Asthma with low sputum eosinophils is common, often unresponsive to inhaled steroids

  • Lazarus SC & al.
  • N Engl J Med
  • 23 May 2019

  • International Clinical Digest
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Takeaway

  • Low eosinophil levels (
  • Mometasone did not correlate with clinical benefit vs long-acting muscarinic antagonist (LAMA) or placebo.
  • Mometasone did help patients with sputum eosinophilia.
  • Data do not support current treatment guidelines, but “provide clinical equipoise for a larger and longer study to compare inhaled glucocorticoids with other treatments,” authors say.

Why this matters

  • How best to treat this population is unclear.

Key results

  • 73% of patients had
  • Of these, 130/221 (59%) had a differential response to study drug or placebo (95% CIs):
    • Mometasone > placebo: 57% (48%-66%); and
    • Placebo > mometasone: 43% (34%-52%; P=.14).
    • Tiotropium > placebo: 60% (51%-68%); and
    • Placebo > tiotropium: 40% (32%-49%; P=.029).
  • Among patients with >2% eosinophils, response to mometasone was better vs to placebo.
  • Results vulnerable to change because of missing data.

Study design

  • Randomized multicenter 42-week double-blind crossover SIENA (n=295).
  • Participants aged ≥12 years with mild persistent asthma randomly assigned to mometasone, tiotropium, or placebo.
  • Outcome: responses among patients with
  • Funding: NIH.

Limitations

  • Much imputation of data.
  • Underpowered for age-related subgroup analyses.