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Am J Perinatol 2023; 40(02): 172-180
DOI: 10.1055/s-0041-1727233
Original Article

Asthma Medication Regimens in Pregnancy: Longitudinal Changes in Asthma Status

Matthew C.H. Rohn 
1   Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
,
Danielle R. Stevens
1   Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
,
Jenna Kanner
1   Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
,
Carrie Nobles
1   Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
,
Zhen Chen
1   Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
,
Katherine L. Grantz 
1   Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
,
Seth Sherman
2   The Emmes Company, Rockville, Maryland
,
William A. Grobman
3   Northwestern University Feinberg School of Medicine, Chicago, Illinois
,
Rajesh Kumar
3   Northwestern University Feinberg School of Medicine, Chicago, Illinois
4   Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
,
Joseph Biggio
5   Ochsner Baptist Medical Center, New Orleans, Louisiana
6   Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, Alabama
,
Pauline Mendola
1   Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
7   Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York
› Author Affiliations Funding This study was supported by the National Institutes of Health Intramural Research Program at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (clinical site contracts HHSN275201300013C to Northwestern University, HHSN275201300014C to the University of Alabama at Birmingham, and the Emmes Company for the Data Coordinating Center HHSN275201300026I, HHSN27500001, HHSN275000017) and the NIH Medical Research Scholars Program Fund.
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Abstract

Objective This study aimed to assess the impact of common asthma medication regimens on asthma symptoms, exacerbations, lung function, and inflammation during pregnancy.

Study Design A total of 311 women with asthma were enrolled in a prospective pregnancy cohort. Asthma medication regimen was categorized into short-acting β agonist (SABA) alone, SABA + inhaled corticosteroid (ICS), SABA + ICS + long-acting β agonist (LABA), and no asthma medications (reference). We evaluated asthma control at enrollment (< 15 weeks' gestation) and its change into trimesters 2 and 3, including per cent predicted forced expiratory volume in 1 second (%FEV1) and peak expiratory flow (%PEF), pulse oximetry, fractional exhaled nitric oxide (FeNO), asthma symptoms (asthma attacks/month, night symptoms/week), and severe exacerbations. Linear mixed models adjusted for site, age, race, annual income, gestational age, body mass index, and smoking, and propensity scores accounted for asthma control status at baseline.

Results Women taking SABA + ICS and SABA + ICS + LABA had better first trimester %PEF (83.5% [75.7–91.3] and 84.6% [76.9–92.3], respectively) compared with women taking no asthma medications (72.7% [66.0–79.3]). Women taking SABA + ICS + LABA also experienced improvements in %FEV1 (+11.1%, p < 0.01) in the third trimester and FeNO in the second (−12.3 parts per billion [ppb], p < 0.01) and third (−11.0 ppb, p < 0.01) trimesters as compared with the trajectory of women taking no medications. SABA + ICS use was associated with increased odds of severe exacerbations in the first (odds ratio [OR]: 2.22 [1.10–4.46]) and second (OR: 3.15 [1.11–8.96]) trimesters, and SABA + ICS + LABA use in the second trimester (OR: 7.89 [2.75–21.47]). Women taking SABA alone were similar to those taking no medication.

Conclusion Pregnant women taking SABA + ICS and SABA + ICS + LABA had better lung function in the first trimester. SABA + ICS + LABA was associated with improvements in lung function and inflammation across gestation. However, both the SABA + ICS and SABA + ICS + LABA groups had a higher risk of severe exacerbation during early to mid-pregnancy.

Key Points

  • Medication regimens may affect perinatal asthma control.

  • Intensive regimens improved lung function/inflammation.

  • Women on intensive regimens had more acute asthma events.

Keywords

asthma - pregnancy - medication

Supplementary Material



Publication History

Received: 18 August 2020

Accepted: 02 March 2021

Article published online:
21 April 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Mendola P, Laughon SK, Männistö TI. et al. Obstetric complications among US women with asthma. Am J Obstet Gynecol 2013; 208 (02) 127.e1-127.e8
    CrossrefPubMedGoogle Scholar
  • 2 Dombrowski MP. Outcomes of pregnancy in asthmatic women. Immunol Allergy Clin North Am 2006; 26 (01) 81-92
    CrossrefPubMedGoogle Scholar
  • 3 Schatz M, Dombrowski MP, Wise R. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, National Heart, Lung, and Blood Institute. Spirometry is related to perinatal outcomes in pregnant women with asthma. Am J Obstet Gynecol 2006; 194 (01) 120-126
    CrossrefPubMedGoogle Scholar
  • 4 Moorman JE, Akinbami LJ, Bailey CM. et al. National surveillance of asthma: United States, 2001-2010. Vital Health Stat 3 2012; (35) 1-58
    PubMedGoogle Scholar
  • 5 Spiegel E, Shoham-Vardi I, Goldbart A, Sergienko R, Sheiner E. Maternal asthma is an independent risk factor for long-term respiratory morbidity of the offspring. Am J Perinatol 2018; 35 (11) 1065-1070
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Belanger K, Hellenbrand ME, Holford TR, Bracken M. Effect of pregnancy on maternal asthma symptoms and medication use. Obstet Gynecol 2010; 115 (03) 559-567
    CrossrefPubMedGoogle Scholar
  • 7 Murphy VE, Gibson P, Talbot PI, Clifton VL. Severe asthma exacerbations during pregnancy. Obstet Gynecol 2005; 106 (5 Pt 1): 1046-1054
    CrossrefPubMedGoogle Scholar
  • 8 Lee CH, Kim J, Jang EJ. et al. Healthcare utilisation by pregnant patients with asthma in South Korea: a cohort study using nationwide claims data. BMJ Open 2015; 5 (11) e008416
    CrossrefPubMedGoogle Scholar
  • 9 Kim S, Kim J, Park SY. et al. Effect of pregnancy in asthma on health care use and perinatal outcomes. J Allergy Clin Immunol 2015; 136 (05) 1215-23.e1 , 6
    CrossrefPubMedGoogle Scholar
  • 10 Murphy VE. Managing asthma in pregnancy. Breathe (Sheff) 2015; 11 (04) 258-267
    CrossrefPubMedGoogle Scholar
  • 11 Dombrowski MP, Schatz M. ACOG Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy. Obstet Gynecol 2008; 111 (2 Pt 1): 457-464
    PubMedGoogle Scholar
  • 12 National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP expert panel report. Managing asthma during pregnancy: recommendations for pharmacologic treatment-2004 update. J Allergy Clin Immunol 2005; 115 (01) 34-46
    CrossrefPubMedGoogle Scholar
  • 13 Bonham CA, Patterson KC, Strek ME. Asthma outcomes and management during pregnancy. Chest 2018; 153 (02) 515-527
    CrossrefPubMedGoogle Scholar
  • 14 Murphy VE, Gibson PG, Smith R, Clifton VL. Asthma during pregnancy: mechanisms and treatment implications. Eur Respir J 2005; 25 (04) 731-750
    Google Scholar
  • 15 Mor G, Aldo P, Alvero AB. The unique immunological and microbial aspects of pregnancy. Nat Rev Immunol 2017; 17 (08) 469-482
    CrossrefPubMedGoogle Scholar
  • 16 National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol 2007; 120 (5, Suppl): S94-S138
    CrossrefPubMedGoogle Scholar
  • 17 Hastie AT, Moore WC, Meyers DA. et al; National Heart, Lung, and Blood Institute Severe Asthma Research Program. Analyses of asthma severity phenotypes and inflammatory proteins in subjects stratified by sputum granulocytes. J Allergy Clin Immunol 2010; 125 (05) 1028-1036.e13
    CrossrefPubMedGoogle Scholar
  • 18 Nathan RA, Sorkness CA, Kosinski M. et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol 2004; 113 (01) 59-65
    CrossrefPubMedGoogle Scholar
  • 19 Austin PC, Stuart EA. Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med 2015; 34 (28) 3661-3679
    CrossrefPubMedGoogle Scholar
  • 20 Thomas L, Li F, Pencina M. Using propensity score methods to create target populations in observational clinical research. JAMA 2020; 323 (05) 466-467
    CrossrefPubMedGoogle Scholar
  • 21 McCaffrey DF, Griffin BA, Almirall D, Slaughter ME, Ramchand R, Burgette LF. A tutorial on propensity score estimation for multiple treatments using generalized boosted models. Stat Med 2013; 32 (19) 3388-3414
    CrossrefPubMedGoogle Scholar
  • 22 Kolarzyk E, Szot WM, Lyszczarz J. Lung function and breathing regulation parameters during pregnancy. Arch Gynecol Obstet 2005; 272 (01) 53-58
    CrossrefPubMedGoogle Scholar
  • 23 McAuliffe F, Kametas N, Costello J, Rafferty GF, Greenough A, Nicolaides K. Respiratory function in singleton and twin pregnancy. BJOG 2002; 109 (07) 765-769
    Google Scholar
  • 24 Grindheim G, Toska K, Estensen ME, Rosseland LA. Changes in pulmonary function during pregnancy: a longitudinal cohort study. BJOG 2012; 119 (01) 94-101
    CrossrefPubMedGoogle Scholar
  • 25 Arnold RJ, Massanari M, Lee TA, Brooks E. A review of the utility and cost effectiveness of monitoring fractional exhaled nitric oxide (FeNO) in asthma management. Manag Care 2018; 27 (07) 34-41
    PubMedGoogle Scholar
  • 26 Powell H, Murphy VE, Taylor DR. et al. Management of asthma in pregnancy guided by measurement of fraction of exhaled nitric oxide: a double-blind, randomised controlled trial. Lancet 2011; 378 (9795): 983-990
    Google Scholar
  • 27 O'Byrne PM, FitzGerald JM, Bateman ED. et al. Inhaled combined budesonide-formoterol as needed in mild asthma. N Engl J Med 2018; 378 (20) 1865-1876
    Google Scholar
  • 28 Rogers L, Sugar EA, Blake K. et al; American Lung Association Airways Clinical Research Centers. Step-down therapy for asthma well controlled on inhaled corticosteroid and long-acting beta-agonist: a randomized clinical trial. J Allergy Clin Immunol Pract 2018; 6 (02) 633-643.e1
    CrossrefPubMedGoogle Scholar
  • 29 Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2020 . Accessed April 7, 2021 at www.ginasthma.org
    PubMedGoogle Scholar
  • 30 Murphy VE, Jensen ME, Gibson PG. Asthma during pregnancy: exacerbations, management, and health outcomes for mother and infant. Semin Respir Crit Care Med 2017; 38 (02) 160-173
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Namazy JA, Schatz M. Management of asthma during pregnancy: optimizing outcomes and minimizing risk. Semin Respir Crit Care Med 2018; 39 (01) 29-35
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Fitzpatrick AM, Moore WC. Severe asthma phenotypes - how should they guide evaluation and treatment?. J Allergy Clin Immunol Pract 2017; 5 (04) 901-908
    CrossrefPubMedGoogle Scholar
  • 33 Hansen C, Joski P, Freiman H. et al. Medication exposure in pregnancy risk evaluation program: the prevalence of asthma medication use during pregnancy. Matern Child Health J 2013; 17 (09) 1611-1621
    CrossrefPubMedGoogle Scholar