在直接观察下的吸入糖皮质激素治疗后的呼出气一氧化氮分数抑制状况,为区别难治性哮喘患者对吸入糖皮质激素治疗的依从性,提供了一个客观的测试方法。

  该研究的主要研究对象为具有呼出气一氧化氮分数升高(>45 ppb)的难治性哮喘患者。研究者将这些研究对象分为吸入糖皮质激素治疗依从组(吸入糖皮质激素治疗处方的应用量>80%)和不依从组(吸入糖皮质激素治疗处方的应用量<50%),并给他们使用7天的吸入糖皮质激素治疗(布地奈德1600μ克)。依据患者治疗前、后的呼出气一氧化氮分数的变化,研究者建立了一个验证其吸入糖皮质激素治疗依从性的测试方法。应用该测试方法,研究者将临床患者前瞻性地分为吸入糖皮质激素治疗依从者或不依从者,然后再根据患者的处方应用记录、泼尼松龙检验结果、以及有关二者一致性的交谈等方法,对测试分类的准确性加以确证。

  该研究的主要结果为:经过7天的吸入糖皮质激素治疗后,非依从组患者(9例)与依从组(13例)的患者相比,其呼出气一氧化氮分数值较基线时的测量值有更大的减少(47±21%对79±26%,P=0.003),而且这种现象在吸入糖皮质激素治疗5天后也同样明显(P=0.02)。研究者定义了一个确认患者不依从性的测试方法(曲线下的面积=0.86;95%置信区间,0.68~1.00),并使用该方法对40例患者进行了前瞻性的依从性测试。测试结果显示,在依据该测试方法确认的13例不依从性患者中,有8例在随后的一致性交谈验证中获得了不依从性患者的确认(其中三人有良好的处方应用记录,但实际并未用药);而另5例则被认定为不属于不依从性患者(其中两人属于缺乏吸入技术,而非故意性不依从;另一人虽然其血中泼尼松龙的水平符合不依从性患者的水平,但也被认定为不属于不依从性患者)。而在依据该测试方法确认的具有依从性的27例患者中,有21例在随后的一致性交谈验证中获得了具有依从性的确认;而另有5人则承认其没有依从吸入糖皮质激素治疗,但在这5人中,有4人习惯使用口服类固醇激素,另一人则习惯使用奥马珠单抗。

  该研究结果显示:在直接观察下的吸入糖皮质激素治疗后的呼出气一氧化氮分数抑制状况,为区别难治性哮喘患者对吸入糖皮质激素治疗的依从性,提供了一个客观的测试方法。 




The Utility of Fractional Exhaled Nitric Oxide Suppression in the Identification of Nonadherence in Difficult Asthma                

Rationale: Nonadherence to inhaled corticosteroid therapy (ICS) is a major contributor to poor control in difficult asthma, yet it is challenging to ascertain.

Objectives: Identify a test for nonadherence using fractional exhaled nitric oxide (FENO) suppression after directly observed inhaled corticosteroid (DOICS) treatment.

Methods: Difficult asthma patients with an elevated FENO (>45 ppb) were recruited as adherent (ICS prescription filling >80%) or nonadherent (filling <50%). They received 7 days of DOICS (budesonide 1,600 μg) and a test for nonadherence based on changes in FENO was developed. Using this test, clinic patients were prospectively classified as adherent or nonadherent and this was then validated against prescription filling records, prednisolone assay, and concordance interview.

Measurements and Main Results: After 7 days of DOICS nonadherent (n = 9) compared with adherent subjects (n = 13) had a greater reduction in FENO to 47 ± 21% versus 79 ± 26% of baseline measurement (P = 0.003), which was also evident after 5 days (P = 0.02) and a FENO test for nonadherence (area under the curve = 0.86; 95% confidence interval, 0.68–1.00) was defined. Prospective validation in 40 subjects found the test identified 13 as nonadherent; eight confirmed nonadherence during interview (three of whom had excellent prescription filling but did not take medication), five denied nonadherence, two had poor inhaler technique (unintentional nonadherence), and one also denied nonadherence to prednisolone despite nonadherent blood level. Twenty-seven participants were adherent on testing, which was confirmed in 21. Five admitted poor ICS adherence but of these, four were adherent with oral steroids and one with omalizumab.

Conclusions: FENO suppression after DOICS provides an objective 

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    2013-01-08 fyxzlh
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