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Wang AL, Tantisira KG. Personalized management of asthma exacerbations: lessons from genetic studies. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2016; 1:487-495. [PMID: 29051920 DOI: 10.1080/23808993.2016.1269600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The genetics of severe asthma and asthma exacerbations are distinct from milder forms of asthma. Gene-environmental interactions contribute to the complexity and heterogeneity of severe asthma and asthma exacerbations, and pharmacogenomic studies have also identified genes that affect susceptibility to asthma exacerbations. AREAS COVERED Studies on the genetics, gene-environment interactions, and pharmacogenomics of asthma exacerbations are reviewed. Multiple individual genetic variants have been identified to be associated with asthma exacerbations but each genetic polymorphism explains only a fraction of the disease and by itself is not able to translate into clinical practice. Research is shifting from candidate gene studies and genome wide association studies towards more integrative approaches to translate genetic findings into clinical diagnostic and therapeutic tools. EXPERT COMMENTARY Integrative approaches combining polygenic or genomic data with multi-omics technologies have the potential to discover new biologic mechanisms and biomarkers for severe asthma and asthma exacerbations. Greater understanding of genomics and underlying biologic pathways will also lead to improved prevention and treatment, lowering costs, morbidity, and mortality. The utilization of genomic testing and personalized medicine may revolutionize asthma management, in particular for patients with severe, refractory asthma.
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Affiliation(s)
- Alberta L Wang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Kelan G Tantisira
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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52
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Sattler C, Malrin R, Garcia G, Humbert M. [New drugs for severe asthma]. Presse Med 2016; 45:1043-1055. [PMID: 27836376 DOI: 10.1016/j.lpm.2016.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/05/2016] [Accepted: 09/22/2016] [Indexed: 12/22/2022] Open
Abstract
Asthma is a very frequent disease with complex and heterogenous immunological and clinical features. Daily inhaled steroids are the cornerstone of the current therapeutics sometimes associated with long-acting β2-agonist. This controller treatment is effective and allows to control asthma symptoms for the vast majority of the patients. Severe asthma is characterized by a poor level of control of symptoms, with recurrent exacerbations or a chronic airflow limitation despite an optimal management. Severe asthma remains a difficult diagnosis but we have now studies proving the clinical efficacy or promising data about monoclonal antibodies targeting IgE, IL-5, IL-4 or IL-13. Most of these monoclonal antibodies target the Th2 type eosinophilic inflammation without any treatment against non-eosinophilic or Th1 inflammation. Last, it will be essential to assess accurately the cost effectiveness of these expensive treatments, to identify and to qualify the target population for each molecule and to assess its financial impact for the community.
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Affiliation(s)
- Caroline Sattler
- Université Paris-Sud, université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France; AP-HP, hôpital Bicêtre, service de physiologie, explorations fonctionnelles respiratoires, 94270 Le Kremlin-Bicêtre, France; Hôpital Marie-Lannelongue, Inserm UMR_S 999, 92350 Le Plessis-Robinson, France
| | - Roxane Malrin
- Université Paris-Sud, université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France; AP-HP, hôpital Bicêtre, service de pneumologie, 94270 Le Kremlin-Bicêtre, France; Hôpital Marie-Lannelongue, Inserm UMR_S 999, 92350 Le Plessis-Robinson, France
| | - Gilles Garcia
- Université Paris-Sud, université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France; AP-HP, hôpital Bicêtre, service de physiologie, explorations fonctionnelles respiratoires, 94270 Le Kremlin-Bicêtre, France; Hôpital Marie-Lannelongue, Inserm UMR_S 999, 92350 Le Plessis-Robinson, France.
| | - Marc Humbert
- Université Paris-Sud, université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France; AP-HP, hôpital Bicêtre, service de pneumologie, 94270 Le Kremlin-Bicêtre, France; Hôpital Marie-Lannelongue, Inserm UMR_S 999, 92350 Le Plessis-Robinson, France
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53
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Liu Z, Chen H, Chen X, Gao J, Guo Z. Characteristics of Allergic Pulmonary Inflammation in CXCR3Knockout Mice Sensitized and Challenged with House Dust Mite Protein. PLoS One 2016; 11:e0162905. [PMID: 27727269 PMCID: PMC5058494 DOI: 10.1371/journal.pone.0162905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 08/30/2016] [Indexed: 11/29/2022] Open
Abstract
Chemokine C-X-C motif receptor 3 (CXCR3) is a chemokine receptor that is mainly expressed by activated T lymphocytes. T cells play important roles in allergic pulmonary inflammation, which is a hallmark of asthma and elicits the localized accumulation of activated T cells in the lung. In China, a marked increase in the incidence rate of chronic allergic pulmonary inflammation has made it a major public health threat. In the present study, we investigated the role of CXCR3 and its ligands in airway inflammation induced by house dust mite protein (HDMP) in a CXCR3 knockout (CXCR3KO) asthma mouse model. Pathological manifestations in the lung, cell counts and bronchoalveolar lavage fluid (BALF) classifications were studied using hematoxylin and eosin (H&E) staining. The levels of IL-4 and IFN-γ in the BALF and splenocyte supernatants were measured using ELISA. CD4+ and CD8+ T cells in the lung and spleen were analyzed by flow cytometry. RT-PCR was applied to measure the mRNA transcript levels of monokines induced by IFN-γ(CXCL9) and IFN-γ inducible protein 10(CXCL10). The total cell counts, eosinophil counts, and IL-4 levels in the BALF and cultured splenocyte supernatants were significantly increased, while the levels of IFN-γ were reduced in the HDMP groups(P<0.01). Changes in the total cell counts, eosinophil counts, and lymphocyte counts, as well as the total protein levels in the BALF, the levels of IL-4 in splenocyte supernatants, and the pathological manifestations in the lung, were all greater in CXCR3KO mice than in C57BL/6 wild-type mice. Furthermore, the expression levels of CXCL9 and CXCL10 mRNA transcripts in the lungs of CXCR3KO mice were lower than those in C57BL/6 wild-type mice (P<0.05). CXCR3 and its ligands (i.e., CXCL9 and CXCL10) may play anti-inflammatory roles in this animal model. Promoting the expression of CXCR3 and its ligands may represent a novel therapeutic approach for preventing and curing asthma.
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Affiliation(s)
- Zhongjuan Liu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huaxia Chen
- Department of Respiratory Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaolan Chen
- Department of Respiratory Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinming Gao
- Department of Respiratory Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zijian Guo
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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54
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Panek M, Pietras T, Fabijan A, Zioło J, Wieteska Ł, Małachowska B, Fendler W, Szemraj J, Kuna P. The NR3C1 Glucocorticoid Receptor Gene Polymorphisms May Modulate the TGF-beta mRNA Expression in Asthma Patients. Inflammation 2016; 38:1479-92. [PMID: 25649164 DOI: 10.1007/s10753-015-0123-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Glucocorticosteroids (GCs) are basic drugs in therapy of a number of diseases, including chronic diseases of the respiratory system. They are the most important anti-inflammatory drugs in the treatment of asthma. GCs after binding to the glucocorticoid receptor (GR) form the complex (transcription factor), which acts on promoter and regulatory parts of genes enhancing the expression of anti-inflammatory proteins and decreasing the proinflammatory protein synthesis, including numerous cytokines mediating inflammation in the course of asthma. Non-sensitivity or resistance to GCs favours an increase in the TGF-β expression. This cytokine plays a central role in asthma inducing fibroblast differentiation and extracellular matrix synthesis. TGF-β isoforms, 1, 2 and 3, are located on chromosome 19q13, 1q41 and 14q24, respectively. GCs reduce TGF-β 1 and TGF-β 2 production and significantly decrease the expression of upregulated TGF-β 1 and TGF-β 2 mRNA induced by exogenous TGF-β. In asthma, TGF-β may play a role in the development of the peribronchiolar and subepithelial fibrosis, which contributes to a significant clinical exacerbation of asthma. Therefore, it is possible that NR3C1 glucocorticoid receptor gene polymorphisms could exert varied effects on the TGF-β mRNA expression and fibrotic process in lungs of asthmatic patients. The aim of the study was to evaluate the impact of polymorphic forms (Tth111I, BclI, ER22/23EK, N363S) of the NR3C1 gene on the level of the TGF-β 1 mRNA expression. A total of 173 patients with asthma and 163 healthy volunteers participated in the study. Genotyping of Tth111I, BclI, ER22/23EK, and N363S polymorphisms of the NR3C1 gene was performed by using PCR-HRM and PCR-RFLP techniques. TGF-β mRNA was assessed by real time RT-PCR. Tth111I SNP significantly (p = 0.0115) correlated with the TGF-β 1 mRNA expression level. The significance of AA and GG genotypes of Tth111I SNP in increasing and decreasing the level of the TGF-β 1 mRNA expression was demonstrated. Both BclI SNP and ER22/23EK SNP did not affect the expression level of the cytokine analysed. The N363S SNP AA genotype of NR3C1 gene statistically significantly influenced the increase in the level of the TGF-β 1 mRNA expression. Thus, SNPs of NR3C1 gene play an important regulatory function in the bronchi of patients suffering from asthma. In the case of the occurrence of Tth111I and N363S polymorphic forms of the gene studied, a reduced ability of GCs to inhibit the TGF-β 1 expression can be observed.
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Affiliation(s)
- Michał Panek
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, 22 Kopcinskiego Str, 90-153, Lodz, Poland,
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Marth K, Spinola M, Kisiel J, Woergetter C, Petrovic M, Pohl W. Treatment response according to small airway phenotypes: a real-life observational study. Ther Adv Respir Dis 2016; 10:200-10. [PMID: 27060186 DOI: 10.1177/1753465816642635] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Scant clinical data are available on the effects of current treatments for asthma on different subgroups of patients with this disease. We conducted a prospective, noninterventional, multicenter real-life study in adult patients with persistent asthma, and we specifically analyzed the effects of treatment with extrafine beclometasone dipropionate/formoterol (BDP/F) in asthma patients categorized by phenotypes related to small airways (i.e. smoking habits, disease duration, and air trapping). METHODS Patients received BDP/F as a fixed combination (100/6 μg), administered in 1-2 inhalations twice daily over a period of 12 weeks. Peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), number of asthma attacks, asthma control, and severity of asthma symptoms were evaluated in the overall population and in different subgroups at three different time points. RESULTS Overall, 213 patients were enrolled. In the overall population the treatment resulted in a significant increase in the proportion of well controlled patients (from 6.1% to 66.3%; p<0.001), and a reduction of uncontrolled subjects (70.3% versus 10.0%; p<0.001). BDP/F was also associated with a reduction in asthma attacks and an improvement of symptoms. These results were confirmed in specific subgroups of patients identified as small airway phenotypes: smokers, elderly patients, those with long duration of disease and air trapping. CONCLUSIONS This real-life observational study indicates that extrafine BDP/F in a fixed combination improves asthma control and symptoms in the overall population as well as specific subgroups of patients.
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Affiliation(s)
| | | | | | | | | | - Wolfgang Pohl
- 1130 Wien, KH Hietzing, Abt. f. Atmungs- u. Lungenkrankheiten, Austria
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56
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Nguyen TH, Maltby S, Simpson JL, Eyers F, Baines KJ, Gibson PG, Foster PS, Yang M. TNF-α and Macrophages Are Critical for Respiratory Syncytial Virus-Induced Exacerbations in a Mouse Model of Allergic Airways Disease. THE JOURNAL OF IMMUNOLOGY 2016; 196:3547-58. [PMID: 27036916 DOI: 10.4049/jimmunol.1502339] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/29/2016] [Indexed: 12/27/2022]
Abstract
Viral respiratory infections trigger severe exacerbations of asthma, worsen disease symptoms, and impair lung function. To investigate the mechanisms underlying viral exacerbation, we established a mouse model of respiratory syncytial virus (RSV)-induced exacerbation after allergen sensitization and challenge. RSV infection of OVA-sensitized/challenged BALB/c mice resulted in significantly increased airway hyperresponsiveness (AHR) and macrophage and neutrophil lung infiltration. Exacerbation was accompanied by increased levels of inflammatory cytokines (including TNF-α, MCP-1, and keratinocyte-derived protein chemokine [KC]) compared with uninfected OVA-treated mice or OVA-treated mice exposed to UV-inactivated RSV. Dexamethasone treatment completely inhibited all features of allergic disease, including AHR and eosinophil infiltration, in uninfected OVA-sensitized/challenged mice. Conversely, dexamethasone treatment following RSV-induced exacerbation only partially suppressed AHR and failed to dampen macrophage and neutrophil infiltration or inflammatory cytokine production (TNF-α, MCP-1, and KC). This mimics clinical observations in patients with exacerbations, which is associated with increased neutrophils and often poorly responds to corticosteroid therapy. Interestingly, we also observed increased TNF-α levels in sputum samples from patients with neutrophilic asthma. Although RSV-induced exacerbation was resistant to steroid treatment, inhibition of TNF-α and MCP-1 function or depletion of macrophages suppressed features of disease, including AHR and macrophage and neutrophil infiltration. Our findings highlight critical roles for macrophages and inflammatory cytokines (including TNF-α and MCP-1) in viral-induced exacerbation of asthma and suggest examination of these pathways as novel therapeutic approaches for disease management.
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Affiliation(s)
- Thi Hiep Nguyen
- Priority Research Centre for Asthma and Respiratory Diseases, Faculty of Health, University of Newcastle, Callaghan, New South Wales 2300, Australia; Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales 2300, Australia; and
| | - Steven Maltby
- Priority Research Centre for Asthma and Respiratory Diseases, Faculty of Health, University of Newcastle, Callaghan, New South Wales 2300, Australia; Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales 2300, Australia; and
| | - Jodie L Simpson
- Priority Research Centre for Asthma and Respiratory Diseases, Faculty of Health, University of Newcastle, Callaghan, New South Wales 2300, Australia; Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales 2300, Australia; and Department of Respiratory and Sleep Medicine, Hunter New England Area Health Service, Newcastle, New South Wales 2305, Australia
| | - Fiona Eyers
- Priority Research Centre for Asthma and Respiratory Diseases, Faculty of Health, University of Newcastle, Callaghan, New South Wales 2300, Australia; Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales 2300, Australia; and
| | - Katherine J Baines
- Priority Research Centre for Asthma and Respiratory Diseases, Faculty of Health, University of Newcastle, Callaghan, New South Wales 2300, Australia; Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales 2300, Australia; and Department of Respiratory and Sleep Medicine, Hunter New England Area Health Service, Newcastle, New South Wales 2305, Australia
| | - Peter G Gibson
- Priority Research Centre for Asthma and Respiratory Diseases, Faculty of Health, University of Newcastle, Callaghan, New South Wales 2300, Australia; Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales 2300, Australia; and Department of Respiratory and Sleep Medicine, Hunter New England Area Health Service, Newcastle, New South Wales 2305, Australia
| | - Paul S Foster
- Priority Research Centre for Asthma and Respiratory Diseases, Faculty of Health, University of Newcastle, Callaghan, New South Wales 2300, Australia; Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales 2300, Australia; and
| | - Ming Yang
- Priority Research Centre for Asthma and Respiratory Diseases, Faculty of Health, University of Newcastle, Callaghan, New South Wales 2300, Australia; Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales 2300, Australia; and
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57
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Dejager L, Dendoncker K, Eggermont M, Souffriau J, Van Hauwermeiren F, Willart M, Van Wonterghem E, Naessens T, Ballegeer M, Vandevyver S, Hammad H, Lambrecht B, De Bosscher K, Grooten J, Libert C. Neutralizing TNFα restores glucocorticoid sensitivity in a mouse model of neutrophilic airway inflammation. Mucosal Immunol 2015; 8:1212-25. [PMID: 25760421 DOI: 10.1038/mi.2015.12] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 01/04/2015] [Indexed: 02/04/2023]
Abstract
Asthma is a heterogeneous disorder, evidenced by distinct types of inflammation resulting in different responsiveness to therapy with glucocorticoids (GCs). Tumor necrosis factor α (TNFα) is involved in asthma pathogenesis, but anti-TNFα therapies have not proven broadly effective. The effects of anti-TNFα treatment on steroid resistance have never been assessed. We investigated the role of TNFα blockade using etanercept in the responsiveness to GCs in two ovalbumin-based mouse models of airway hyperinflammation. The first model is GC sensitive and T helper type 2 (Th2)/eosinophil driven, whereas the second reflects GC-insensitive, Th1/neutrophil-predominant asthma subphenotypes. We found that TNFα blockade restores the therapeutic effects of GCs in the GC-insensitive model. An adoptive transfer indicated that the TNFα-induced GC insensitivity occurs in the non-myeloid compartment. Early during airway hyperinflammation, mice are GC insensitive specifically at the level of thymic stromal lymphopoietin (Tslp) transcriptional repression, and this insensitivity is reverted when TNFα is neutralized. Interestingly, TSLP knockout mice displayed increased inflammation in the GC-insensitive model, suggesting a limited therapeutic application of TSLP-neutralizing antibodies in subsets of patients suffering from Th2-mediated asthma. In conclusion, we demonstrate that TNFα reduces the responsiveness to GCs in a mouse model of neutrophilic airway inflammation. Thus antagonizing TNFα may offer a new strategy for therapeutic intervention in GC-resistant asthma.
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Affiliation(s)
- L Dejager
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - K Dendoncker
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - M Eggermont
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - J Souffriau
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - F Van Hauwermeiren
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - M Willart
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - E Van Wonterghem
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - T Naessens
- Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - M Ballegeer
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - S Vandevyver
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - H Hammad
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Respiratory Medicine, Ghent University, Ghent, Belgium
| | - B Lambrecht
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Respiratory Medicine, Ghent University, Ghent, Belgium.,Department Pulmonary Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - K De Bosscher
- Cytokine Receptor Laboratory, Department of Medical Protein Research, VIB, Ghent, Belgium.,Cytokine Receptor Lab, Department of Biochemistry, Ghent University, Ghent, Belgium
| | - J Grooten
- Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - C Libert
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
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Madama D, Silva A, Matos MJ. Overlap syndrome--Asthma and obstructive sleep apnea. REVISTA PORTUGUESA DE PNEUMOLOGIA 2015; 22:6-10. [PMID: 26603307 DOI: 10.1016/j.rppnen.2015.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 08/13/2015] [Accepted: 08/14/2015] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Asthma is a chronic inflammatory disease with multiple phenotypes. There is still a major gap in the understanding of its complex causality. Obstructive sleep apnea (OSA) is a common condition that has been implicated as a risk factor for asthma exacerbations. OBJECTIVES This study aims to characterize patients with the diagnosis of asthma and suspected OSA; identify the presence of OSA and review, on the current literature, the association between asthma and OSA, as an overlap syndrome. MATERIALS AND METHODS The authors present a retrospective study that included patients diagnosed with asthma that underwent sleep study in a 3 year period. Demographic, clinical data, body mass index (BMI), sleep study parameters and treatments were analyzed. RESULTS The sample consisted of 47 patients. The majority of population was females (68%) and the mean age was 55.65 ± 13.04 years. The most common nighttime symptom was snoring (93.6%). Regarding BMI, values above the normal limit were observed in 89.36% of the patients. 68% underwent polysomnography and the others cardiorespiratory polygraphy. In 57.4% of the patients, OSA was confirmed with a higher prevalence in males (73.3%) compared to females (50%). The therapeutic approach in 81.8% of these patients was home ventilation therapy. CONCLUSION The combination of asthma and OSA has become increasingly more frequent. In the described study, the prevalence of OSA was 57.4%, value that is in fact higher than in general population. After the therapeutic approach, all patients referred improvement of symptoms. It is therefore essential that OSA is investigated in patients with asthma when there is poor control of symptoms, in order to achieve a better control.
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Affiliation(s)
- D Madama
- Pulmonology Department, Coimbra Hospital and University Centre, Portugal.
| | - A Silva
- Pulmonology Department, Coimbra Hospital and University Centre, Portugal
| | - M J Matos
- Pulmonology Department, Coimbra Hospital and University Centre, Portugal
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59
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Zeiger RS, Schatz M, Dalal AA, Qian L, Chen W, Ngor EW, Suruki RY, Kawatkar AA. Utilization and Costs of Severe Uncontrolled Asthma in a Managed-Care Setting. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 4:120-9.e3. [PMID: 26439182 DOI: 10.1016/j.jaip.2015.08.003] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 07/30/2015] [Accepted: 08/11/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Clinical and economic burden of patients with severe uncontrolled asthma (SUA) in a real-world managed-care setting required further documentation. OBJECTIVE The objective of this study was to determine the characteristics, clinical, and economic burden of SUA in a managed-care setting. METHODS This observational study identified patients with persistent asthma aged 12 years or more (N = 25,935) using the International Classification of Diseases, 9th Revision asthma codes and Healthcare Effectiveness Data and Information Set administrative criteria. An SUA subgroup was identified when all of the following 3 criteria were met in 2012: (1) 2 or more asthma exacerbations; (2) 6 or more medium- or high-dose dispensed canisters of inhaled corticosteroid (ICS) as monotherapy or with long-acting β2-agonist; and (3) 3 or more dispensed non-ICS controllers. Health care utilization and direct costs (all-cause and asthma-related) in 2013 were compared between SUA and non-SUA subgroups using multivariable regression. RESULTS Compared with the non-SUA subgroup (N = 25,350, 97.7%), the SUA subgroup (N = 585, 2.3%) at baseline was significantly older and had more comorbidities, asthma specialist care, controller medication dispensed, and asthma exacerbations. During follow-up, patients with SUA exhibited significantly more asthma exacerbations and short-acting β2-agonist use, and higher all-cause and asthma-related costs than patients with non-SUA. The adjusted asthma-related average direct cost per patient at follow-up was significantly higher for SUA (mean ± SE) ($2325 ± $75) than non-SUA ($1261 ± $9) with an incremental cost of $1056 (95% CI, $907-$1205). Asthma drugs accounted for the major difference (incremental cost of $848/patient; 95% CI, $737-$959). CONCLUSION Increases and disparities in health care utilization and direct cost by SUA status suggest that patients with SUA require more intensive therapy, greater attention to adherence and comorbidities, more specialist care, and, possibly, personalized treatment approaches including novel biologic treatments.
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Affiliation(s)
- Robert S Zeiger
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif.
| | - Michael Schatz
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | | | - Lei Qian
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | - Wansu Chen
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | - Eunice W Ngor
- Kaiser Permanente Northern California Region, Oakland, Calif
| | | | - Aniket A Kawatkar
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
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60
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Shipe R, Burdick MD, Strieter BA, Liu L, Shim YM, Sung SS, Teague WG, Mehrad B, Strieter RM, Rose CE. Number, activation, and differentiation of circulating fibrocytes correlate with asthma severity. J Allergy Clin Immunol 2015; 137:750-7.e3. [PMID: 26371837 DOI: 10.1016/j.jaci.2015.07.037] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 06/25/2015] [Accepted: 07/08/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND A biomarker that predicts poor asthma control would be clinically useful. Fibrocytes are bone marrow-derived circulating progenitor cells that have been implicated in tissue fibrosis and T(H)2 responses in asthmatic patients. OBJECTIVE We sought to test the hypothesis that the concentration and activation state of peripheral blood fibrocytes correlates with asthma severity. METHODS By using fluorescence-activated cell sorting analysis, fibrocytes (CD45(+) and collagen 1 [Col1](+)) were enumerated and characterized in the buffy coats of fresh peripheral blood samples from 15 control subjects and 40 asthmatic patients. RESULTS Concentrations of peripheral blood total (CD45(+)Col1(+)), activated (the TGF-β transducing protein phosphorylated SMAD2/3 [p-SMAD2/3](+) or phosphorylated AKT [p-AKT](+)), and differentiated (α-smooth muscle actin [α-SMA](+)) fibrocytes were increased in asthmatic patients compared with control subjects. The increase in total and CD45(+)Col1(+)CXCR4(+) fibrocytes was primarily seen in patients with severe asthma (Global Initiative for Asthma steps 4-5) as opposed to those with milder asthma (Global Initiative for Asthma steps 1-3). In addition, numbers of circulating α-SMA(+) and α-SMA(+)CXCR4(+) fibrocytes were increased in asthmatic patients experiencing an asthma exacerbation in the preceding 12 months. A significant correlation (P < .05) was observed between CD45(+)Col1(+)CXCR4(+) fibrocytes and the activation phenotypes CD45(+)Col1(+)p-SMAD2/3(+) and CD45(+)Col1(+)p-AKT(+). CONCLUSION There was correlation between circulating fibrocyte subsets and asthma severity, and there was an increased number of activated/differentiated fibrocytes in circulating blood of asthmatic patients experiencing an exacerbation in the preceding 12 months.
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Affiliation(s)
- Ryan Shipe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Marie D Burdick
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Brett A Strieter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Ling Liu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Yun Michael Shim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Sun-sang Sung
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - W Gerald Teague
- Pulmonary Division, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Borna Mehrad
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Robert M Strieter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - C Edward Rose
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va.
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Chu PY, Sun HL, Ko JL, Ku MS, Lin LJ, Lee YT, Liao PF, Pan HH, Lu HL, Lue KH. Oral fungal immunomodulatory protein-Flammulina velutipes has influence on pulmonary inflammatory process and potential treatment for allergic airway disease: A mouse model. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 50:297-306. [PMID: 26427878 DOI: 10.1016/j.jmii.2015.07.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 06/30/2015] [Accepted: 07/23/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND/PURPOSE House dust mite (HDM) is well known as one of the major indoor allergens that trigger allergic inflammation, especially asthma, and accounts for 85% of all cases. So far, asthma has been thought of as a condition of imbalance between T helper (Th)1 and Th2. Fungal immunomodulatory protein-Flammulina velutipes (FIP-fve) has been seemingly demonstrated to modulate the response to Th1 cytokine production. The aim of this study was to investigate if the oral administration of FIP-fve can inhibit HDM-induced asthma inflammation in the mouse model. METHODS We divided the mice (female BALB/c, 4-6 weeks) into four groups: the prevention group, which consisted of mice sensitized by HDM (intraperitoneally on Day 1, Day 7, and Day 14, and intranasally on Day 14, Day 17, Day 21, Day 24, and Day 27) fed with FIP-fve from Day 1 to Day 14; the treatment group, which comprised mice that received treatment from Day 14 to Day 28; the positive control (PC, sensitized by HDM fed without FIP-fve) group; and the negative control group (NC, nonsensitized). Airway hyperresponsiveness induced by methacholine challenge was determined using whole-body barometric plethysmography. In addition, cytokines were analyzed from bronchoalveolar lavage fluid and serum. Histopathological studies and Liu's staining method in mice lungs were also performed. RESULTS The results showed that both pre- and posttreated FIP-fve groups had significantly reduced airway hyperresponsiveness compared with the PC group after methacholine challenge. In addition, a significantly decreased level of HDM-specific immunoglobulin E in serum and decreased production of Th2 cytokines in bronchoalveolar lavage fluid and serum were observed in these two FIP-fve fed groups. Moreover, more decreased amounts of infiltrating inflammatory cells were present in the lungs of FIP-fve fed groups than those of the PC group. CONCLUSION Oral FIP-fve had an anti-inflammatory effect on the acute phase of the airway inflammatory process induced by HDM in the mouse model and might have a potentially therapeutic role for allergic airway diseases.
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Affiliation(s)
- Po-Yu Chu
- Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan, ROC; Department of Pediatrics, Ministry of Health and Welfare Feng-Yuan Hospital, Taichung, Taiwan, ROC
| | - Hai-Lun Sun
- Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan, ROC; Institute of Medicine, Chung-Shan Medical University, Taichung, Taiwan, ROC
| | - Jiunn-Liang Ko
- Institute of Medicine, Chung-Shan Medical University, Taichung, Taiwan, ROC
| | - Min-Sho Ku
- Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Ling-Jun Lin
- Institute of Microbiology and Immunology, Chung-Shan Medical University, Taichung, Taiwan, ROC
| | - Yu-Tzu Lee
- Institute of Medicine, Chung-Shan Medical University, Taichung, Taiwan, ROC
| | - Pei-Fen Liao
- Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Hui-Hsien Pan
- Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Hsueh-Lin Lu
- Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Ko-Huang Lue
- Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan, ROC; Institute of Medicine, Chung-Shan Medical University, Taichung, Taiwan, ROC; School of Medicine, Chung-Shan Medical University, Taichung, Taiwan, ROC.
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Alavoine L, Taillé C, Ball J, Knauer C, Witte S, Kent J, Aubier M. Nocturnal Asthma: Proof-of-Concept Open-Label Study with Delayed-Release Prednisone. Pulm Ther 2015. [DOI: 10.1007/s41030-015-0001-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Santos BAHD, Gbary AR, Kpozehouen A, Kassa F. [Factors associated with a severe asthma in asthmatic patients followed at Pneumo-phthisiology National Hospital of Cotonou (Benin) in 2014]. Pan Afr Med J 2015; 22:11. [PMID: 26600910 PMCID: PMC4646438 DOI: 10.11604/pamj.2015.22.11.5625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 08/16/2015] [Indexed: 11/11/2022] Open
Abstract
Introduction la présente étude vise à déterminer la fréquence de l'asthme sévère chez les patients asthmatiques suivis au Centre National Hospitalier de Pneumo-Phtisiologie (CNHPP) de Cotonou et identifier les facteurs de risque qui lui sont associés Méthodes l’étude transversale, descriptive et analytique a porté sur 213 patients asthmatiques de la file active 2013 du CNHPP. Les données ont été collectées par l'exploitation des dossiers et l'entretien individuel avec les patients. Elles ont été traitées et analysées à l'aide des logiciels EPIINFO7 et STATA11. Le test Chi2 de Pearson, la régression logistique uni variée et multi variée ont été utilisés au seuil de signification de 0,05 Résultats au total, 154 patients asthmatiques soit 72,7% ont répondu au questionnaire. Parmi eux 20,8% (IC95%:(14,67; 28,05)) souffraient d'asthme sévère. L’âge des patients s’étendait de 10 à 76 ans avec une médiane de 41 ans; 51,3% étaient de sexe féminin, 79,9% avaient des antécédents d'allergie, 61,7% ont commencé leur asthme après l’âge de 12 ans et seuls 11% ont consommé ou consommaient du tabac. Les facteurs associés à la survenue de l'asthme sévère étaient: l’âge de 46 à 55 ans (p = 0,04); les troisième et quatrième quintiles du bien-être économique (p = 0,01) et le début de l'asthme après l’âge de 12 ans (p < 0,001) Conclusion l’étude a montré une fréquence élevée de l'asthme sévère au Bénin et permettra d'améliorer sa prise en charge au CNHPP.
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Doberer D, Trejo Bittar HE, Wenzel SE. Should lung biopsies be performed in patients with severe asthma? Eur Respir Rev 2015; 24:525-39. [PMID: 26324815 PMCID: PMC9487699 DOI: 10.1183/16000617.0045-2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Asthma, and severe asthma, in particular, is increasingly recognised as a heterogeneous disease. Identifying these different phenotypes of asthma and assigning patients to phenotype-specific treatments is one of the current conundrums in respiratory medicine. Any diagnostic procedure in severe asthma (or any disease) should have two aims: 1) better understanding or identifying the diagnosis, and 2) providing information on the heterogeneity of asthma phenotypes to guide therapy with the objective of improving outcomes. Lung biopsies can target the large and small airways as well as the lung parenchyma. All compartments are affected in severe asthma; however, knowledge on the distal lung is limited. At this point, it remains uncertain whether lung specimens routinely add diagnostic information that is unable to be obtained otherwise. Indeed, whether a lung biopsy is indicated in the workup of a patient with severe asthma remains an individual decision. It is hoped this review will support rational decision-making and provide a detailed synopsis of the varied histopathological features seen in biopsies of patients with a diagnosis of severe asthma. Due to limited data on this topic this review is primarily based on opinion with recommendations arising primarily from the personal experience of the authors.
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Affiliation(s)
- Daniel Doberer
- University of Pittsburgh Asthma Institute at UPMC, Pittsburgh, PA, USA,Dept of Internal and Pulmonary Medicine, Wilhelminenspital Wien, Medical University of Vienna, Vienna, Austria,Daniel Doberer, Dept of Internal and Pulmonary Medicine, Wilhelminenspital, Montleartstrasse 37, 1160 Vienna, Austria. E-mail:
| | | | - Sally E. Wenzel
- University of Pittsburgh Asthma Institute at UPMC, Pittsburgh, PA, USA
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Abstract
The Global Initiative for Asthma (GINA) was established in 1993 by the World Health Organization and National Heart Lung and Blood Institute to develop a global strategy for managing and preventing asthma. GINA reports, now funded independently through the sale of GINA products, have provided the foundation for many national guidelines. They are prepared by international experts from primary, secondary and tertiary care, and are annually updated following a review of evidence. In 2014, a major revision of the GINA report was published, that took into account advances in evidence not only about asthma and its treatment, but also about how to improve implementation of evidence-based recommendations in clinical practice. This paper summarises key changes relevant to primary care in the new GINA report. A noticeable difference is the report’s radically different approach, now clinically-focussed, with multiple practical tools and flow charts to improve its utility for busy frontline clinicians. Key changes in recommendations include a new, diagnosis-centred definition of asthma; more detail about how to assess current symptom control and future risk; a comprehensive approach to tailoring treatment for individual patients; expanded indications for commencing inhaled corticosteroids; new recommendations for written asthma action plans; a new chapter on diagnosis and initial treatment of patients with asthma–COPD overlap syndrome; and a revised approach to diagnosing asthma in preschool children. The 2014 GINA report (further updated in 2015) moved away from a ‘textbook’ approach to provide clinicians with up-to-date evidence about strategies to control symptoms and minimise asthma risk, in a practical, practice-centred format.
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Prins LCJ, van Son MJM, van Keimpema ARJ, van Ranst D, Pommer A, Meijer JWG, Pop VJM. Psychopathology in difficult asthma. J Asthma 2015; 52:587-92. [PMID: 25539025 DOI: 10.3109/02770903.2014.999281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Within the asthma population, difficult asthma (DA) is a severe condition in which patients present with frequent exacerbations, hospitalizations and emergency room visits. The identification and treatment of psychopathology is included in the management of DA. Psychopathology is supposed to predispose patients to DA or vice versa; psychopathology may develop as a consequence of DA. We reviewed the available literature on empirical findings regarding psychopathology in adult patients with DA. METHODS Studies in English language journals using MEDLINE, Cochrane and PsycINFO databases, were retrieved by an electronic search published from 1990 till July 2014. RESULTS Literature on psychopathology in DA is scarce. The search identified 16 articles of which only 6 articles were specifically about psychopathology in adult patients with DA. Almost half of the patients with DA had evidence of psychopathology at both syndrome and symptom level. Moreover, psychopathology appeared to be related to frequent exacerbations in patients with DA. CONCLUSIONS This literature review suggests a high prevalence of psychopathology of patients with DA, although it remains unclear whether psychopathology occurs more often in DA compared to "stable asthma". More research is needed on a possible role of psychopathology on clinical signs and symptoms in DA.
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Teodorescu M, Broytman O, Curran-Everett D, Sorkness RL, Crisafi G, Bleecker ER, Erzurum S, Gaston BM, Wenzel SE, Jarjour NN. Obstructive Sleep Apnea Risk, Asthma Burden, and Lower Airway Inflammation in Adults in the Severe Asthma Research Program (SARP) II. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:566-75.e1. [PMID: 26004304 DOI: 10.1016/j.jaip.2015.04.002] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 03/04/2015] [Accepted: 04/02/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) may worsen asthma, but large studies are lacking and the underlying mechanisms are unknown. OBJECTIVE The objective of this study was to determine the prevalence of OSA risk among patients with asthma of different severity compared with normal controls (NC), and among asthmatics, to test the relationship of OSA risk with asthma burden and airway inflammation. METHODS Subjects with severe (SA, n = 94) and nonsevere asthma (NSA, n = 161), and NC (n = 146) were recruited in an add-on substudy, to the observational Severe Asthma Research Program (SARP) II; subjects completed sleep quality, sleepiness and OSA risk (Sleep Apnea scale of the Sleep Disorders Questionnaire [SA-SDQ]) questionnaires, and clinical assessments. Sputum was induced in a subset of asthmatics. RESULTS Relative to NC, despite similar sleep duration, the subjects with SA and NSA had worse sleep quality, were sleepier, and had higher SA-SDQ scores. Among asthmatics, higher SA-SDQ was associated with increased asthma symptoms, β-agonist use, health care utilization, and worse asthma quality of life. A significant association of SA-SDQ with sputum polymorphonuclear cells% was noted: each increase in SA-SDQ by its standard deviation (6.85 units) was associated with a rise in % sputum neutrophils of 7.78 (95% CI 2.33-13.22, P = .0006), independent of obesity and other confounders. CONCLUSIONS OSA symptoms are more prevalent among asthmatics, in whom they are associated with higher disease burden. OSA risk is associated with a neutrophilic airway inflammation in asthma, which suggests that OSA may be an important contributor to the neutrophilic asthma. Further studies are necessary to confirm these findings and better understand the mechanistic underpinnings of this relationship.
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Affiliation(s)
- Mihaela Teodorescu
- James B. Skatrud Pulmonary/Sleep Research Laboratory, Medical Service, William S. Middleton Memorial Veterans Hospital, Madison, Wis; Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Center for Sleep Medicine and Sleep Research/Wisconsin Sleep, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Oleg Broytman
- James B. Skatrud Pulmonary/Sleep Research Laboratory, Medical Service, William S. Middleton Memorial Veterans Hospital, Madison, Wis; Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Douglas Curran-Everett
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colo; Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Denver, Colo
| | - Ronald L Sorkness
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Gina Crisafi
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Eugene R Bleecker
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Serpil Erzurum
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin M Gaston
- Division of Respiratory Medicine, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Sally E Wenzel
- Asthma Institute, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Nizar N Jarjour
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Guilbert TW, Bacharier LB, Fitzpatrick AM. Severe asthma in children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 2:489-500. [PMID: 25213041 DOI: 10.1016/j.jaip.2014.06.022] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/27/2014] [Accepted: 06/30/2014] [Indexed: 11/19/2022]
Abstract
Severe asthma in children is characterized by sustained symptoms despite treatment with high doses of inhaled corticosteroids or oral corticosteroids. Children with severe asthma may fall into 2 categories, difficult-to-treat asthma or severe therapy-resistant asthma. Difficult-to-treat asthma is defined as poor control due to an incorrect diagnosis or comorbidities, or poor adherence due to adverse psychological or environmental factors. In contrast, treatment resistant is defined as difficult asthma despite management of these factors. It is increasingly recognized that severe asthma is a highly heterogeneous disorder associated with a number of clinical and inflammatory phenotypes that have been described in children with severe asthma. Guideline-based drug therapy of severe childhood asthma is based primarily on extrapolated data from adult studies. The recommendation is that children with severe asthma be treated with higher-dose inhaled or oral corticosteroids combined with long-acting β-agonists and other add-on therapies, such as antileukotrienes and methylxanthines. It is important to identify and address the influences that make asthma difficult to control, including reviewing the diagnosis and removing causal or aggravating factors. Better definition of the phenotypes and better targeting of therapy based upon individual patient phenotypes is likely to improve asthma treatment in the future.
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Affiliation(s)
- Theresa W Guilbert
- Division of Pulmonology Medicine, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Anne M Fitzpatrick
- Division of Pulmonary, Allergy & Immunology, Cystic Fibrosis, and Sleep, Department of Pediatrics, Emory University, Atlanta, Ga
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Cibella F, Bruno A, Cuttitta G, Bucchieri S, Melis MR, De Cantis S, La Grutta S, Viegi G. An elevated body mass index increases lung volume but reduces airflow in Italian schoolchildren. PLoS One 2015; 10:e0127154. [PMID: 25970463 PMCID: PMC4430514 DOI: 10.1371/journal.pone.0127154] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 04/12/2015] [Indexed: 01/17/2023] Open
Abstract
Background Asthma and obesity are important and growing health issues worldwide. Obesity is considered a risk factor for asthma, due to the induction of changes in airway mechanics and altered airway inflammation. Methods We cross-sectionally investigated the effect of increased weight on pulmonary function in a large population sample of healthy children, aged 10–17 yrs living in Palermo, Italy. Explanatory effect of weight on lung function variables were evaluated by multiple linear regression models, taking into account height, gender, and age-class. Results Among the 2,393 subjects, FVC and FEV1 were positively correlated to weight. Multiple regression models showed that the weight beta coefficient for FEV1 was significantly lower with respect to that for FVC (0.005 and 0.009 l/kg, respectively), indicating a different magnitude in explanatory effect of weight on FVC and FEV1. Both FEV1/FVC and FEF25–75%/FVC ratios were negatively correlated to weight, while FEF25–75% was not significantly correlated. Similar results were obtained also when 807 symptomatic subjects were introduced in the model through a sensitivity analysis. Conclusion In healthy children, the disproportionate increase of FEV1 and FVC with weight produces airflow decrease and consequently apparent poorer lung function independently from respiratory disease status.
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Affiliation(s)
- Fabio Cibella
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
- * E-mail:
| | - Andreina Bruno
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Giuseppina Cuttitta
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Salvatore Bucchieri
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Mario Raphael Melis
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Stefano De Cantis
- Department of Economics, Statistics, and Business Sciences—University of Palermo, Palermo, Italy
| | - Stefania La Grutta
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Giovanni Viegi
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
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Zedan MM, Laimon WN, Osman AM, Zedan MM. Clinical asthma phenotyping: A trial for bridging gaps in asthma management. World J Clin Pediatr 2015; 4:13-18. [PMID: 26015875 PMCID: PMC4438436 DOI: 10.5409/wjcp.v4.i2.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/19/2015] [Accepted: 04/20/2015] [Indexed: 02/06/2023] Open
Abstract
Asthma is a common disease affecting millions of people worldwide and exerting an enormous strain on health resources in many countries. Evidence is increasing that asthma is unlikely to be a single disease but rather a series of complex, overlapping individual diseases or phenotypes, each defined by its unique interaction between genetic and environmental factors. Asthma phenotypes were initially focused on combinations of clinical characteristics, but they are now evolving to link pathophysiological mechanism to subtypes of asthma. Better characterization of those phenotypes is expected to be most useful for allocating asthma therapies. This article reviews different published researches in terms of unbiased approaches to phenotype asthma and emphasizes how the phenotyping exercise is an important step towards proper asthma treatment. It is structured into three sections; the heterogeneity of asthma, the impact of asthma heterogeneity on asthma management and different trials for phenotyping asthma.
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Liu B, Lee JB, Chen CY, Hershey GKK, Wang YH. Collaborative interactions between type 2 innate lymphoid cells and antigen-specific CD4+ Th2 cells exacerbate murine allergic airway diseases with prominent eosinophilia. THE JOURNAL OF IMMUNOLOGY 2015; 194:3583-93. [PMID: 25780046 DOI: 10.4049/jimmunol.1400951] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 02/16/2015] [Indexed: 01/21/2023]
Abstract
Type-2 innate lymphoid cells (ILC2s) and the acquired CD4(+) Th2 and Th17 cells contribute to the pathogenesis of experimental asthma; however, their roles in Ag-driven exacerbation of chronic murine allergic airway diseases remain elusive. In this study, we report that repeated intranasal rechallenges with only OVA Ag were sufficient to trigger airway hyperresponsiveness, prominent eosinophilic inflammation, and significantly increased serum OVA-specific IgG1 and IgE in rested mice that previously developed murine allergic airway diseases. The recall response to repeated OVA inoculation preferentially triggered a further increase of lung OVA-specific CD4(+) Th2 cells, whereas CD4(+) Th17 and ILC2 cell numbers remained constant. Furthermore, the acquired CD4(+) Th17 cells in Stat6(-/-)/IL-17-GFP mice, or innate ILC2s in CD4(+) T cell-ablated mice, failed to mount an allergic recall response to OVA Ag. After repeated OVA rechallenge or CD4(+) T cell ablation, the increase or loss of CD4(+) Th2 cells resulted in an enhanced or reduced IL-13 production by lung ILC2s in response to IL-25 and IL-33 stimulation, respectively. In return, ILC2s enhanced Ag-mediated proliferation of cocultured CD4(+) Th2 cells and their cytokine production, and promoted eosinophilic airway inflammation and goblet cell hyperplasia driven by adoptively transferred Ag-specific CD4(+) Th2 cells. Thus, these results suggest that an allergic recall response to recurring Ag exposures preferentially triggers an increase of Ag-specific CD4(+) Th2 cells, which facilitates the collaborative interactions between acquired CD4(+) Th2 cells and innate ILC2s to drive the exacerbation of a murine allergic airway diseases with an eosinophilic phenotype.
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Affiliation(s)
- Bo Liu
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45220
| | - Jee-Boong Lee
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45220
| | - Chun-Yu Chen
- Division of Hematology, Oncology, and Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH 43205; and
| | - Gurjit K Khurana Hershey
- Division of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45220
| | - Yui-Hsi Wang
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45220;
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Alagha K, Jarjour B, Bommart S, Aviles B, Varrin M, Gamez AS, Molinari N, Vachier I, Paganin F, Chanez P, Bourdin A. Persistent severe hypereosinophilic asthma is not associated with airway remodeling. Respir Med 2015; 109:180-7. [PMID: 25592243 DOI: 10.1016/j.rmed.2014.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 11/17/2014] [Accepted: 12/23/2014] [Indexed: 12/12/2022]
Abstract
Hypereosinophilic asthma (HEA) is considered as a specific severe asthma phenotype. Whether eosinophils have a link with airway remodeling characterized by pathological (thickening of the basement membrane), functional (persistent airflow impairment and decline in lung function) and imaging features (increase airway wall thickness at CT scan) is still debated. In a one year prospective cohort of 142 severe asthma patients (according to IMI), 14 persistent HEA patients (defined by a persistent blood eosinophilia >500/mm(3) at two consecutive visits) were identified and compared with ten patients without any blood eosinophilia during the follow-up period (NEA, blood eosinophilia always <500/mm(3)). Airflow and lung volumes were recorded. Bronchial biopsies obtained at enrollment were stained for eosinophils (EG2) and basement membrane thickness (BM) was quantified. Imaging by CT scan acquisition was standardized and bronchial abnormalities quantified. ACQ score and exacerbations were prospectively recorded. HEA was not associated with preeminent features of airway remodeling assessed by airflow impairment (Best ever FEV1 values 97% ± 20 in HEA vs. 80 ± 24% in NEA, p = 0.020), decline of FEV1 (FEV1 Decline 40 ± 235 ml/y in HEA vs. 19 ± 40 ml/y in NEA, P = 0.319), submucosal abnormalities (BM thickness 7.80 ± 2.66 μm in HEA vs. 6.84 ± 2.59 in NEA, p = 0.37) and airway wall thickening at CT-scan (0.250 ± 0.036 mm vs. 0.261 ± 0.043, p = 0.92). Eosinophils blood count was inversely correlated with semiquantitative imaging score (rho -0.373, p = 0.039). Smoking history and positive skin prick tests were independent risk factors for increased BM thickening. Outcomes were similar in both populations (Control and exacerbations). Persistent HEA is not associated with evidences of airway remodeling.
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Affiliation(s)
- Khuder Alagha
- Department of Respiratory Disease, APHM, Marseille, France
| | - Baihas Jarjour
- Department of Respiratory Disease, CHU Montpellier, Montpellier, France
| | - Sebastien Bommart
- Department of Radiology, CHU Montpellier, Montpellier, France; INSERM U1046, Université Montpellier I et II, Montpellier, France
| | - Berta Aviles
- Department of Respiratory Disease, Palamos, Spain
| | - Muriel Varrin
- Department of Biostatistics, CHU Montpellier, Montpellier, France
| | - Anne Sophie Gamez
- Department of Respiratory Disease, CHU Montpellier, Montpellier, France
| | - Nicolas Molinari
- Department of Biostatistics, CHU Montpellier, Montpellier, France
| | - Isabelle Vachier
- Department of Respiratory Disease, CHU Montpellier, Montpellier, France
| | - Fabrice Paganin
- Department of Respiratory Disease, GHSR, Saint Pierre de La Réunion, France; INSERM UMR, Université Aix Marseille, France
| | - Pascal Chanez
- Department of Respiratory Disease, APHM, Marseille, France; INSERM UMR, Université Aix Marseille, France
| | - Arnaud Bourdin
- Department of Respiratory Disease, CHU Montpellier, Montpellier, France; INSERM U1046, Université Montpellier I et II, Montpellier, France.
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73
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Rynko AE, Fryer AD, Jacoby DB. Interleukin-1β mediates virus-induced m2 muscarinic receptor dysfunction and airway hyperreactivity. Am J Respir Cell Mol Biol 2014; 51:494-501. [PMID: 24735073 DOI: 10.1165/rcmb.2014-0009oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Respiratory viral infections are associated with the majority of asthma attacks. Inhibitory M2 receptors on parasympathetic nerves, which normally limit acetylcholine (ACh) release, are dysfunctional after respiratory viral infection. Because IL-1β is up-regulated during respiratory viral infections, we investigated whether IL-1β mediates M2 receptor dysfunction during parainfluenza virus infection. Virus-infected guinea pigs were pretreated with the IL-1β antagonist anakinra. In the absence of anakinra, viral infection increased bronchoconstriction in response to vagal stimulation but not to intravenous ACh, and neuronal M2 muscarinic receptors were dysfunctional. Pretreatment with anakinra prevented virus-induced increased bronchoconstriction and M2 receptor dysfunction. Anakinra did not change smooth muscle M3 muscarinic receptor response to ACh, lung viral loads, or blood and bronchoalveolar lavage leukocyte populations. Respiratory virus infection decreased M2 receptor mRNA expression in parasympathetic ganglia extracted from infected animals, and this was prevented by blocking IL-1β or TNF-α. Treatment of SK-N-SH neuroblastoma cells or primary cultures of guinea pig parasympathetic neurons with IL-1β directly decreased M2 receptor mRNA, and this was not synergistic with TNF-α treatment. Treating guinea pig trachea segment with TNF-α or IL-1β in vitro increased tracheal contractions in response to activation of airway nerves by electrical field stimulation. Blocking IL-1β during TNF-α treatment prevented this hyperresponsiveness. These data show that virus-induced hyperreactivity and M2 dysfunction involves IL-1β and TNF-α, likely in sequence with TNF-α causing production of IL-1β.
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Affiliation(s)
- Abby E Rynko
- 1 Department of Molecular Microbiology and Immunology, and
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74
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Wu CT, Chen PJ, Lee YT, Ko JL, Lue KH. Effects of immunomodulatory supplementation with Lactobacillus rhamnosus on airway inflammation in a mouse asthma model. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 49:625-635. [PMID: 25440975 DOI: 10.1016/j.jmii.2014.08.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 07/15/2014] [Accepted: 08/07/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Asthma is a common allergic disease. In previous studies, probiotics improved the balance of intestinal microbes, reduced inflammation, and promoted mucosal tolerance. This study investigated whether oral administrations of Lactobacillus rhamnosus GG (LGG) inhibited allergen (ovalbumin or OVA)-induced airway inflammation in a mouse asthma model. METHODS The allergy/asthma animal model in this study was sensitization with OVA. After intranasal challenge with OVA, the airway inflammation and hyper-responsiveness were determined by a Buxco system, bronchoalveolar lavage fluid analysis with Liu stain, and enzyme-linked immunosorbent assay. Histopathologic changes in the lung were detected by hematoxylin and eosin staining and immunohistochemistry staining. RESULTS Both pre- and post-treatment with LGG suppressed the airway hyper-responsiveness to methacholine and significantly decreased the number of infiltrating inflammatory cells and Th2 cytokines in bronchoalveolar lavage fluid and serum compared with the OVA-sensitized mice. In addition, LGG reduced OVA-specific IgE levels in serum. Oral LGG decreased matrix metalloproteinase 9 expression in lung tissue and inhibited inflammatory cell infiltration. CONCLUSION LGG had an anti-inflammatory effect on OVA-induced airway inflammation and might be an additional or supplementary therapy for allergic airway diseases.
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Affiliation(s)
- Chia-Ta Wu
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Peng-Jung Chen
- School of Public Health, Chung Shan Medical University, Taichung, Taiwan
| | - Yu-Tzu Lee
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Jiunn-Liang Ko
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ko-Haung Lue
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan.
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75
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Oreo KM, Gibson PG, Simpson JL, Wood LG, McDonald VM, Baines KJ. Sputum ADAM8 expression is increased in severe asthma and COPD. Clin Exp Allergy 2014; 44:342-52. [PMID: 24147597 DOI: 10.1111/cea.12223] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/02/2013] [Accepted: 10/07/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Severe asthma and chronic obstructive pulmonary disease (COPD) are chronic inflammatory airway diseases in which the mechanisms are not fully understood. A disintegrin and metalloproteinase domain 8 (ADAM8) is an enzyme expressed on most leucocytes and may be important for facilitating leucocyte migration in respiratory disease. OBJECTIVE To investigate ADAM8 mRNA and protein expression in asthma and COPD and its relationship between asthma severity and inflammatory phenotypes. METHODS Induced sputum was collected from 113 subjects with asthma (severe n = 31, uncontrolled n = 39 and controlled n = 35), 20 subjects with COPD and 21 healthy controls. Sputum ADAM8 mRNA expression was measured by qPCR, and soluble ADAM8 (sADAM8) protein was measured in the sputum supernatant by validated ELISA. RESULTS ADAM8 mRNA correlated with ADAM8 protein levels (r = 0.27, P < 0.01). ADAM8 mRNA (P = 0.004) and sADAM8 protein (P = 0.014) levels were significantly higher in both asthma and COPD compared with healthy controls. ADAM8 mRNA (P = 0.035) and sADAM8 protein (P = 0.002) levels were significantly higher in severe asthma compared with controlled asthma. Total inflammatory cell count (P < 0.01) and neutrophils (P < 0.01) were also elevated in severe asthmatic sputum. Although ADAM8 mRNA was significantly higher in eosinophilic and neutrophilic asthma (P < 0.001), sADAM8 did not differ between asthma inflammatory phenotypes. ADAM8 expression positively correlated with sputum total cell count and sputum neutrophils. CONCLUSIONS AND CLINICAL RELEVANCE ADAM8 expression is increased in both severe asthma and COPD and associated with sputum total cell count and neutrophils. ADAM8 may facilitate neutrophil migration to the airways in severe asthma and COPD.
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Affiliation(s)
- K M Oreo
- Virus Infections/Immunity Vaccines & Asthma, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; Priority Research Centre for Asthma and Respiratory Diseases, The University of Newcastle, Callaghan, NSW, Australia; Severe Asthma Network, Woolcock Institute of Medical Research, Glebe, NSW, Australia; The University of Sydney, Camperdown/Darlington, NSW, Australia
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Hantera M, Abd El-Hafiz H, Abdelnaby AY. Serum levels of angiopoietin-2 and vascular endothelial growth factor in severe refractory asthma. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Ortega HG, Liu MC, Pavord ID, Brusselle GG, FitzGerald JM, Chetta A, Humbert M, Katz LE, Keene ON, Yancey SW, Chanez P. Mepolizumab treatment in patients with severe eosinophilic asthma. N Engl J Med 2014; 371:1198-207. [PMID: 25199059 DOI: 10.1056/nejmoa1403290] [Citation(s) in RCA: 1507] [Impact Index Per Article: 150.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Some patients with severe asthma have frequent exacerbations associated with persistent eosinophilic inflammation despite continuous treatment with high-dose inhaled glucocorticoids with or without oral glucocorticoids. METHODS In this randomized, double-blind, double-dummy study, we assigned 576 patients with recurrent asthma exacerbations and evidence of eosinophilic inflammation despite high doses of inhaled glucocorticoids to one of three study groups. Patients were assigned to receive mepolizumab, a humanized monoclonal antibody against interleukin-5, which was administered as either a 75-mg intravenous dose or a 100-mg subcutaneous dose, or placebo every 4 weeks for 32 weeks. The primary outcome was the rate of exacerbations. Other outcomes included the forced expiratory volume in 1 second (FEV1) and scores on the St. George's Respiratory Questionnaire (SGRQ) and the 5-item Asthma Control Questionnaire (ACQ-5). Safety was also assessed. RESULTS The rate of exacerbations was reduced by 47% (95% confidence interval [CI], 29 to 61) among patients receiving intravenous mepolizumab and by 53% (95% CI, 37 to 65) among those receiving subcutaneous mepolizumab, as compared with those receiving placebo (P<0.001 for both comparisons). Exacerbations necessitating an emergency department visit or hospitalization were reduced by 32% in the group receiving intravenous mepolizumab and by 61% in the group receiving subcutaneous mepolizumab. At week 32, the mean increase from baseline in FEV1 was 100 ml greater in patients receiving intravenous mepolizumab than in those receiving placebo (P=0.02) and 98 ml greater in patients receiving subcutaneous mepolizumab than in those receiving placebo (P=0.03). The improvement from baseline in the SGRQ score was 6.4 points and 7.0 points greater in the intravenous and subcutaneous mepolizumab groups, respectively, than in the placebo group (minimal clinically important change, 4 points), and the improvement in the ACQ-5 score was 0.42 points and 0.44 points greater in the two mepolizumab groups, respectively, than in the placebo group (minimal clinically important change, 0.5 points) (P<0.001 for all comparisons). The safety profile of mepolizumab was similar to that of placebo. CONCLUSIONS Mepolizumab administered either intravenously or subcutaneously significantly reduced asthma exacerbations and was associated with improvements in markers of asthma control. (Funded by GlaxoSmithKline; MENSA ClinicalTrials.gov number, NCT01691521.).
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Affiliation(s)
- Hector G Ortega
- From the Respiratory Therapeutic Area Unit, GlaxoSmithKline, Research Triangle Park, NC (H.G.O., L.E.K., S.W.Y.); Johns Hopkins Asthma and Allergy Center, Baltimore (M.C.L.); Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.), and Clinical Statistics, GlaxoSmithKline, Stockley Park, Middlesex (O.N.K.) - both in the United Kingdom; the Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium (G.G.B.); the Lung Centre, Institute for Heart and Lung Health, Vancouver, BC, Canada (J.M.F.); the Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy (A.C.); and Assistance Publique-Hôpitaux de Paris, Département Hospitalo-Universitaire Thorax Innovation, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, and INSERM Unité Mixte de Recherche 999, Le Kremlin-Bicêtre (M.H.), and Unités Mixtes de Recherche INSERM Unité 1067 Centre Nationale de la Recherche Scientifique 7733, Aix-Marseille Université, Department of Respiratory Diseases and Clinical Investigation Center, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille (P.C.) - both in France
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Abstract
The National Heart, Lung, and Blood Institute has sponsored several asthma clinical networks, but the Severe Asthma Research Program (SARP) is unique, because it is not a clinical trials network, and it includes both adults and children. Investigators in SARP have comprehensively characterized 1,644 patients with asthma over the past 10 years, including 583 individuals with severe asthma and 300 children below the age of 18 years. The diversity in clinical characteristics, physiologic measures, and biomarkers in a large number of subjects across the ages provides an ideal cohort in which to investigate asthma heterogeneity. Using both biased and unbiased approaches, multiple asthma phenotypes have been described in SARP. These phenotypic analyses have improved our understanding of heterogeneity in asthma, and may provide a starting point to transform clinical practice through the evidence-based classification of disease severity. Although these new phenotypes strive to make order out of a heterogeneous group of patients, they are limited by that heterogeneity. There may be large groups of patients, especially those with milder asthma, that can be grouped into a clinical phenotype to guide therapy, but there will always be patients on the "edge" of a phenotype who will not fit into these groupings. In the SARP cluster analysis, subjects on the "edge" of a phenotype frequently had lung function that was better or worse than other subjects in the same cluster, despite similar clinical characteristics. This suggests that different pathophysiologic mechanisms may be responsible for decrements in lung function in some subjects. This is extremely important for subjects with severe asthma who may be on the "edge" of two phenotypes that may be driven by different pathobiologic mechanisms that warrant different therapeutic approaches.
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von Bülow A, Kriegbaum M, Backer V, Porsbjerg C. The prevalence of severe asthma and low asthma control among Danish adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:759-67. [PMID: 25439368 DOI: 10.1016/j.jaip.2014.05.005] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 05/03/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The prevalence of severe asthma is unknown. However, international expert statements estimate that severe asthma represents 5% to 10 % of the entire asthma population. OBJECTIVE Based on register data from a nationwide population, we wanted to investigate the prevalence of severe asthma, the extent of asthma control, and contact with specialist care. METHODS A descriptive cross-sectional register study was performed. By using a nationwide prescription database, we identified current patients with asthma (age, 18-44 years) in 2010. Severity was classified as severe versus mild-moderate asthma according to the level of antiasthma treatment. We investigated prescription drug use, hospitalizations, emergency department visits, and outpatient clinic visits according to severity. RESULTS Among a nationwide population, we identified 61,583 current patients with asthma. Based on the level of antiasthma treatment, 8.1% of identified patients was classified as having severe asthma. Low asthma control (dispensed prescriptions of prednisolone, emergency department visits, hospitalization, or excessive short-acting β₂-agonist use) was more frequent in subjects with severe asthma (36.4% vs 25.2%, P < .0001); 63.8% with severe asthma and low asthma control were not managed by specialist care. Patients with severe asthma with specialist contact more frequently had impaired asthma control compared with subjects not treated by a specialist (44.4% vs 33.1%, P < .0001). CONCLUSION Based on the level of treatment, 8.1% of a nationwide population of current patients with asthma was classified as having severe asthma. Low asthma control was more frequent among subjects with severe asthma, and only a minority had access to specialist care. There is room for optimizing asthma management, particularly among patients with severe disease.
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Affiliation(s)
- Anna von Bülow
- Respiratory Research Unit, Department of Respiratory Medicine L, Bispebjerg Hospital, Copenhagen, Denmark.
| | - Margit Kriegbaum
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Backer
- Respiratory Research Unit, Department of Respiratory Medicine L, Bispebjerg Hospital, Copenhagen, Denmark
| | - Celeste Porsbjerg
- Respiratory Research Unit, Department of Respiratory Medicine L, Bispebjerg Hospital, Copenhagen, Denmark
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Bourdin A, Molinari N, Vachier I, Varrin M, Marin G, Gamez AS, Paganin F, Chanez P. Prognostic value of cluster analysis of severe asthma phenotypes. J Allergy Clin Immunol 2014; 134:1043-50. [PMID: 24985405 DOI: 10.1016/j.jaci.2014.04.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/27/2014] [Accepted: 04/01/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cross-sectional severe asthma cluster analysis identified different phenotypes. We tested the hypothesis that these clusters will follow different courses. OBJECTIVE We aimed to identify which asthma outcomes are specific and coherently associated with these different phenotypes in a prospective longitudinal cohort. METHODS In a longitudinal cohort of 112 patients with severe asthma, the 5 Severe Asthma Research Program (SARP) clusters were identified by means of algorithm application. Because patients of the present cohort all had severe asthma compared with the SARP cohort, homemade clusters were identified and also tested. At the subsequent visit, we investigated several outcomes related to asthma control at 1 year (6-item Asthma Control Questionnaire [ACQ-6], lung function, and medication requirement) and then recorded the 3-year exacerbations rate and time to first exacerbation. RESULTS The SARP algorithm discriminated the 5 clusters at entry for age, asthma duration, lung function, blood eosinophil measurement, ACQ-6 scores, and diabetes comorbidity. Four homemade clusters were mostly segregated by best ever achieved FEV1 values and discriminated the groups by a few clinical characteristics. Nonetheless, all these clusters shared similar asthma outcomes related to asthma control as follows. The ACQ-6 score did not change in any cluster. Exacerbation rate and time to first exacerbation were similar, as were treatment requirements. CONCLUSION Severe asthma phenotypes identified by using a previously reported cluster analysis or newly homemade clusters do not behave differently concerning asthma control-related outcomes, which are used to assess the response to innovative therapies. This study demonstrates a potential limitation of the cluster analysis approach in the field of severe asthma.
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Affiliation(s)
- Arnaud Bourdin
- Department of Respiratory Diseases, Montpellier, France; INSERM U1046, Hôpital Arnaud de Villeneuve, Université Montpellier I et 2, Montpellier, France.
| | - Nicolas Molinari
- INSERM U1046, Hôpital Arnaud de Villeneuve, Université Montpellier I et 2, Montpellier, France; Service DIM, MISTEA, CHU Montpellier, Montpellier, France
| | | | - Muriel Varrin
- Service DIM, MISTEA, CHU Montpellier, Montpellier, France
| | - Grégory Marin
- Department of Respiratory Diseases, Montpellier, France; Service DIM, MISTEA, CHU Montpellier, Montpellier, France
| | | | - Fabrice Paganin
- Department of Respiratory Diseases, Groupe Hospitalier Sud Reunion, Saint Pierre de La Réunion, France
| | - Pascal Chanez
- Département des Maladies Respiratoires, AP-HM, UMR7733, Aix-Marseille Université, Marseille, France; Laboratoire INSERM CNRS U 1067, UMR7733, Aix-Marseille Université, Marseille, France
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Oral administration of heat-inactivated Lactobacillus plantarum K37 modulated airway hyperresponsiveness in ovalbumin-sensitized BALB/c mice. PLoS One 2014; 9:e100105. [PMID: 24936861 PMCID: PMC4061068 DOI: 10.1371/journal.pone.0100105] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 05/21/2014] [Indexed: 11/30/2022] Open
Abstract
This study aimed to investigate the anti-allergic effects of Lactobacillus plantarum K37 (K37) on airway hyperresponsiveness (AHR) and systemic allergic responses in ovalbumin (OVA)-sensitized and -challenged BALB/c mice. Heat-inactivated K37 (105, 107, and 109 CFU/mouse, day) were orally administered to OVA-sensitized BALB/c mice to investigate their effects on AHR, immunoglobulin (Ig) and cytokine production. The results showed that K37 dose-dependently lowered the serum levels of IgE, OVA-specific IgE and OVA-specific IgG1, ameliorated AHR induced by methacholine and suppressed eosinophil infiltration in bronchoalveolar lavage fluid (BALF). The cytokine production in spleen cells culture and BALF showed that K37 drove the immune responses toward T-helper cell type 1 (Th1) responses, elevated levels of IL-2 and IFN-γ, and reduced of IL-4, IL-5 and IL-13. K37 also improved cell infiltration in lung sections. Our results demonstrated that oral administration of K37 alleviated effectively the allergic responses invivo. Thus, K37 can be a good source material and a promising candidate for prophylactic and therapeutic treatments of allergic diseases, like asthma.
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Lindén A, Dahlén B. Interleukin-17 cytokine signalling in patients with asthma. Eur Respir J 2014; 44:1319-31. [PMID: 24925921 DOI: 10.1183/09031936.00002314] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Asthma remains a global health problem and, therefore, more effective pharmacotherapy is needed. This is particularly true for chronic and severe asthma. In these clinical phenotypes, chronic inflammation involving neutrophils is likely to play a pathogenic role, making it interesting to target cytokine signalling involved in the accumulation of neutrophils. Therefore, it is of interest that the archetype T-helper 17 cell cytokine interleukin (IL)-17A, perhaps also IL-17F, controls neutrophil accumulation, mucus secretion, macrophage mobilisation and smooth muscle reactivity in various experimental airway models. However, much less is known about the involvement of signalling via IL-17 cytokines in humans with asthma. Existing evidence suggests that these cytokines are released from several types of immune cells in asthma and, for IL-17A, there is a local increase associated with disease severity, with the mobilisation of neutrophils and smooth muscle cells locally in the airways. Even though the causative role of IL-17 cytokines remains unclear, there is potential for clinical utility in targeting IL-17A specifically in patients with moderate-to-severe asthma and high reversibility. There is a need for new and well-powered clinical investigations of signalling via IL-17 cytokines in this clinical phenotype.
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Affiliation(s)
- Anders Lindén
- Unit for Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden Lung Allergy Clinic, Dept of Medicine at Karolinska University Hospital, Stockholm, Sweden
| | - Barbro Dahlén
- Lung Allergy Clinic, Dept of Medicine at Karolinska University Hospital, Stockholm, Sweden
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Lung function decline and variable airway inflammatory pattern: longitudinal analysis of severe asthma. J Allergy Clin Immunol 2014; 134:287-94. [PMID: 24928647 DOI: 10.1016/j.jaci.2014.04.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 04/09/2014] [Accepted: 04/11/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Eosinophilic airway inflammation measured by using induced sputum is an important treatment stratification tool in patients with severe asthma. In addition, sputum eosinophilia has been shown to be associated with severe exacerbations and airflow limitation. OBJECTIVES We sought to identify whether eosinophilic inflammation in sputum is associated with FEV₁ decrease in patients with severe asthma and whether we could identify subgroups of decrease behavior based on the variation of eosinophilic airway inflammation over time. METHODS Ninety-seven patients with severe asthma from the Glenfield Asthma Cohort were followed up with scheduled 3-month visits; the median duration of follow-up and number of visits was 6 years (interquartile range, 5.6-7.6 years) and 2.7 visits per year. Induced sputum was analyzed for eosinophilic inflammation at scheduled visits. Linear mixed-effects models were used to identify variables associated with lung function and overall decrease. In addition, using individual patients' mean and SD sputum eosinophil percentages over time, a 2-step cluster analysis was performed to identify patient clusters with different rates of decrease. RESULTS FEV₁ decrease was -25.7 mL/y in the overall population. Postbronchodilator FEV₁ was also dependent on exacerbations, age of onset, height, age, sex, and log10 sputum eosinophil percentages (P < .001). Three decrease patient clusters were identified: (1) noneosinophilic with low variation (mean decrease, -14.0 mL/y), (2) eosinophilic with high variation (mean decrease, -40.9 mL/y), and (3) hypereosinophilic with low variation (mean decrease in lung function, -19.2 mL/y). CONCLUSION The amplitude of sputum eosinophilia was associated with postbronchodilator FEV₁ in asthmatic patients. In contrast, high variability rather than the amplitude at baseline or over time of sputum eosinophils was associated with accelerated FEV₁ decrease.
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84
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Bruno A, Pace E, Cibella F, Chanez P. Body mass index and comorbidities in adult severe asthmatics. BIOMED RESEARCH INTERNATIONAL 2014; 2014:607192. [PMID: 24987694 PMCID: PMC4058470 DOI: 10.1155/2014/607192] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/05/2014] [Accepted: 05/14/2014] [Indexed: 02/07/2023]
Abstract
Both severe asthma and obesity are growing health problems. Severe asthma leads to a poor quality of life. The relationship among BMI, comorbidities, and severe asthma control in adults is still unclear. The aim of the study is to better understand the effect of the comorbidities as atopy, type II diabetes, OSAS, gastroesophageal reflux, hypertension, cardiovascular diseases, osteoporosis, infections, and psychological factors with BMI on asthma control in a cohort of adult severe asthmatics. One hundred and two patients were enrolled in a cross-sectional study assessing asthma control, treatments, pulmonary function, inflammatory markers, and comorbidities. Patients were divided into 3 classes according to BMI: normal weight, overweight, and obese. We found that the optimal state of asthma control is lower. whereas the score of Asthma Control Questionnaire, the number of asthma exacerbations during last year, the oral corticosteroids requirement during the previous year, and the LABA treatments are higher in obese than in overweight and normal weight severe asthmatics. The number of subjects with type II diabetes and OSAS are higher among obese and overweight patients than in normal weight asthmatics. In conclusion, BMI represents per se a factor for the deterioration in disease control in severe asthma.
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Affiliation(s)
- Andreina Bruno
- Istituto di Biomedicina e Immunologia Molecolare (IBIM), Consiglio Nazionale delle Ricerche (CNR), Via Ugo La Malfa 153, 90146 Palermo, Italy
| | - Elisabetta Pace
- Istituto di Biomedicina e Immunologia Molecolare (IBIM), Consiglio Nazionale delle Ricerche (CNR), Via Ugo La Malfa 153, 90146 Palermo, Italy
| | - Fabio Cibella
- Istituto di Biomedicina e Immunologia Molecolare (IBIM), Consiglio Nazionale delle Ricerche (CNR), Via Ugo La Malfa 153, 90146 Palermo, Italy
| | - Pascal Chanez
- Département de Pneumoallergology, AP-HM, Laboratoire d'Immunologie, Inserm CNRS U 1067, UMR7333, Aix Marseille Université, 13009 Marseille, France
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Desai D, Newby C, Symon FA, Haldar P, Shah S, Gupta S, Bafadhel M, Singapuri A, Siddiqui S, Woods J, Herath A, Anderson IK, Bradding P, Green R, Kulkarni N, Pavord I, Marshall RP, Sousa AR, May RD, Wardlaw AJ, Brightling CE. Elevated sputum interleukin-5 and submucosal eosinophilia in obese individuals with severe asthma. Am J Respir Crit Care Med 2013; 188:657-63. [PMID: 23590263 DOI: 10.1164/rccm.201208-1470oc] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The relationship between airway inflammation and obesity in severe asthma is poorly understood. OBJECTIVES We sought to determine the relationship between sputum mediator profiles and the distribution of eosinophilic inflammation and obesity in people with severe asthma. METHODS Clinical parameters and eight mediators in sputum were assessed in 131 subjects with severe asthma from a single center categorized into lean, overweight, and obese groups defined by their body mass index. In an independent group of people with severe asthma (n = 45) and healthy control subjects (n = 19) eosinophilic inflammation was enumerated in bronchial submucosa, blood, and sputum and related to their body mass index. MEASUREMENTS AND MAIN RESULTS Sputum IL-5 geometric mean (95% confidence interval) (pg/ml) was elevated in the obese (1.8 [1.2-2.6]) compared with overweight (1.1 [0.8-1.3]; P = 0.025) and lean (0.9 [0.6-1.2]; P = 0.018) subjects with asthma and was correlated with body mass index (r = 0.29; P < 0.001). There was no relationship among body mass index, the sputum cell count, or other sputum mediators. In the bronchoscopy group the submucosal eosinophil number in the subjects with asthma was correlated with body mass index (Spearman rank correlation, rs = 0.38; P = 0.013) and the median (interquartile range) number of submucosal eosinophils was increased in obese (19.4 [11.8-31.2]) (cells per square millimeter) versus lean subjects (8.2 [5.4-14.6]) (P = 0.006). There was no significant association between sputum or peripheral blood eosinophil counts and body mass index. CONCLUSIONS Sputum IL-5 and submucosal eosinophils, but not sputum eosinophils, are elevated in obese people with severe asthma. Whether specific antieosinophilic therapy is beneficial, or improved diet and lifestyle in obese asthma has antiinflammatory effects beyond weight reduction, requires further study.
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Affiliation(s)
- Dhananjay Desai
- 1 Institute for Lung Health, NIHR Respiratory Biomedical Research Unit, Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
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Abstract
INTRODUCTION For decades glucocorticoids have been considered as the gold standard for the treatment of asthma. We present a case report of typical glucocorticoid-resistant asthma and current consensus in definitions of "severe refractory", "difficult" and "glucocorticoid-resistant" asthma. METHODS Full-text papers and abstracts were identified on the basis of a comprehensive literature search primarily in MEDLINE (1966 to June 2012) but also in the Cochrane Central Register of Controlled Trials database. RESULTS Glucocorticoid-resistant asthmatics are a small subset of patients who pose noteworthy diagnostic challenges while contributing disproportionately to health care costs. Recognition of various asthma phenotypes has aided in characterizing groups with severe asthma and given a better understanding of its pathophysiological process. The molecular mechanism of glucocorticoid action is complicated and several pathways have been identified to explain drug resistance, which in turn is crucial for drug development. Tobacco smoking appears to be the single most important contributor of glucocorticoid resistance. We present the emerging and promising concepts in the management of glucocorticoid-resistant asthma, which mainly include drugs targeting specific molecules, receptors, inflammatory cells or immune processes. CONCLUSION The challenges in making a diagnosis of glucocorticoid-resistant asthma may contribute to underestimating its prevalence and impact on patient care. Considerable progress has been made in identifying distinct phenotypes and mechanisms of glucocorticoid resistance; therefore the future of new drug development in management of asthma is promising.
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Affiliation(s)
- Divya Reddy
- Department of Pulmonary, Allergy, Sleep and Critical Care Medicine, Pulmonary Center, Boston University School of Medicine , Boston, MA , USA
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88
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Woodman LB, Wan WYH, Milone R, Grace K, Sousa A, Williamson R, Brightling CE. Synthetic response of stimulated respiratory epithelium: modulation by prednisolone and iKK2 inhibition. Chest 2013; 143:1656-1666. [PMID: 23238614 PMCID: PMC3673662 DOI: 10.1378/chest.12-1187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: The airway epithelium plays a central role in wound repair and host defense
and is implicated in the immunopathogenesis of asthma. Whether there are
intrinsic differences between the synthetic capacity of epithelial cells
derived from subjects with asthma and healthy control subjects and how this
mediator release is modulated by antiinflammatory therapy remains uncertain.
We sought to examine the synthetic function of epithelial cells from
different locations in the airway tree from subjects with and without asthma
and to determine the effects of antiinflammatory therapies upon this
synthetic capacity. Methods: Primary epithelial cells were derived from 17 subjects with asthma and 16
control subjects. The release of 13 cytokines and chemokines from nasal,
bronchial basal, and air-liquid interface differentiated epithelial cells
before and after stimulation with IL-1β, IL-1β and
interferon-γ, or Poly-IC (Toll-like receptor 3 agonist) was measured
using MesoScale discovery or enzyme-linked immunosorbent assay, and the
effects of prednisolone and an inhibitor of nuclear factor κ-B2
(IKK2i) were determined. Results: The pattern of release of cytokines and chemokines was significantly
different between nasal, bronchial basal, and differentiated epithelial
cells but not between health and disease. Stimulation of the epithelial
cells caused marked upregulation of most mediators, which were broadly
corticosteroid unresponsive but attenuated by IKK2i. Conclusion: Synthetic capacity of primary airway epithelial cells varied between location
and degree of differentiation but was not disease specific. Activation of
epithelial cells by proinflammatory cytokines and toll-like receptor 3
agonism is attenuated by IKK2i, but not corticosteroids, suggesting that
IKK2i may represent an important novel therapy for asthma.
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Affiliation(s)
- Lucy Bianca Woodman
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester and Department of Respiratory Medicine, Glenfield Hospital, Leicester, England
| | - Wing Yan Heidi Wan
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester and Department of Respiratory Medicine, Glenfield Hospital, Leicester, England
| | - Roberta Milone
- GlaxoSmithKline, Refractory Respiratory Inflammation DPU, Respiratory CEDD Biomarker Discovery Group, Stevenage, England
| | - Ken Grace
- GlaxoSmithKline, Refractory Respiratory Inflammation DPU, Respiratory CEDD Biomarker Discovery Group, Stevenage, England
| | - Ana Sousa
- GlaxoSmithKline, Refractory Respiratory Inflammation DPU, Respiratory CEDD Biomarker Discovery Group, Stevenage, England
| | - Rick Williamson
- GlaxoSmithKline, Refractory Respiratory Inflammation DPU, Respiratory CEDD Biomarker Discovery Group, Stevenage, England
| | - Christopher Edward Brightling
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester and Department of Respiratory Medicine, Glenfield Hospital, Leicester, England.
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89
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Yu ZH, Xu JR, Wang YX, Xu GN, Xu ZP, Yang K, Wu DZ, Cui YY, Chen HZ. Targeted inhibition of KCa3.1 channel attenuates airway inflammation and remodeling in allergic asthma. Am J Respir Cell Mol Biol 2013; 48:685-93. [PMID: 23492185 DOI: 10.1165/rcmb.2012-0236oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
KCa3.1 has been suggested to be involved in regulating cell activation, proliferation, and migration in multiple cell types, including airway inflammatory and structural cells. However, the contributions of KCa3.1 to airway inflammation and remodeling and subsequent airway hyperresponsiveness (AHR) in allergic asthma remain to be explored. The main purpose of this study was to elucidate the roles of KCa3.1 and the potential therapeutic value of KCa3.1 blockers in chronic allergic asthma. Using real-time PCR, Western blotting, or immunohistochemical analyses, we explored the precise role of KCa3.1 in the bronchi of allergic mice and asthmatic human bronchial smooth muscle cells (BSMCs). We found that KCa3.1 mRNA and protein expression were elevated in the bronchi of allergic mice, and double labeling revealed that up-regulation occurred primarily in airway smooth muscle cells. Triarylmethane (TRAM)-34, a KCa3.1 blocker, dose-dependently inhibited the generation and maintenance of the ovalbumin-induced airway inflammation associated with increased Th2-type cytokines and decreased Th1-type cytokine, as well as subepithelial extracellular matrix deposition, goblet-cell hyperplasia, and AHR in a murine model of asthma. Moreover, the pharmacological blockade and gene silencing of KCa3.1, which was evidently elevated after mitogen stimulation, suppressed asthmatic human BSMC proliferation and migration, and arrested the cell cycle at the G0/G1 phase. In addition, the KCa3.1 activator 1-ethylbenzimidazolinone-induced membrane hyperpolarization and intracellular calcium increase in asthmatic human BSMCs were attenuated by TRAM-34. We demonstrate for the first time an important role for KCa3.1 in the pathogenesis of airway inflammation and remodeling in allergic asthma, and we suggest that KCa3.1 blockers may represent a promising therapeutic strategy for asthma.
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Affiliation(s)
- Zhi-Hua Yu
- Department of Pharmacology, Institute of Medical Sciences, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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90
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Lin RYW, Ji R, Liao W. Age dependent sex disproportion in US asthma hospitalization rates, 2000-2010. Ann Allergy Asthma Immunol 2013; 111:176-81. [PMID: 23987191 DOI: 10.1016/j.anai.2013.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 06/10/2013] [Accepted: 06/10/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Age-stratified sex differences in asthma hospitalizations rates have been reported to be most marked between the ages of 40 and 54 years in New York. It is not known whether age-dependent sex differences in asthma hospitalization rates also exist for the entire United States. OBJECTIVES To compare sex-specific hospitalization rates for asthma in adults in the United States and to describe the adjusted associations between female sex and age in the fifth to sixth decades of life. METHODS The National Inpatient Sample databases for 2000-2010 were queried for a principal diagnosis of asthma to calculate the ratio of female to male hospitalization rates for different decades of adult life. Logistic regression modeling was used to determine whether age in the fifth to sixth decades of life had associations with female sex that remained significant after adjusting for comorbidities and demographic features. RESULTS For all years of the study, there was a distinct peaking in female to male ratio most manifested in the fifth to sixth decades of life. This age grouping was significantly associated with female sex. Models revealed that female sex was significantly associated with this age grouping, even after adjustment for obesity, chronic obstructive pulmonary disease, race, insurance status, discharge year, and smoking. Excluding identifiable repeat admissions also did not abrogate the age grouping association. CONCLUSION There is a striking propensity of women in their fifth to sixth decades of life to be admitted for asthma, which appears to be independent of many known comorbidities.
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Affiliation(s)
- Robert Yao-wen Lin
- Department of Medicine, New York Downtown Hospital, New York, New York, USA.
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91
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Reddy AT, Lakshmi SP, Dornadula S, Pinni S, Rampa DR, Reddy RC. The nitrated fatty acid 10-nitro-oleate attenuates allergic airway disease. THE JOURNAL OF IMMUNOLOGY 2013; 191:2053-63. [PMID: 23913958 DOI: 10.4049/jimmunol.1300730] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asthma is a serious, growing problem worldwide. Inhaled steroids, the current standard therapy, are not always effective in this chronic inflammatory disease and can cause adverse effects. We tested the hypothesis that nitrated fatty acids (NFAs) may provide an effective alternative treatment. NFAs are endogenously produced by nonenzymatic reaction of NO with unsaturated fatty acids and exert anti-inflammatory actions both by activating the nuclear hormone receptor peroxisome proliferator-activated receptor (PPAR)γ and via PPAR-independent mechanisms, but whether they might ameliorate allergic airway disease was previously untested. We found that pulmonary delivery of the NFA 10-nitro-oleic acid (OA-NO2) reduced the severity of murine allergic airway disease, as assessed by various pathological and molecular markers. Fluticasone, an inhaled steroid commonly used to treat asthma, produced similar effects on most end points, but only OA-NO2 induced robust apoptosis of neutrophils and their phagocytosis by alveolar macrophages. This suggests that OA-NO2 may be particularly effective in neutrophil-rich, steroid-resistant severe asthma. In primary human bronchial epithelial cells, OA-NO2 blocked phosphorylation and degradation of IκB and enhanced inhibitory binding of PPARγ to NF-κB. Our results indicate that the NFA OA-NO2 is efficacious in preclinical models of allergic airway disease and may have potential for treating asthma patients.
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Affiliation(s)
- Aravind T Reddy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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92
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Gras D, Chanez P, Vachier I, Petit A, Bourdin A. Bronchial epithelium as a target for innovative treatments in asthma. Pharmacol Ther 2013; 140:290-305. [PMID: 23880290 DOI: 10.1016/j.pharmthera.2013.07.008] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/10/2013] [Indexed: 01/03/2023]
Abstract
Increasing evidence of a critical role played by the bronchial epithelium in airway homeostasis is opening new therapeutic avenues. Its unique situation at the interface with the environment suggests that the subtle regulation orchestrated by the epithelium between tolerance and specific immune response might be impaired in asthma. Airway mucus is acting as a physical and a biological fluid between the environment and the epithelium, synergistically moved by the cilia. In asthma, excessive mucus production is a hallmark of airway remodeling. Since many years we tried to therapeutically target mucus hypersecretion, but actually this option is still not achieved. The present review discusses the dynamic processes regulating airway mucus production. Airway inflammation is central in current asthma management. Understanding of how the airway epithelium influences the TH2 paradigm in response to deleterious agents is improving. The multiple receptors expressed by the airway epithelium are the transducers of the biological signals induced by various invasive agents to develop the most adapted response. Airway remodeling is observed in severe chronic airway diseases and may result from ongoing disturbance of signal transduction and epithelial renewal. Chronic airway diseases such as asthma will require assessment of these epithelial abnormalities to identify phenotypic characteristics associated with predicting a clinical benefit for epithelial-directed therapies.
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Affiliation(s)
- Delphine Gras
- UMR INSERM U1067 CNRS 7333, Aix-Marseille University, Marseille, France
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93
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Lee JH, Sohn JH, Ryu SY, Hong CS, Moon KD, Park JW. A novel human anti-VCAM-1 monoclonal antibody ameliorates airway inflammation and remodelling. J Cell Mol Med 2013; 17:1271-81. [PMID: 23855490 PMCID: PMC4159019 DOI: 10.1111/jcmm.12102] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 06/05/2013] [Accepted: 06/07/2013] [Indexed: 12/13/2022] Open
Abstract
Asthma is a chronic inflammatory disease induced by Type 2 helper T cells and eosinophils. Vascular cell adhesion molecule-1 (VCAM-1) has been implicated in recruiting eosinophils and lymphocytes to pathological sites in asthma as a regulatory receptor. Accordingly, monoclonal antibody (mAb) against VCAM-1 may attenuate allergic inflammation and pathophysiological features of asthma. We attempted to evaluate whether a recently developed human anti-VCAM-1 mAb can inhibit the pathophysiological features of asthma in a murine asthma model induced by ovalbumin (OVA). Leucocyte adhesion inhibition assay was performed to evaluate the in vitro blocking activity of human anti-VCAM-1 mAb. OVA-sensitized BALB/c mice were treated with human anti-VCAM-1 mAb or isotype control Ab before intranasal OVA challenge. We evaluated airway hyperresponsiveness (AHR) and bronchoalveolar lavage fluid analysis, measured inflammatory cytokines and examined histopathological features. The human anti-VCAM-1 mAb bound to human and mouse VCAM-1 molecules and inhibited adhesion of human leucocytes in vitro. AHR and inflammatory cell counts in bronchoalveolar lavage fluid were reduced in mice treated with human anti-VCAM-1 mAb as compared with a control Ab. The levels of interleukin (IL)-5 and IL-13, as well as transforming growth factor-β, in lung tissue were decreased in treated mice. Human anti-VCAM-1 mAb reduced goblet cell hyperplasia and peribronchial fibrosis. In vivo VCAM-1 expression decreased in the treated group. In conclusion, human anti-VCAM-1 mAb attenuated allergic inflammation and the pathophysiological features of asthma in OVA-induced murine asthma model. The results suggested that human anti-VCAM-1 mAb could potentially be used as an additional anti-asthma therapeutic medicine.
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Affiliation(s)
- Jae-Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea; Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
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94
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Papaporfyriou A, Tseliou E, Loukides S, Kostikas K, Bakakos P. Noninvasive evaluation of airway inflammation in patients with severe asthma. Ann Allergy Asthma Immunol 2013; 110:316-21. [PMID: 23622000 DOI: 10.1016/j.anai.2012.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 12/26/2012] [Accepted: 12/30/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Anastasia Papaporfyriou
- Second Respiratory Medicine Department, University of Athens Medical School, Attiko Hospital, Athens, Greece
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95
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Charriot J, Gamez AS, Humbert M, Chanez P, Bourdin A. [Targeted therapies in severe asthma: the discovery of new molecules]. Rev Mal Respir 2013; 30:613-26. [PMID: 24182649 DOI: 10.1016/j.rmr.2013.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 02/24/2013] [Indexed: 11/25/2022]
Abstract
The pathophysiological mechanisms involved in the chronicity and phenotypic heterogeneity of asthma offer the prospect of new therapeutic opportunities. A better clinical and biological characterisation of selected patients has led to the development of targeted therapies. Studies are under way to demonstrate their efficacy and tolerance and also their impact on the natural history of the disease. This revue aims to examine the therapies, developed during the last ten years, that are based on the immunological mechanisms involved in the pathophysiology of asthma, essentially in its severe form. The rapid expansion of human monoclonal antibodies has allowed testing of various immunological pathways. Anti-IgE, anti- IL-5, and anti-IL-13 strategies seem the most promising. Antagonists to TNF-alpha and I'IL-4 have not succeeded in reducing the events related to severe asthma in a convincing manner. Molecules targeted against thymic stromal lymphopoietin (TSLP) and I'IL-9 are under development. These approaches are involved in the development of therapeutic programmes adapted to the patient's phenotype, that is to say a personalised approach to care.
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Affiliation(s)
- J Charriot
- Département des maladies respiratoires, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, 371, avenue du Doyen-Giraud, 34295 Montpellier cedex 5, France
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96
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Bourdin A, Halimi L, Vachier I, Paganin F, Lamouroux A, Gouitaa M, Vairon E, Godard P, Chanez P. Adherence in severe asthma. Clin Exp Allergy 2013; 42:1566-74. [PMID: 23106657 DOI: 10.1111/j.1365-2222.2012.04018.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Adherence in asthma is an important cause for concern. Although nearly 50% of asthma patients are considered poorly adherent to therapeutic advices, adherence is still difficult to assess, understand and improve despite major medical consequences. In this review, we revisited the literature of the last 10 years related to adherence in severe asthma. The concepts have changed and "compliance" is usually replaced by "adherence". Assessment of adherence is addressing ethical issues, but provides important insight into difficult-to-treat asthma. Different tools have been used but none is routinely recommended. Health-related outcomes (poor control, exacerbations, hospitalizations, lung function decline), which are clearly associated with severe asthma, are often worsened by non-adherence with consequences also on patient related outcomes (quality of life). The potential behaviour associated with non-adherence and all other related factors including easy-to-recognize psychological traits can help for patient's future management. Therapeutic educational interventions have been recognized with a scientifically proven efficiency even though evolution and improvements are needed. A multidisciplinary approach is required in severe asthma. Therapeutic adherence for a given patient is always a prerequisite to any other aspects when addressing severe asthma phenotypes. Severe asthma should be considered only in those who still experienced poor asthma outcomes despite optimal adherence. At a glance, poor adherence and severe asthma should be considered antinomic. Better understanding of the causes and customised management are potential future directions.
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Affiliation(s)
- A Bourdin
- Department of Respiratory Diseases, CHU Montpellier, and INSERM U1046, Université Montpellier 1, Université Montpellier 2, Montpellier, France.
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97
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Pillai RR, Divekar R, Brasier A, Bhavnani S, Calhoun WJ. Strategies for molecular classification of asthma using bipartite network analysis of cytokine expression. Curr Allergy Asthma Rep 2013; 12:388-95. [PMID: 22777399 DOI: 10.1007/s11882-012-0279-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Asthma is a chronic inflammatory disease of the airways that leads to various degrees of recurrent respiratory symptoms affecting patients globally. Specific subgroups of asthma patients have severe disease leading to increased healthcare costs and socioeconomic burden. Despite the overwhelming prevalence of the asthma, there are limitations in predicting response to therapy and identifying patients who are at increased risk of morbidity. This syndrome presents with common clinical signs and symptoms; however, awareness of subgroups of asthma patients with distinct characteristics has surfaced in recent years. Investigators attempt to describe the phenotypes of asthma to ultimately assist with diagnostic and therapeutic applications. Approaches to asthma phenotyping are multifold; however, it can be partitioned into 2 essential groups, clinical phenotyping and molecular phenotyping. Innovative techniques such as bipartite network analysis and visual analytics introduce a new dimension of data analysis to identify underlying mechanistic pathways.
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Affiliation(s)
- Regina R Pillai
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Medical Branch, 5.140 John Sealy Annex, 301 University Blvd, Galveston, TX 77555-0561, USA.
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98
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Caruso M, Crisafulli E, Demma S, Holgate S, Polosa R. Disabling inflammatory pathways with biologics and resulting clinical outcomes in severe asthma. Expert Opin Biol Ther 2013; 13:393-402. [PMID: 23289846 DOI: 10.1517/14712598.2013.743989] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Patients with severe asthma have a significant unmet need with persistent symptoms and/or frequent exacerbations despite high intensity treatment. These severe unrelenting symptoms have a huge impact on heathcare resources due to frequent hospital admissions and requirement for intensive and expensive medications. There is a compelling need for more effective and safer therapies to help severe asthma sufferers to achieve adequate control of their disease. AREAS COVERED Expanding knowledge of innate and adaptive immune responses has led to development of new biologic approaches for severe asthma. Here, the authors will review the existing efficacy and safety data from clinical trials of some of the new biologic therapies that are in development for severe asthma. Their specific role in distinctively targeted subpopulations of severe asthmatics will be also discussed. EXPERT OPINION Defining and phenotyping severe asthma patients will become increasingly important as some patients who were previously classified as having severe asthma may become well-controlled with a targeted phenotype-specific treatment. However, pharmacoeconomic concerns should also be taken into account given the elevated acquisition costs of recombinant human monoclonals and of the diagnostic screening procedures for the identification of potential responders.
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Affiliation(s)
- Massimo Caruso
- University of Catania-AOU Policlinico-V. Emanuele, Department of Clinical and Molecular Bio-Medicine-Institute of Internal Medicine and Clinical Immunology, Catania, 95124, Italy
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99
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Sismanopoulos N, Delivanis DA, Mavrommati D, Hatziagelaki E, Conti P, Theoharides TC. Do mast cells link obesity and asthma? Allergy 2013; 68:8-15. [PMID: 23066905 DOI: 10.1111/all.12043] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2012] [Indexed: 12/13/2022]
Abstract
Asthma is a chronic inflammatory disease of the lungs. Both the number of cases and severity of asthma have been increasing without a clear explanation. Recent evidence suggests that obesity, which has also been increasing alarmingly, may worsen or precipitate asthma, but there is little evidence of how obesity may contribute to lung inflammation. We propose that mast cells are involved in both asthma and obesity by being the target and source of adipocytokines, 'alarmins' such as interleukin-9 (IL-9) and interleukin-33 (IL-33), and stress molecules including corticotropin-releasing hormone (CRH) and neurotensin (NT), secreted in response to the metabolic burden. In particular, CRH and NT have synergistic effects on mast cell secretion of vascular endothelial growth factor (VEGF). IL-33 augments VEGF release induced by substance P (SP) and tumor necrosis factor (TNF) release induced by NT. Both IL-9 and IL-33 also promote lung mast cell infiltration and augment allergic inflammation. These molecules are also expressed in human mast cells leading to autocrine effects. Obese patients are also less sensitive to glucocorticoids and bronchodilators. Development of effective mast cell inhibitors may be a novel approach for the management of both asthma and obesity. Certain flavonoid combinations may be a promising new treatment approach.
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Affiliation(s)
- N. Sismanopoulos
- Laboratory of Molecular Immunopharmacology and Drug Discovery; Department of Molecular Physiology and Pharmacology; Tufts University School of Medicine; Boston; MA; USA
| | - D.-A. Delivanis
- Laboratory of Molecular Immunopharmacology and Drug Discovery; Department of Molecular Physiology and Pharmacology; Tufts University School of Medicine; Boston; MA; USA
| | - D. Mavrommati
- Laboratory of Molecular Immunopharmacology and Drug Discovery; Department of Molecular Physiology and Pharmacology; Tufts University School of Medicine; Boston; MA; USA
| | - E. Hatziagelaki
- Second Department of Internal Medicine; Athens University Medical School; ‘Attikon’ General Hospital; Athens; Greece
| | - P. Conti
- Department of Oncology and Experimental Medicine; University of Chieti-Pescara; Chieti; Italy
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100
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Aspirin-intolerant asthma in the Korean population: prevalence and characteristics based on a questionnaire survey. Respir Med 2012. [PMID: 23195335 DOI: 10.1016/j.rmed.2012.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Aspirin-intolerant asthma is a unique clinical syndrome characterized by acute bronchoconstriction following the administration of aspirin and/or non-steroidal anti-inflammatory drugs. OBJECTIVE We assessed the prevalence and investigated the demographic and clinical characteristics of adult patients with aspirin-intolerant asthma in Korea. METHODS Using an adult asthma cohort (COREA) from 11 university hospitals in Korea, we analyzed the prevalence of aspirin-intolerant asthma, defined as a positive response to the question: "Have you ever experienced dyspnea and cough after taking an aspirin or any NSAID (cold medicine)?" Demographic and clinical characteristics were compared between patients with aspirin-intolerant asthma and aspirin-tolerant asthma. RESULTS Aspirin-intolerant asthma was reported in 68 (5.8%) of 1173 adult asthmatics (age 15-84). Patients with aspirin-intolerant asthma had a lower mean age (43.9 ± 13.4 vs. 49.0 ± 15.6, P = 0.003) and a higher prevalence of rhinosinusitis (77.9% vs. 61.7%, P = 0.012) and atopic dermatitis (16.2% vs. 5.7%, P = 0.001) than aspirin-tolerant asthma patients. There were no significant differences in lung function, asthma severity or the use of asthma controllers. However, aspirin-intolerant asthma was associated with greater use of healthcare services over a lifetime and over the past 12 months. Aspirin-intolerant asthma was significantly associated with emergency room visits over the past 12 months (P = 0.029, OR 2.19, 95% CI 1.08-4.42). CONCLUSION Based on histories, the prevalence of aspirin-intolerant asthma is 5.8% among adult asthma patients in Korea. Aspirin-intolerant asthma is associated with lower age, higher prevalence of rhinosinusitis and atopic dermatitis, and more frequent exacerbations.
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