Which inhaled corticosteroid and long-acting β-agonist combination is better in patients with moderate-to-severe asthma, a dry powder inhaler or a pressurized metered-dose inhaler?

Figures & data

Table 1. Patient characteristics.

N	68	Pulmonary function test
	Diskus preceding; 35	IC (L)	2.26 ± 0.63
	Aerosol preceding; 33	FVC (L)	3.18 ± 0.95
Male:female	32:36	%FVC (%)	101.8 ± 16.1
Age (years old)	62.1 ± 15.6	FEV1 (L)	2.24 ± 0.71
Height (cm)	161.6 ± 9.3	%FEV1 (%)	88.6 ± 17.6
Body weight (kg)	62.2 ± 12.6	Post-BD FEV1 (L)	2.36 ± 0.73
BMI (kg/m2)	23.7 ± 3.7	%Post-BD FEV1 (%)	92.9 ± 16.7
Smoking	Never; 42 (61.8%)	Previous medications
	Ex-smoker; 26 (38.2%)	ICS/LABA	SFC (DPI)	41
Pediatric asthma	12 (17.6%)		SFC (pMDI)	20
Disease duration (y)	10.5 ± 10.9		FBC	2
Allergic comorbidities	Allergic rhinitis; 39 (57.4%)		CIC + Sal	3
	Hay fever; 32 (47.1%)	ICS	Mo	1
			FP	1
ACT	22.8 ± 2.7 (median; 24)	Concomitant	LTRA	32
			TEO	4
			Other	12
Pinch meter (kg)	7.0 ± 2.1	Device type	pMDI	20
PIF (adaptor-free, L/min)	216.9 ± 77.7		DPI	45
(A/A/D, L/min)	92.3 ± 26.2		Both	3

BMI: body mass index; ACT: Asthma Control Test; A/A/D: adapter for Diskus^® resistance; PIF: peak inspiratory flow; IC: inspiratory capacity; FVC: forced vital capacity; FEV1: forced expiratory volume in the first second; BD: bronchodilator; ICS: inhaled corticosteroid; LABA: long-acting β-agonist; SFC: salmeterol/fluticasone combination; DPI: dry powder inhaler; pMDI: pressurized metered-dose inhaler; FBC: formoterol/budesonide combination (DPI); CIC: ciclesonide (pMDI); Sal: salmeterol (DPI); Mo: mometasone (DPI); FP: fluticasone propionate (DPI); LTRA: leukotriene receptor antagonists; TEO: theophylline.

Table 2. Vital signs, FeNO levels and QoL scores (ACT and AHQ-33-Japan) after using the DPI or the pMDI.

	Adoair^® Diskus^®	Adoair^® Aerosol	p-Value
Systolic BP (mmHg)	129.6 ± 17.2	130.3 ± 16.7	.3407
Diastolic BP (mmHg)	76.8 ± 9.6	77.1 ± 9.6	.3655
Pulse rate (/min)	79.5 ± 11.1	78.1 ± 11.4	.1190
FeNO (ppb)	28.9 ± 19.6	29.9 ± 25.4	.3304
ACT	23.1 ± 2.5	22.9 ± 2.4	.2857
AHQ-33-Japan
AS	4.41 ± 4.05	4.75 ± 4.18	.2134
FWS	3.10 ± 3.88	3.32 ± 4.09	.2811
Em	3.07 ± 4.42	3.69 ± 4.25	.0504
DA	0.88 ± 1.43	1.01 ± 1.42	.2139
SA	0.93 ± 1.44	1.22 ± 1.90	.1013
Ec	0.51 ± 0.80	0.56 ± 0.89	.2762
Total	12.91 ± 11.90	14.54 ± 12.85	.0822
Face scale	0.99 ± 0.84	1.07 ± 0.74	.1383

FeNO: fractional exhaled nitric oxide; QoL: quality of life; ACT: Asthma Control Test; AHQ: Asthma Health Questionnaire; DPI: dry powder inhaler; pMDI: pressurized metered-dose inhaler; BP: blood pressure; ACT: Asthma Control Test; AS: asthma symptoms; FWS: factors which worsened symptoms; Em: emotion; DA: daily activity; SA: social activity; Ec: economic.

Table 3. Scores on the original questionnaire after using the DPI or the pMDI.

	Adoair® Diskus®	Adoair® Aerosol	p-Value
1) Handling	1.38 ± 0.60	1.79 ± 1.04	N.A.
2) Inhalation technique	1.62 ± 0.79	1.62 ± 0.71	N.A.
3) Mouthwash	1.40 ± 0.74	1.35 ± 0.62	.2584
4) Inhale well?	1.75 ± 0.82	1.88 ± 0.76	.0957
5) Difficulty of handling	1.65 ± 0.71	1.99 ± 0.80	.0005
6) Hoarseness, dysphonia	2.26 ± 1.28	2.06 ± 1.08	.0661
7) Throat irritation	1.66 ± 0.84	1.75 ± 0.92	.2001
8) Discomfort in the throat	1.93 ± 1.03	1.94 ± 1.09	.4636
9) Cough immediately after inhalation	1.5 ± 0.84	1.5 ± 0.76	.5000
10) Aftertaste	1.78 ± 0.79	1.90 ± 0.94	.1566
11) Headache	1.24 ± 0.55	1.17 ± 0.49	.2091
12) Palpitation	1.24 ± 0.58	1.18 ± 0.52	.2418
13) Tremor	1.18 ± 0.42	1.18 ± 0.62	.5000
14) Adherence	1.76 ± 0.79	1.82 ± 0.86	.2877
15) Overall evaluation	2.18 ± 0.69	2.22 ± 0.73	.3445

DPI: dry powder inhaler; pMDI: pressurized metered-dose inhaler; N.A.: not assessed.

Table 4. Spirometry and MostGraph-01^® after using the DPI or the pMDI.

Spirometry	Adoair^® Diskus^®	Adoair^® Aerosol	p-Value
IC (L)	2.30 ± 0.66	2.29 ± 0.63	.6168
FVC (L)	3.22 ± 0.98	3.23 ± 0.98	.3878
FEV1 (L)	2.29 ± 0.72	2.30 ± 0.74	.4116
PEF (L/s)	6.37 ± 1.75	6.36 ± 1.80	.5619
FEF50% (L/s)	2.32 ± 1.24	2.31 ± 1.25	.6174
FEF25% (L/s)	0.62 ± 0.46	0.62 ± 0.49	.4976
FEF50%/FEF25%	4.29 ± 1.22	4.33 ± 1.36	.4024
MostGraph-01^® (mean)
R5	3.36 ± 1.43	3.35 ± 1.29	.5627
R20	2.82 ± 1.03	2.85 ± 0.98	.3195
R5-R20	0.54 ± 0.52	0.49 ± 0.46	.8491
X5	−0.79 ± 1.15	−0.78 ± 0.81	.4806
Fres	9.27 ± 4.29	9.50 ± 3.78	.2597
ALX	4.87 ± 11.70	4.34 ± 6.80	.7029

DPI: dry powder inhaler; pMDI: pressurized metered-dose inhaler; IC: inspiratory capacity; FVC: forced vital capacity; FEV1: forced expiratory volume in the first second; PEF: peak expiratory flow; FEF: forced expiratory flow; R5: resistance at 5 Hz; R20: resistance at 20 Hz; X5: reactance at 5 Hz; Fres: frequency of resonance; ALX: low-frequency reactance area.

Figure 1. Questionnaire administered at the end of the study in which the subjects compared the DPI and the pMDI.

Figure 2. Questionnaire administered at the end of study, in which the subjects provided their overall evaluations and preferences for the DPI and the pMDI. (A) Overall evaluation. (B) The ‘Which would you like to use from now?’ item.