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Patient factors used by pediatricians to assign asthma treatment.
Pediatrics. 2008 Jul; 122(1): e195-201
Okelo SO, Patino CM, Riekert KA, Merriman B, Bilderback A, Hansel NN, Thompson K, Thompson J, Quartey R, Rand CS, Diette GB
OBJECTIVE: Although asthma is often inappropriately treated in children, little is known about what information pediatricians use to adjust asthma therapy. The purpose of this work was to assess the importance of various dimensions of patient asthma status as the basis of pediatrician treatment decisions. PATIENTS AND METHODS: We conducted a cross-sectional, random-sample survey, between November 2005 and May 2006, of 500 members of the American Academy of Pediatrics using standardized case vignettes. Vignettes varied in regard to (1) acute health care use (hospitalized 6 months ago), (2) bother (parent bothered by the child's asthma status), (3) control (frequency of symptoms and albuterol use), (4) direction (qualitative change in symptoms), and (5) wheezing during physical examination. Our primary outcome was the proportion of pediatricians who would adjust treatment in the presence or absence of these 5 factors. RESULTS: Physicians used multiple dimensions of asthma status other than symptoms to determine treatment. Pediatricians were significantly more likely to increase treatment for a recently hospitalized patient (45% vs 18%), a bothered parent (67% vs 18%), poorly controlled symptoms (4-5 times per week; 100% vs 18%), or if there was wheezing on examination (45% vs 18%) compared with patients who only had well-controlled symptoms. Pediatricians were significantly less likely to decrease treatment for a child with well-controlled symptoms and recent hospitalization (28%), parents who reported being bothered (43%), or a child whose symptoms had worsened since the last doctor visit (10%) compared with children with well-controlled symptoms alone. CONCLUSIONS: Pediatricians treat asthma on the basis of multiple dimensions of asthma status, including hospitalization, bother, symptom frequency, direction, and wheezing but use these factors differently to increase and decrease treatment. Tools that systematically assess multiple dimensions of asthma may be useful to help further improve pediatric asthma care.
Ann Allergy Asthma Immunol. 2008 Jun; 100(6): 551-7
Naqvi M, Tcheurekdjian H, DeBoard JA, Williams LK, Navarro D, Castro RA, Rodriguez-Santana JR, Chapela R, Watson HG, Meade K, Rodriguez-Cintron W, LeNoir M, Thyne SM, Avila PC, Choudhry S, González Burchard E
BACKGROUND: National asthma guidelines recommend that patients with persistent asthma regularly use an inhaled corticosteroid (ICS) in addition to as-needed albuterol, yet recent debates question whether this combination is equally efficacious in all ethnicities. OBJECTIVE: To examine the effect of ICS use on bronchodilator responsiveness to albuterol in 3 different ethnic populations. METHODS: A cross-sectional study of 106 Mexican Americans, 246 Puerto Ricans, and 163 African Americans with physician-diagnosed persistent asthma. Asthma severity, ethnicity, and medication use were evaluated using spirometry and questionnaires. Percentage change in forced expiratory volume in 1 second (FEV) was compared in patients who used ICSs vs those who used a short-acting beta2-agonist as their only asthma medication. RESULTS: Inhaled corticosteroid use was associated with improvements in the percentage change in FEV1 after albuterol administration in Mexican Americans (21.7%, P = .01) and Puerto Ricans (18.5%, P = .02) but not in African Americans (3.0%, P = .73). CONCLUSIONS: Inhaled corticosteroid use is associated with augmented bronchodilator responsiveness to albuterol in Mexican Americans and Puerto Ricans, but not in African Americans, with persistent asthma. This underscores the need for an improved understanding of ethnic-specific drug-drug interactions, particularly in those subgroups experiencing the highest burden of asthma morbidity and mortality in the United States.
Inhaled corticosteroid use in asthmatic children receiving Ohio Medicaid: trend analysis, 1997-2001.
Ann Allergy Asthma Immunol. 2008 Jun; 100(6): 538-44
Stevenson MD, Heaton PC, Moomaw CJ, Bean JA, Ruddy RM
BACKGROUND: In 1997, national guidelines emphasized that inhaled corticosteroids (ICSs) are key therapy for individuals with all classes of persistent asthma, including children. OBJECTIVE: To examine the effect of these guidelines via time-trend analysis of ICS dispensation among children with asthma and Ohio Medicaid insurance. METHODS: A retrospective cross-sectional analysis by yearly cohorts was performed. From January 1, 1997, to December 31, 2001, all children from birth to the age of 18 years with 6 months of Ohio Medicaid enrollment or more, 1 or more asthma diagnoses associated with a provider claim, and 1 or more prescription claims for an asthma medication in a given calendar year were identified using claims data. The daily beclomethasone equivalent (BME) dose, the daily albuterol equivalent dose, and asthma-related health care use were calculated for each child within each yearly cohort. A time-trend regression analysis of subjects enrolled in all 5 years examined factors associated with BME. RESULTS: A total of 77,557 children met the study criteria. Among the 1,475 children enrolled during all 5 years, year of enrollment was a positive independent predictor of BME after adjustment for age, race, sex, systemic steroid bursts, albuterol equivalent dose, and health care use (P < .001). CONCLUSIONS: The daily BME dose significantly increased for children with asthma insured by Ohio Medicaid from 1997 to 2001. However, the percentages of children receiving both ICS and a therapeutic BME dose were alarmingly low. The mean BME dose was particularly low among children with 1 or more emergency department visits, no hospitalizations, and 3 or fewer physician visits for asthma per year, suggesting that broader efforts to target this group are needed.
Drugs R D. 2008; 9(4): 243-250
Usharani P, Mateen AA, Naidu MU, Raju YS, Chandra N
BACKGROUND AND OBJECTIVE: Hyperglycaemia leads to increased oxidative stress resulting in endothelial dysfunction. ACE inhibitors, antioxidants and HMG-CoA reductase inhibitors (statins) have been shown to improve endothelial function. The aim of this study was to compare the effects of NCB-02 (a standardized preparation of curcuminoids), atorvastatin and placebo on endothelial function and its biomarkers in patients with type 2 diabetes mellitus. METHODS: A total of 72 patients with type 2 diabetes were randomized to receive NCB-02 (two capsules containing curcumin 150 mg twice daily), atorvastatin 10 mg once daily or placebo for 8 weeks. Endothelial function assessment was performed at baseline and post-treatment using digital volume plethysmography (salbutamol [albuterol] challenge test) to measure change in reflective index, an indicator of arterial vascular tone. Blood samples were similarly collected at baseline and post-treatment for estimations of malondialdehyde, endothelin-1 (ET-1), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNFalpha). Pre-and post-treatment safety assessments were also conducted. ANOVA and paired t-test evaluations were used for comparison. RESULTS: A total of 67 patients completed the study. At baseline, there was no significant difference in the various parameters tested. In all three groups, the change in reflective index at baseline was
Chest. 2008 Jun 26;
Blake K, Madabushi R, Derendorf H, Lima J
Background Because interpatient variability in bronchodilation from inhaled albuterol is large and clinically important, we characterized the albuterol dose-response relationship by pharmacodynamic modeling and quantified variability. Methods 81 asthmatics (24% African American (AA)), 8-65 years, baseline FEV(1) 40-80% predicted, received 180mug albuterol from a MDI then 90mug every 15 minutes until maximum improvement or 540mug was administered; all then received 2.5mg nebulized albuterol. FEV(1) was measured 15 minutes after each dose. The population cumulative dose-response data were fitted with a sigmoid E(max) (maximum % predicted FEV(1) effect) model by non-linear mixed effects modeling. The influence of covariates on R(max) (maximum increase in % predicted FEV(1)) and ED(50) (cumulative dose eliciting half of E(max)), and differences between AA and Whites were explored. Results ED(50) was141mug and E(max) was 24.0%. Coefficient of variation for ED(50) and E(max) was 40% and 56%, respectively. Ethnicity was a statistically significant covariate (p
Albuterol and exercise effects on ankle extensor strength during 40 days of unloading.
Aviat Space Environ Med. 2008 Jun; 79(6): 577-84
Caruso JF, Hamill JL, Yamauchi M, Cook TD, Mercado DR, Wickel EE
INTRODUCTION: In-flight ankle extensor (AEXT) strength losses are an impediment to long-term space travel. The current study examines if albuterol helps resistance exercise (RE) abate AEXT strength loss incurred over a 40-d unloading period. METHODS: All subjects (21 men, M; 15 women, W) performed unilateral limb suspension (ULLS) and exercised on a flywheel ergometer (FERG) with their otherwise unloaded AEXT. With a double-blind randomization assignment, subjects either received placebo (PLA, lactose) or albuterol (ALB, 16 mg x d(-1)) via four daily capsule doses with no crossover. FERG calf press workouts done 3 d x wk(-1) provided concentric and eccentric total work (CTW, ETW) and average power (CAP, EAP) measures. Workout data from the 40-d period were averaged and partitioned into four consecutive 10-d periods. Data were compared with a 2 (gender) x 2 (treatment) x 4 (time) MANCOVA, with day 0 AEXT strength measurements and a drug/body mass ratio as covariates. RESULTS: CTW and ETW days 11-20, 21-30, and 31-40, as well as CAP and EAP days 11-20 and 21-30 showed the following significant results: ALB-W > ALB-M, PLA-M > PLA-W. CAP and EAP days 31-40 showed the following significant results: ALB-W, ALB-M, PLA-M > PLA-W. DISCUSSION: The combined RE-albuterol treatment most likely evoked unloaded AEXT strength gains in women due to heightened myofibril sensitivity for Ca+2. Despite a drug/body mass covariate, gender-related differences should be interpreted with caution. Future work should compare absolute and relative beta2 agonist dosages on gender-related muscle mass and strength changes.
Daily salbutamol in young patients with SMA type II.
Neuromuscul Disord. 2008 Jun 23;
Pane M, Staccioli S, Messina S, D'Amico A, Pelliccioni M, Mazzone ES, Cuttini M, Alfieri P, Battini R, Main M, Muntoni F, Bertini E, Villanova M, Mercuri E
The aim of this open pilot study was to establish the profile of tolerability and clinical response of salbutamol (albuterol) in a cohort of young children affected by type II spinal muscular atrophy (SMA). Twenty-three children between 30 months and 6 years of age were treated with salbutamol (2mg three times a day) for 1 year. All children were longitudinally assessed using the Hammersmith motor functional scale 6 months before treatment started (T0), at baseline (T1) and 6 and 12 months later. There was no significant change in function between T0 and T1 assessments, but the functional scores recorded after 6 and 12 months of treatment were significantly higher than those recorded at baseline (p=0.006). Our results suggest that salbutamol may be beneficial to SMA patients without producing any major side effect. Larger prospective randomized, double-blind, placebo controlled trials are needed to confirm these preliminary findings.
J Emerg Med. 2008 Jun 20;
Maak CA, Tabas JA, McClintock DE
In patients with dyspnea, prehospital and emergency providers make therapeutic decisions before a diagnosis is established. Inhaled beta-2 agonists are frontline treatment for patients with dyspnea due to asthma or chronic obstructive pulmonary disease (COPD) exacerbations. However, these agents have been associated with increased adverse events when administered chronically to heart failure patients. Our goal was to determine the safety and efficacy of acute administration of inhaled beta-2 agonists to patients with heart failure. MEDLINE and EMBASE searches were performed using the terms "beta agonists," "albuterol," "congestive heart failure," and "pulmonary edema." Bibliographies of relevant articles were searched. Only studies addressing acute effects of beta-2 agonists were included for analysis. Twenty-four studies comprising 434 patients were identified that addressed the acute delivery of beta-2 agonists in subjects with heart failure-five studies with inhaled administration and 19 with systemic administration. No study directly evaluated the effects of inhaled beta-2 agonists to patients with acutely decompensated heart failure. Treatment of heart failure patients with beta-2 agonists resulted in transient improvements in pulmonary function and cardiovascular hemodynamics. Only one investigation reported an association between beta-2 agonist use and an increase in malignant dysrhythmias. Investigations in animal models of heart failure and acute lung injury demonstrated resolution of pulmonary edema with beta agonist administration. There is insufficient evidence to suggest that acute treatment with inhaled beta-2 agonists should be avoided in patients with dyspnea who may have heart failure. Based on small studies and indirect evidence, administration of beta-2 agonists to patients with heart failure seems to improve pulmonary function, cardiovascular hemodynamics, and resorption of pulmonary edema. Although an increase in adverse effects with the use of beta-2 agonists cannot be ruled out based on these data, there was no evidence of an increase in clinically significant dysrhythmias, especially when administered by inhalation. Based on these findings, further study should focus on the clinical outcomes of patients with acutely decompensated heart failure who are treated with inhaled beta-2 agonist therapy.
Can Respir J. 2008 May-Jun; 15(4): 193-8
Gelb AF, Taylor CF, Shinar CM, Gutierrez CA, Zamel N
BACKGROUND: Monitoring noninvasive biomarkers of inflammation is an important adjunct in asthma therapy. OBJECTIVE: The goal of the present study was to identify airway and alveolar site(s) of inflammation using exhaled nitric oxide (NO) as a marker in asthmatic patients, and to evaluate the NO response to maintenance fluticasone 250 mug/salmeterol 50 mug (F/S) and add-on montelukast 10 mg (M). METHODS: Thirty (24 women) nonsmoking, mild to moderate asthmatic patients were studied, mean age (+/- SD) 43+/-9 years, treated with F/S for more than one year. All were clinically stable for longer than eight weeks and had not taken oral corticosteroids and/or leukotriene antagonists for eight weeks before the present study. Spirometry, Juniper asthma symptom score, fractional exhaled NO (FENO) 100 mL/s, bronchial NO and alveolar NO concentration (CANO) were measured in a single-blind, nonrandomized crossover study. Protocol: Visit 1: baseline F/S; visit 2: after four weeks of F/S plus M; visit 3: after four weeks of S plus M; and visit 4: after four weeks of S only. Values in asthmatic patients were also compared with 34 nonsmoking age-matched healthy controls with normal lung function. RESULTS: After 180 mug aerosolized metered dose inhaler albuterol, the forced expiratory volume in 1 s at baseline was 2.6+/-0.8 L (86%+/-16% of the predicted value) and the forced expiratory volume in 1 s over the forced vital capacity was 77%+/-9% (mean +/- SD), and was similar at visits 2 to 4. Juniper scores were mildly abnormal at visits 1 to 3, but significantly worse (P=0.03) at visit 4 versus visits 1 to 3. FENO values at visits 1 to 3 were similar but significantly increased (P=0.007) at visit 4. Bronchial NO was higher (P=0.03) at visit 4, versus visits 1 and 2, and was no different at visit 3. Compared with the healthy subjects, FENO and bronchial NO values were abnormal (greater than the normal mean plus 2 SD) in 33% of asthmatic patients at visits 1 to 3. CANO was similar for visits 1 to 4. CANO was abnormal (greater than the normal mean + 2 SD) in 20% of asthmatic patients. CONCLUSION: In clinically stable asthmatic patients, despite controller treatment including moderate-dose inhaled corticosteroids and add-on M, 33% of mild to moderate asthmatic patients have ongoing nonsuppressed bronchial sites of increased NO production, compared with healthy control subjects. These controllers have no effect on CANO, which was abnormal in 20% of the asthmatic patients studied. The addition of add-on M to baseline moderate-dose inhaled corticosteroid did not further reduce total exhaled, bronchial and/or alveolar NO production.
Temporal Strength Changes From Resistance Exercise and Albuterol on Unloaded Muscle.
J Strength Cond Res. 2008 Jun 9;
Caruso JF, Hamill JL, Yamauchi M, Saito K, Cook TD, Mercado DR
Caruso, JF, Hamill, JL, Yamauchi, M, Saito, K, Cook, TD, and Mercado, DR. Temporal strength changes from resistance exercise and albuterol on unloaded muscle. J Strength Cond Res 22, 1156-1163, 2008-To assess unloaded knee extensor temporal strength changes, healthy subjects without asthma performed 40 continuous days of unilateral limb suspension, whereby their left leg refrained from normal weight-bearing and ambulatory activity. During the 40-day period, subjects performed resistance exercise (REX) with their unloaded leg on an inertial resistance ergometer and, as part of a double-blind design, consumed the maximal oral therapeutic dosage of albuterol (i.e., 16 mg.d) or a placebo (i.e., lactose) with no crossover. Workout data were partitioned into 4 10-day periods that ran consecutively. Dependent strength variables included concentric total work, eccentric total work, concentric average power (CAP), and eccentric average power (EAP). Dependent variables were analyzed with 5 (time) x 2 (group) x 2 (gender) mixed factorial analyses of variance and the Tukey honestly significant difference test. Concentric total work, CAP, and EAP each demonstrated a time-group-gender (p < 0.05) interaction. Female REX-placebo subjects had the greatest percentage of unloaded knee extensor strength loss. However, female REX-albuterol subjects fared best throughout the 40-day period and incurred significant unloaded knee extensor strength gains. Differences in strength changes between male and female REX-albuterol subjects was likely due to the higher relative dosage administered to the latter, as body mass showed a gender (i.e., men > women) effect. Future research may elucidate the ideal dose-response relationship for REX-albuterol treatment for use aboard manned space flights and in other disuse models. Coaches and practitioners should carefully examine their sport-governing bodies' rules on albuterol administration and give the drug only if an athlete's health warrants such treatment.