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ORIGINAL ARTICLE

Effects of budesonide/formoterol combination therapy versus budesonide alone on airway dimensions in asthma
resp_2130 639..646

MAKOTO HOSHINO1 AND JUNICHI OHTAWA2

1

Department of Respiratory Medicine, and 2Department of Radiology, Atami Hospital, International University of Health and Welfare, Atami, Japan

ABSTRACT
Background and objective: Combination therapy with inhaled corticosteroids and long-acting b2-agonists results in improved asthma symptom control compared with the use of inhaled corticosteroids alone. However, the effects of combination therapy on structural changes and inammation of the airways are still unknown. The aim of this study was to compare the effects of budesonide/formoterol with those of budesonide alone on airway dimensions and inammation in individuals with asthma. Methods: Fifty asthmatic patients were randomized to treatment with budesonide/formoterol (200/6 mg, two inhalations bd) or budesonide (200 mg, two inhalations bd) for 24 weeks. Airway dimensions were assessed using a validated computed tomography technique, and airway wall area (WA) corrected for body surface area (BSA), percentage WA (WA%), wall thickness/square root BSA, and luminal area (Ai)/BSA at the right apical segmental bronchus, were measured. The percentage of eosinophils in induced sputum, pulmonary function, and Asthma Quality of Life Questionnaires (AQLQ) were also evaluated. Results: There were signicantly greater decreases in WA/BSA (P < 0.05),WA% (P < 0.001) and wall thickness/ square root BSA (P < 0.05), and increases in Ai/BSA (P < 0.05), in subjects treated with budesonide/ formoterol compared with those treated with budesonide. The reduction in sputum eosinophils and increase in per cent of predicted forced expiratory volume in 1 s (FEV1%) were greater for subjects treated with budesonide/formoterol compared with those treated with budesonide alone. In the budesonide/ formoterol group, the changes in WA% were signicantly correlated with changes in sputum eosinophils and FEV1% (r = 0.84 and r = 0.64, respectively). There were improvements in the AQLQ scores after treatment with budesonide/formoterol.

SUMMARY AT A GLANCE
The mechanism by which budesonide/formoterol combination therapy exerts clinically benecial effects appears to be related to increased antiinammatory activity and attenuation of aspects of airway remodelling in asthmatic patients.

Conclusions: Budesonide/formoterol combination therapy is more effective than budesonide alone for reducing airway wall thickness and inammation in individuals with asthma. Key words: airway inammation, airway wall thickness, asthma, budesonide, formoterol.

INTRODUCTION
Asthma is a disease characterized by episodic airow obstruction with bronchial hyperreactivity. Airway remodelling, which involves structural changes in airway wall components, is thought to be the result of airway inammation. Worsening inammation is hypothesized to lead to more long-term remodelling and potentially greater xed airway narrowing.1 Airway remodelling has been studied histologically and signicant increases in subepithelial basement membrane thickening were observed. However, bronchial biopsy is an invasive procedure with potential risks and poor tolerability and repeatability. Airway wall thickening in asthmatic patients has also been evaluated non-invasively, using high-resolution computed tomography.25 By both these measures, airway wall thickness was correlated with the severity of disease2,5 and airow limitation.4,5 It is well established that the addition of a longacting b2-agonist (LABA) to inhaled corticosteroids (ICS) provides more effective asthma control than use of ICS alone.68 Current international asthma guidelines recommend treatment with ICS/LABA for patients with moderate to severe persistent asthma.9 The combination of budesonide with formoterol in a single inhaler allows the simultaneous delivery
Respirology (2012) 17, 639646 doi: 10.1111/j.1440-1843.2012.02130.x

Correspondence: Makoto Hoshino, Department of Respiratory Medicine, Atami Hospital, International University of Health and Welfare, 13-1 Higashikaigan-cho, Atami, Shizuoka 413-0012, Japan. Email: hoshino@iuhw.ac.jp Received 14 July 2011; invited to revise 20 August 2011, 24 October 2011; revised 5 September 2011, 29 October 2011; accepted 15 November 2011 (Associate Editor: Darryl Knight). 2012 The Authors Respirology 2012 Asian Pacic Society of Respirology

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of an anti-inammatory medication and a fastacting bronchodilator. Treatment with budesonide/ formoterol has been shown to improve lung function and reduce symptoms,10,11 as well as attenuate the number of allergen-induced eosinophils, myobroblast numbers and smooth muscle area in patients with asthma, to a greater extent than treatment with budesonide alone.12 It has been suggested that in addition to relaxing airway smooth muscle, LABAs also have anti-inammatory properties, similar to those of ICS.1315 However, there is little evidence that budesonide/formoterol has an effect on airway dimensions in patients with asthma. The aim of the present study was to use CT to compare the effect of inhaled budesonide/formoterol combination therapy with that of inhaled budesonide alone, on airway wall thickness in subjects with asthma. Furthermore, the effects of budesonide/ formoterol or budesonide alone on eosinophilic inammation, pulmonary function and quality of life (QoL) were also investigated.

M Hoshino and J Ohtawa

Murrysville, PA, USA). Patients began taking their study medications and continued through to 24 weeks. During the treatment phase, patients visited the hospital at 4-week intervals. At the end of the 24-week period, patients returned to the hospital for a nal evaluation.

Outcomes
The primary outcome measure was the effect of treatment on airway wall thickness, as assessed by CT scans. The secondary outcomes were the effect of treatment on induced sputum eosinophils, pulmonary function and QoL parameters.

CT measurements
All CT scans were performed on a 64-detector instrument (Aquilion-64, Toshiba Medical, Tokyo, Japan), with the patient at full inspiration. Inhaler medications were not withheld prior to CT scanning. Scans were obtained at 64 0.5 mm collimation, 120 kV, 200 mA, a slice thickness of 1 mm and 0.5 s rotation time. Images were reconstructed using a high spatial frequency algorithm bone, with a slice thickness of 1 mm and a reconstruction interval of 0.5 mm. Images were stored in the Digital Imaging and Communications in Medicine format. After loading the Digital Imaging and Communications in Medicine images with a window width of 1600 HU and a window level of -600 HU, crosssectional images of the right upper lobe apical segmental bronchus were selected. Right upper lobe apical segmental bronchus was chosen because its long axis is generally perpendicular to the axial imaging plane, and previous studies have shown that measurements at this site correlated with lung function.16 From the central point of the lumen, rays fanning out over 360 were examined to identify airway walls along the rays using the full width at halfmaximum principle.17 The following airway parameters were then automatically computed by the software program: luminal area (Ai), total area of the airway (Ao), wall area (WA = Ao - Ai), percentage wall area (WA% = WA/Ao 100) and absolute wall thickness (T). Because airway size may be affected by body size, Ai, WA and T were normalized to body surface area (BSA). To assess changes in lung volume, the cross-sectional area of the lung was measured before and after treatment, by tracing the outer perimeter of the lung parenchyma on the same slice that was used for measurement of airway dimensions.18 After removal of the patients name and the date of the examination, the images were analysed by a radiologist (J.O.) in random order.

METHODS
Subjects
Fifty-ve non-smoking subjects with a denite history of relevant symptoms and documented reversible airway obstruction (>12% improvement in forced expiratory volume in 1 s (FEV1) after inhalation of short-acting b2-agonist, and/or a methacholine (Mch) PC20 of <8 mg/mL), were included in the study. The inclusion criteria were mild-to-moderate persistent asthma, and non-use of systemic or ICS or any antiasthma medication, except inhaled short-acting b2-agonists as needed, during the eight weeks preceding the study. Total serum immunoglobulin E levels were measured and skin prick tests with common aeroallergens were also performed. The study was approved by the Ethics Committee at the International University of Health and Welfare, and all subjects provided written informed consent to participation in the study. The study was registered as a clinical trial at http://www.umin.ac.jp (No. UMIN 000003745).

Study design
This was a double-blind, randomized, parallel-group study with a 24-week treatment phase, and outcome measures of airway dimensions, sputum eosinophils, pulmonary function and QoL. Eligible patients were randomized to receive budesonide/formoterol (Symbicort Turbuhaler, AstraZeneca, Lund, Sweden), 200/ 6 mg, two inhalations bd, or budesonide (Pulmicort Turbuhaler, AstraZeneca), 200 mg, two inhalations bd. Mch inhalation challenge, sputum induction, and CT scan were performed, and a QoL questionnaire was administered to assess baseline pretreatment airway inammation, airway dimensions and health status, respectively. Morning peak expiratory ow was measured using a Personal Best ow meter (Respironics,
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Sputum induction
Sputum induction and processing were performed according to the methods of Pin et al.,19 with a slight
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modication.20 Briey, subjects inhaled a 5% hypertonic saline solution from an ultrasonic nebulizer for 15 min, and adequate plugs of sputum were separated from saliva. Sputum was examined within 2 h of collection. After treatment with 0.1% dithiothreitol (Sputasol, Oxoid Ltd., Basingstoke, UK), the sample was cytocentrifuged and cells were stained by the MayGrnwaldGiemsa method. Differential cell counts were expressed as percentages of 400 nonsquamous cells.

RESULTS
A total of 55 patients were enrolled in the study, but ve patients were withdrawn due to lack of follow-up. Therefore, data for 27 patients treated with budesonide/formoterol and 23 patients treated with budesonide alone were analysed. The treatment groups were comparable with regard to demographic and clinical baseline characteristics (Table 1). Selfrecorded adherence with study medications was >98% in both treatment groups.

Mch challenge
Mch inhalation challenges were performed as previously described.21 The concentration of Mch required to achieve a decrease in FEV1 of 20% (PC20) was calculated by linear interpolation on the plot of percentage decrease in FEV1 against log-transformed Mch concentration.

Airway measurements
There were no signicant differences in baseline bronchial morphometric parameters between the groups. Patients receiving budesonide/formoterol showed signicant decreases from baseline in WA/BSA, WA% and T/BSA (12.3 mm2/m2 (6.122.0) to 11.3 mm2/m2 (4.920.9); 65.3% (50.281.1) to 59.2% (51.578.8); and 0.92 mm/m (0.691.50) to 0.78 mm/m (0.461.19), respectively, P < 0.001). No signicant changes in WA/BSA, WA%, or T/BSA were observed in the patients receiving budesonide therapy (14.7 mm2/m2 (8.926.6) to 14.8 mm2/m2 (9.127.9); 68.7% (54.6 80.7) to 66.4% (57.680.0); and 1.14 mm/m (0.601.70) to 1.00 mm/m (0.601.80), respectively). The differences between the two groups for changes in WA/BSA, WA% and T/BSA from baseline to post-treatment were statistically signicant (P < 0.05, P < 0.001 and P < 0.05, respectively). Budesonide/formoterol treatment resulted in signicantly increased Ai/BSA (7.0 mm2/m2 (3.015.7) to 7.8 mm2/m2 (3.316.9), P < 0.05). This increase was signicantly greater than with budesonide alone (6.8 mm2/m2 (2.914.1) to 7.3 mm2/m2 (3.813.9), P = 0.30; P < 0.05 for the difference between budesonide/formoterol and budesonide treatments) (Fig. 1). In the budesonide/ formoterol group, the duration of asthma was inversely related to the changes in WA% (r = -0.60, P < 0.01). There were no signicant changes in lung area between baseline and the end of the study in either group (budesonide/formoterol: 70.4 to 72.6 cm2/m2; budesonide: 68.2 to 69.5 cm2/m2).

QoL
The Asthma Quality of Life Questionnaire (AQLQ) contains 32 items covering ve domains (symptoms, activities, emotions, environmental and overall), and has a 7-point scale.22 A change of >0.5 point indicates a clinically meaningful improvement in QoL.

Statistical analysis
Data are presented as mean standard deviation and median (range). For all outcomes, mean changes from baseline were compared using paired t-tests, and between-group differences in changes from baseline were compared using the Wilcoxon rank sum test. A P value <0.05 was considered statistically signicant. Relationships between parameters were assessed using Pearson correlation coefcients. All data were analysed using StatView software (SAS Institute, Cary, NC, USA).

Table 1 Baseline characteristics of the asthmatic patients Budesonide/formoterol (n = 27)

Gender (males/females) Age, years Body surface area, m2 Duration of disease, years Serum total immunoglobulin E, IU/mL PC20 methacholine, mg/mL Morning peak expiratory ow, L/min Forced expiratory volume in 1 s, % predicted Forced expiratory volume in 1 s, L 13/14 53.8 (17.3) 1.64 (0.25) 13.4 (14.8) 840.6 (881.9) 1.44 (1.80) 306.2 (105.9) 73.5 (25.5) 1.78 (0.89)

Budesonide (n = 23)
9/14 52 (20.2) 1.64 (0.17) 8.9 (9.7) 566.9 (627.4) 1.08 (1.62) 320.4 (132.5) 77.9 (21.0) 2.19 (0.86)

P value

0.37 0.46 0.11 0.13 0.64 0.17 0.26 0.08

Data are presented as mean (standard deviation).

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M Hoshino and J Ohtawa

Figure 1 Changes in airway measurements before and after 24 weeks of treatment with budesonide (BUD)/formoterol (FORM) or BUD alone. Bars indicate medians (range). *P < 0.05, **P < 0.001 for within-group comparisons with baseline; P < 0.05, P < 0.001 for between-group comparisons of BUD/FORM with BUD. Ai, airway luminal area; BSA, body surface area; n.s., not signicant; T, wall thickness; WA, airway wall area; WA%, percentage of wall area.

Figure 2 Changes in percentages of sputum eosinophils before and after 24 weeks of treatment with budesonide (BUD)/formoterol (FORM) or BUD alone. Horizontal bars indicate median values.

Induced sputum
The median (range) percentage of eosinophils in induced sputum was signicantly decreased in the budesonide/formoterol group (4.9% (0.012.6) to 2.9% (0.87.6), P < 0.05, n = 14) and in the budesonide group (5.2% (1.210.0) to 4.6% (1.07.1), P < 0.05, n = 13), with the budesonide/formoterol group showing greater improvement than the budesonide group (P = 0.05) (Fig. 2).
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Pulmonary function
Morning peak expiratory ow, FEV1% and FEV1 increased signicantly relative to baseline values in both groups. There were signicant between-group differences in FEV1% (Table 2). Changes in WA% were signicantly correlated with changes in sputum eosinophils (r = 084, P < 0.01) and FEV1% (r = 0.64, P < 0.01) in the budesonide/formoterol treatment group (Fig. 3).
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Table 2 Pulmonary function of asthmatic patients before and after treatment with budesonide/formoterol or budesonide alone Budesonide/formoterol Before
Morning PEF, L/min FEV1, % predicted FEV1, L 306.2 (105.7) 73.5 (25.5) 1.78 (0.89)

Budesonide Before
320.4 (132.5) 77.9 (21.0) 2.19 (0.86)

After
350.4 (119.1) 92.1 (22.2) 2.21 (0.92)**

After
361.3 (106.7)* 87.1 (16.9)* 2.43 (0.86)*

P value
0.12 0.04 0.11

Data are presented as mean (standard deviation). * P < 0.05, ** P < 0.001, P < 0.0001 compared with baseline for within-group comparisons.

Figure 3 Correlations between changes in (a) percentage wall area (WA) and percentage of sputum eosinophils, and (b) percentage WA and FEV1%, before and after treatment of asthmatic patients with budesonide/formoterol.

Figure 4 Changes in Asthma Quality of Life Questionnaire (AQLQ) scores from baseline to after treatment with budesonide (BUD)/ formoterol (FORM) or BUD alone. Bars indicate medians (range). *P < 0.05 for between-group comparisons of BUD/FORM with BUD. Dashed line indicates clinically meaningful improvement in AQLQ score (>0.5 points).

AQLQ
Analysis of the domain scores revealed that signicantly better scores for each domain contributed to the overall improvement in total AQLQ scores in the budesonide/formoterol group (differences in symptoms 2.08, activities 1.09, emotions 1.20, environmental 1.37 and overall 1.13). Patients receiving budesonide alone showed similar improvements in AQLQ scores (differences in symptoms 1.17, activities 0.54, emotions 1.00, environmental 0.5 and overall 0.65). The differences in activities, emotions, and
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overall scores between the groups were statistically signicant (P < 0.05) (Fig. 4).

DISCUSSION
This study showed that treatment with budesonide/ formoterol over a 24-week period signicantly reduced airway wall thickness and sputum eosinophilia, and signicantly improved pulmonary function and QoL, compared with treatment with budesonide alone. The change in airway wall
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thickness was associated with a reduction in sputum eosinophils and improvement in pulmonary function. This is the rst clinical study that has used CT in asthmatic patients to demonstrate that combination therapy with budesonide/formoterol decreases airway wall thickness. Recently, combination therapy, that is, the addition of a LABA to low-to-medium doses of ICS, has become the preferred treatment for patients with moderate and severe persistent asthma. Clinical studies have demonstrated that combination therapy is superior to corticosteroid monotherapy in terms of improving asthma symptoms and reducing the frequency of exacerbations in adults and children.6 8,11,23,24 The mechanism for the therapeutic benets seen with budesonide/formoterol, as compared with budesonide alone, is not yet fully understood. ICS and LABA may act independently on distinct pathophysiological processes in asthma; thus ICS may target the inammatory component, whereas LABA target the bronchoconstrictive component of the disease. ICS/ LABA combination therapy may also exert its effects not only by producing bronchodilation and functional antagonism but also by reinforcing antiinammatory activity and attenuating airway wall thickness, as compared with ICS therapy alone.25 Recent in vitro studies suggest that the synergistic and complementary interactions between antiinammatory effects of ICS and LABA result from corticosteroid induced increases in the number of b2-receptors, and inhibition of the down-regulation of b2-receptors.26 Corticosteroids have been reported to also modulate the efciency of coupling between b2-receptors and the adenylate cyclase system.27 In contrast, LABA exert a priming effect for subsequent steroid binding to the glucocorticoid receptor (GR),28 and also enhance the translocation of GR from the cytoplasm to the nucleus of airway cells.29,30 Corticosteroids and b2-agonists, when used in combination, may have additional and/or synergistic effects on inammatory cells and airway structural cells.31,32 Structural changes in the airways of asthmatic patients include subepithelial basement membrane brosis, increased smooth muscle mass, hyperplasia of mucus-producing goblet cells and angiogenesis. Importantly, whether airway remodelling can be prevented or reversed is highly relevant because these changes to the airway wall are thought to contribute to airway dysfunction.33 In the present study, budesonide/formoterol was more effective in reducing airway wall thickness than budesonide alone. Budesonide/formoterol combination therapy, but not budesonide alone, signicantly attenuated the allergen-induced increase in airway myobroblast numbers and prevented the concomitant decrease in airway smooth muscle area.12 The components of airway wall thickening that respond to treatment may include inammatory factors, as the decrease in wall thickness correlated with a decrease in sputum eosinophil numbers. Transforming growth factor-b is a key mediator of extracellular matrix (ECM) remodelling, and may be responsible for the increase in eosinophil numbers and the thickness of the reticular basement
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membrane in asthmatic airways.34,35 Budesonide/ formoterol combination therapy may counteract excessive transforming growth factor-b1-induced ECM production but not the increase in a-smooth muscle actin in human lung broblasts.36 Vascular endothelial growth factor is a specic and potent angiogenic factor, and colocalization studies show that eosinophils are a major source of vascular endothelial growth factor.37 Budesonide/formoterol combination therapy has been shown to reduce the expression of vascular endothelial growth factor, as well as submucosal gland hyperplasia, reticular basement membrane thickness and neovascularization.38 We attempted to measure airway thickness by CT, as a marker of airway remodelling, because CT is less invasive than bronchial biopsy and it can be used to evaluate overall airway wall thickness. We showed that formoterol, when combined with budesonide may be primarily responsible for the observed decrease in airway wall thickness. Niimi et al.39 used CT to demonstrate a decrease in airway wall thickness in corticosteroid-nave asthmatic patients treated with beclomethasone. The discrepancy in these results may be related to differences in the treatment period and patient selection, and it is possible that the duration of disease was longer in patients in the present study, which may have made their airways less responsive to budesonide alone. In the present study, airway lumen area increased as a result of bronchodilatation after treatment with budesonide/formoterol. The change in luminal area may reect the potential effects of lung volume on airway dimensions.18 However, lung area before and after inhalation of budesonide/formoterol did not differ signicantly, and there was no relationship between changes in lung area and airway calibre. CT scans were performed at total lung capacity; therefore any changes in static volumes would not have affected the CT images. It was reported that the addition of formoterol to low-dose inhaled budesonide reduced exacerbation rates to a signicantly greater degree than did treatment with low-dose inhaled budesonide alone.8,11 This suggested that formoterol/budesonide combination therapy showed enhanced clinical efcacy as compared with budesonide monotherapy. Budesonide/formoterol and budesonide had similar effects on AQLQ scores in patients with asthma. However, patients treated with budesonide/ formoterol showed greater improvements in activity, emotion and overall scores, as compared to those treated with budesonide. The results of the present study are consistent with these and other previous observations,40,41 and also advance understanding of how these two classes of drugs, when administered together, show superior clinical efcacy. There are some limitations to the present study. First, a group of patients using inhaled formoterol was not included, primarily because LABA monotherapy is not recommended in current guidelines for the treatment of asthma.9 Second, only the right upper lobe apical segmental bronchus was assessed. However, a recent study suggested that the extent of changes in airway measurements of right upper lobe
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11 OByrne PM, Barnes PJ, Rodriguez-Roisin R et al. Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial. Am. J. Respir. Crit. Care Med. 2001; 164: 13927. 12 Kelly MM, OConnor TM, Leigh R et al. Effects of budesonide and formoterol on allergen-induced airway responses, inammation, and airway remodeling in asthma. J. Allergy Clin. Immunol. 2010; 125: 34956. 13 Whelan CJ, Johnson M, Vardey CJ. Comparison of the antiinammatory properties of formoterol, salbutamol and salmeterol in guinea-pig skin and lung. Br. J. Pharmacol. 1993; 110: 61318. 14 Li X, Ward C, Thien F et al. An antiinammatory effect of salmeterol, a long-acting beta(2) agonist, assessed in airway biopsies and bronchoalveolar lavage in asthma. Am. J. Respir. Crit. Care Med. 1999; 160: 14939. 15 Anderson GP. Interactions between corticosteroids and b-adrenergic agonists in asthma disease induction, progression, and exacerbation. Am.J.Respir.Crit.Care Med. 2000; 161: S18896. 16 Nakano Y, Muro S, Sakai H et al. Computed tomographic measurements of airway dimensions and emphysema in smokers. Correlation with lung function. Am. J. Respir. Crit. Care Med. 2000; 162: 11028. 17 Matsuoka S, Kurihara Y, Yagihashi K et al. Airway dimensions on inspiratory and expiratory multisection CT in chronic obstructive pulmonary disease: correlation with airow limitation. Radiology 2008; 248: 10429. 18 Okazawa M, Mller N, McNamara AE et al. Human airway narrowing measured using high resolution computed tomography. Am. J. Respir. Crit. Care Med. 1996; 154: 155762. 19 Pin I, Gibson PG, Kolendowicz R et al. Use of induced sputum cell counts to investigate airway inammation in asthma. Thorax 1992; 47: 259. 20 Hoshino M, Handa H, Miyazawa T. Effects of salmeterol and uticasone propionate combination versus uticasone propionate on airway function and eosinophilic inammation in mild asthma. Allergol. Int. 2009; 58: 35763. 21 Cockcroft DW, Killian DN, Mellon JJ et al. Bronchial reactivity to inhaled histamine; a method and clinical survey. Clin. Allergy 1977; 7: 23543. 22 Juniper EF, Guyatt GH, Epstein RS et al. Evaluation of impairment of health related quality of life in asthma: development of a questionnaire for use in clinical trials. Thorax 1992; 47: 7683. 23 Bateman ED, Bantje TA, Joo Gomes M et al. Combination therapy with single inhaler budesonide/formoterol compared with high dose of uticasone propionate alone in patients with moderate persistent asthma. Am. J. Respir. Med. 2003; 2: 27581. 24 Jenkins C, Kolarikova R, Kuna P et al. Efcacy and safety of highdose budesonide/formoterol (Symbicort) compared with budesonide administered either concomitantly with formoterol or alone in patients with persistent symptomatic asthma. Respirology 2006; 11: 27686. 25 Roth M, Johnson PR, Rdiger JJ et al. Interaction between glucocorticoids and beta2 agonists on bronchial airway smooth muscle cells through synchronised cellular signalling. Lancet 2002; 360: 12939. 26 Hadcock JR, Wang HY, Malbon CC. Agonist-induced destabilization of beta-adrenergic receptor mRNA. Attenuation of glucocorticoid-induced up-regulation of beta-adrenergic receptors. J. Biol. Chem. 1989; 264: 1992833. 27 Mak JC, Nishikawa M, Shirasaki H et al. Protective effects of a glucocorticoid on downregulation of pulmonary beta 2-adrenergic receptors in vivo. J. Clin. Invest. 1995; 96: 99106. 28 Adcock IM, Maneechotesuwan K, Usmani O. Molecular interactions between glucocorticoids and long-acting beta2-agonists. J. Allergy Clin. Immunol. 2002; 110: S2618. 29 Eickelberg O, Roth M, Lrx R et al. Ligand-independent activation of the glucocorticoid receptor by beta2-adrenergic receptor agonists in primary human lung broblasts and vascular smooth muscle cells. J. Biol. Chem. 1999; 274: 100510. Respirology (2012) 17, 639646

apical segmental bronchus were similar across different cross-sectional levels of the lung.42 Therefore, we think that the measurements reported here are correct and provide true indications of airway anatomy in these patients. Third, although CT images were obtained on two occasions while the patients held their breath upon deep inspiration, the CT scans may not have been performed at precisely the same lung volume at each session, leading to potential errors in comparisons before and after therapy. However, such effects were unlikely because lung areas did not differ signicantly between the beginning and the end of the study. In conclusion, this study demonstrated that both airway wall thickness and airway inammation showed greater improvement in asthmatic individuals treated with budesonide/formoterol than in those treated with budesonide alone. Treatment with budesonide/formoterol may modify the progressive nature of airway inammation and airway remodelling in asthma.

ACKNOWLEDGEMENTS
The authors thank the staff of the Department of Laboratory Medicine, Atami Hospital, International University of Health and Welfare.

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2012 The Authors Respirology 2012 Asian Pacic Society of Respirology