51
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Bonniaud P, Fabre A, Frossard N, Guignabert C, Inman M, Kuebler WM, Maes T, Shi W, Stampfli M, Uhlig S, White E, Witzenrath M, Bellaye PS, Crestani B, Eickelberg O, Fehrenbach H, Guenther A, Jenkins G, Joos G, Magnan A, Maitre B, Maus UA, Reinhold P, Vernooy JHJ, Richeldi L, Kolb M. Optimising experimental research in respiratory diseases: an ERS statement. Eur Respir J 2018; 51:13993003.02133-2017. [PMID: 29773606 DOI: 10.1183/13993003.02133-2017] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 04/02/2018] [Indexed: 12/15/2022]
Abstract
Experimental models are critical for the understanding of lung health and disease and are indispensable for drug development. However, the pathogenetic and clinical relevance of the models is often unclear. Further, the use of animals in biomedical research is controversial from an ethical perspective.The objective of this task force was to issue a statement with research recommendations about lung disease models by facilitating in-depth discussions between respiratory scientists, and to provide an overview of the literature on the available models. Focus was put on their specific benefits and limitations. This will result in more efficient use of resources and greater reduction in the numbers of animals employed, thereby enhancing the ethical standards and translational capacity of experimental research.The task force statement addresses general issues of experimental research (ethics, species, sex, age, ex vivo and in vitro models, gene editing). The statement also includes research recommendations on modelling asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, lung infections, acute lung injury and pulmonary hypertension.The task force stressed the importance of using multiple models to strengthen validity of results, the need to increase the availability of human tissues and the importance of standard operating procedures and data quality.
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Affiliation(s)
- Philippe Bonniaud
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre Hospitalo-Universitaire de Bourgogne, Dijon, France.,Faculté de Médecine et Pharmacie, Université de Bourgogne-Franche Comté, Dijon, France.,INSERM U866, Dijon, France
| | - Aurélie Fabre
- Dept of Histopathology, St Vincent's University Hospital, UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - Nelly Frossard
- Laboratoire d'Innovation Thérapeutique, Université de Strasbourg, Strasbourg, France.,CNRS UMR 7200, Faculté de Pharmacie, Illkirch, France.,Labex MEDALIS, Université de Strasbourg, Strasbourg, France
| | - Christophe Guignabert
- INSERM UMR_S 999, Le Plessis-Robinson, France.,Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Mark Inman
- Dept of Medicine, Firestone Institute for Respiratory Health at St Joseph's Health Care MDCL 4011, McMaster University, Hamilton, ON, Canada
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tania Maes
- Dept of Respiratory Medicine, Laboratory for Translational Research in Obstructive Pulmonary Diseases, Ghent University Hospital, Ghent, Belgium
| | - Wei Shi
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute of Children's Hospital Los Angeles, Los Angeles, CA, USA.,Dept of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Martin Stampfli
- Dept of Medicine, Firestone Institute for Respiratory Health at St Joseph's Health Care MDCL 4011, McMaster University, Hamilton, ON, Canada.,Dept of Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University
| | - Stefan Uhlig
- Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Eric White
- Division of Pulmonary and Critical Care Medicine, Dept of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Martin Witzenrath
- Dept of Infectious Diseases and Respiratory Medicine And Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Pierre-Simon Bellaye
- Département de Médecine nucléaire, Plateforme d'imagerie préclinique, Centre George-François Leclerc (CGFL), Dijon, France
| | - Bruno Crestani
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, DHU FIRE, Service de Pneumologie A, Paris, France.,INSERM UMR 1152, Paris, France.,Université Paris Diderot, Paris, France
| | - Oliver Eickelberg
- Division of Pulmonary Sciences and Critical Care Medicine, Dept of Medicine, University of Colorado, Aurora, CO, USA
| | - Heinz Fehrenbach
- Priority Area Asthma & Allergy, Research Center Borstel, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany.,Member of the Leibniz Research Alliance Health Technologies
| | - Andreas Guenther
- Justus-Liebig-University Giessen, Universitary Hospital Giessen, Agaplesion Lung Clinic Waldhof-Elgershausen, German Center for Lung Research, Giessen, Germany
| | - Gisli Jenkins
- Nottingham Biomedical Research Centre, Respiratory Research Unit, City Campus, University of Nottingham, Nottingham, UK
| | - Guy Joos
- Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Antoine Magnan
- Institut du thorax, CHU de Nantes, Université de Nantes, Nantes, France
| | - Bernard Maitre
- Hôpital H Mondor, AP-HP, Centre Hospitalier Intercommunal de Créteil, Service de Pneumologie et de Pathologie Professionnelle, DHU A-TVB, Université Paris Est - Créteil, Créteil, France
| | - Ulrich A Maus
- Hannover School of Medicine, Division of Experimental Pneumology, Hannover, Germany
| | - Petra Reinhold
- Institute of Molecular Pathogenesis at the 'Friedrich-Loeffler-Institut' (Federal Research Institute for Animal Health), Jena, Germany
| | - Juanita H J Vernooy
- Dept of Respiratory Medicine, Maastricht University Medical Center+ (MUMC+), AZ Maastricht, The Netherlands
| | - Luca Richeldi
- UOC Pneumologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy
| | - Martin Kolb
- Dept of Medicine, Firestone Institute for Respiratory Health at St Joseph's Health Care MDCL 4011, McMaster University, Hamilton, ON, Canada
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52
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Affiliation(s)
- Ahmed Yousuf
- NIHR Leicester Biomedical Research Centre, Institute for Lung Health, Department of Infection, Immunity & Inflammation, University of Leicester, Leicester, United Kingdom
| | - Christopher E Brightling
- NIHR Leicester Biomedical Research Centre, Institute for Lung Health, Department of Infection, Immunity & Inflammation, University of Leicester, Leicester, United Kingdom
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53
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Gibson PG, McDonald VM. Management of severe asthma: targeting the airways, comorbidities and risk factors. Intern Med J 2018; 47:623-631. [PMID: 28580744 DOI: 10.1111/imj.13441] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 02/03/2023]
Abstract
Severe asthma is a complex heterogeneous disease that is refractory to standard treatment and is complicated by multiple comorbidities and risk factors. In mild to moderate asthma, the burden of disease can be minimised by inhaled corticosteroids, bronchodilators and self-management education. In severe asthma, however, management is more complex. When patients with asthma continue to experience symptoms and exacerbations despite optimal management, severe refractory asthma (SRA) should be suspected and confirmed, and other aetiologies ruled out. Once a diagnosis of SRA is established, patients should undergo a systematic and multidimensional assessment to identify inflammatory endotypes, risk factors and comorbidities, with targeted and individualised management initiated. We describe a practical approach to assessment and management of patients with SRA.
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Affiliation(s)
- Peter G Gibson
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, The University of Newcastle, Newcastle, New South Wales, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia.,VIVA, Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Vanessa M McDonald
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, The University of Newcastle, Newcastle, New South Wales, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia.,VIVA, Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
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54
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Abstract
Eosinophils are the prominent cells in asthma, allergic bronchopulmonary mycosis (ABPMs), and fungal-sensitization-associated asthma, but their roles in the immunopathology of these disorders are not well understood. Moreover, the immunological mechanisms underlying the molecular direct effector interactions between fungi and eosinophils are rare and not fully known. Here, we provide an overview of eosinophil contributions to allergic asthma and ABPMs. We also revise the major general mechanisms of fungal recognition by eosinophils and consider past and recent advances in our understanding of the molecular mechanisms associated with eosinophil innate effector responses to different fungal species relevant to ABPMs (Alternaria alternata, Candida albicans, and Aspergillus fumigatus). We further examine and speculate about the therapeutic relevance of these findings in fungus-associated allergic pulmonary diseases.
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Affiliation(s)
- Rodrigo T Figueiredo
- Institute of Biomedical Sciences/Unit of Xerem, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Josiane S Neves
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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55
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Porsbjerg C, Ulrik C, Skjold T, Backer V, Laerum B, Lehman S, Janson C, Sandstrøm T, Bjermer L, Dahlen B, Lundbäck B, Ludviksdottir D, Björnsdóttir U, Altraja A, Lehtimäki L, Kauppi P, Karjalainen J, Kankaanranta H. Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults. Eur Clin Respir J 2018. [PMID: 29535852 PMCID: PMC5844041 DOI: 10.1080/20018525.2018.1440868] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma ('difficult asthma') should undergo systematic assessment, in order to differentiate between true severe asthma, and 'difficult-to-treat' patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.
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Affiliation(s)
- Celeste Porsbjerg
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Respiratory Research unit, Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Charlotte Ulrik
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Respiratory Medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - Tina Skjold
- Dept of Respiratory Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Vibeke Backer
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Respiratory Research unit, Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Sverre Lehman
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Crister Janson
- Department of Medical Sciences: Respiratory, Allergy & Sleep Research, Uppsala University, Uppsala, Sweden
| | - Thomas Sandstrøm
- Department of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
| | - Leif Bjermer
- Department of Respiratory Medicine & Allergology, Skåne University Hospital, Lund, Sweden
| | - Barbro Dahlen
- Division of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Bo Lundbäck
- Institute of Medicine/Krefting Research Centre University of Gothenburg, Gothenburg, Sweden
| | - Dora Ludviksdottir
- Dept. of Allergy, Respiratory Medicine and Sleep Landspitali University Hospital Reykjavik Iceland, University of Iceland, Reykjavik, Iceland
| | - Unnur Björnsdóttir
- Dept. of Allergy, Respiratory Medicine and Sleep Landspitali University Hospital Reykjavik Iceland, University of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Alan Altraja
- Department of Pulmonary Medicine, University of Tartu and Department of Pulmponary Medicine, Tartu University Hospital, Tartu, Estonia
| | - Lauri Lehtimäki
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Paula Kauppi
- Department of Allergy, Respiratory Diseases and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jussi Karjalainen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Hannu Kankaanranta
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
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56
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Biomarkers for severe eosinophilic asthma. J Allergy Clin Immunol 2017; 140:1509-1518. [PMID: 29221581 DOI: 10.1016/j.jaci.2017.10.005] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/13/2017] [Accepted: 10/17/2017] [Indexed: 01/20/2023]
Abstract
The last decade has seen the approval of several new biologics for the treatment of severe asthma-targeting specific endotypes and phenotypes. This review will examine how evidence generated from the mepolizumab clinical development program showed that blood eosinophil counts, rather than sputum or tissue eosinophil counts, evolved as a pharmacodynamic and predictive biomarker for the efficacy of treatment with mepolizumab in patients with severe eosinophilic asthma. Based on the available evidence and combined with clinical judgement, a baseline blood eosinophil threshold of 150 cells/μL or greater or a historical blood eosinophil threshold of 300 cells/μL or greater will allow selection of patients with severe eosinophilic asthma who are most likely to achieve clinically significant reductions in the rate of exacerbations with mepolizumab treatment.
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57
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McDonald VM, Yorke J. Adherence in severe asthma: time to get it right. Eur Respir J 2017; 50:50/6/1702191. [PMID: 29269587 DOI: 10.1183/13993003.02191-2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Vanessa M McDonald
- Priority Research Centre for Healthy Lungs and Centre of Excellence in Severe Asthma, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia .,Dept of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Janelle Yorke
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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58
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Beghé B, Fabbri LM, Contoli M, Papi A. Update in Asthma 2016. Am J Respir Crit Care Med 2017; 196:548-557. [PMID: 28530112 DOI: 10.1164/rccm.201702-0318up] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Bianca Beghé
- 1 Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Leonardo M Fabbri
- 2 Research Centre on Asthma and Chronic Obstructive Pulmonary Disease, Department of Medical Sciences, University of Ferrara, Ferrara, Italy; and.,3 Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marco Contoli
- 2 Research Centre on Asthma and Chronic Obstructive Pulmonary Disease, Department of Medical Sciences, University of Ferrara, Ferrara, Italy; and
| | - Alberto Papi
- 2 Research Centre on Asthma and Chronic Obstructive Pulmonary Disease, Department of Medical Sciences, University of Ferrara, Ferrara, Italy; and
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59
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Kelly EA, Esnault S, Liu LY, Evans MD, Johansson MW, Mathur S, Mosher DF, Denlinger LC, Jarjour NN. Mepolizumab Attenuates Airway Eosinophil Numbers, but Not Their Functional Phenotype, in Asthma. Am J Respir Crit Care Med 2017; 196:1385-1395. [PMID: 28862877 DOI: 10.1164/rccm.201611-2234oc] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
RATIONALE Mepolizumab, an IL-5-blocking antibody, reduces exacerbations in patients with severe eosinophilic asthma. Mepolizumab arrests eosinophil maturation; however, the functional phenotype of eosinophils that persist in the blood and airway after administration of IL-5 neutralizing antibodies has not been reported. OBJECTIVES To determine the effect of anti-IL-5 antibody on the numbers and phenotypes of allergen-induced circulating and airway eosinophils. METHODS Airway inflammation was elicited in participants with mild allergic asthma by segmental allergen challenge before and 1 month after a single intravenous 750-mg dose of mepolizumab. Eosinophils were examined in blood, bronchoalveolar lavage, and endobronchial biopsies 48 hours after challenge. MEASUREMENTS AND MAIN RESULTS Segmental challenge without mepolizumab induced a rise in circulating eosinophils, bronchoalveolar lavage eosinophilia, and eosinophil peroxidase deposition in bronchial mucosa. IL-5 neutralization before allergen challenge abolished the allergen-induced rise in circulating eosinophils and expression of IL-3 receptors, whereas airway eosinophilia and eosinophil peroxidase deposition were blunted but not eliminated. Before mepolizumab treatment, bronchoalveolar lavage eosinophils had more surface IL-3 and granulocyte-monocyte colony-stimulating factor receptors, CD69, CD44, and CD23 and decreased IL-5 and eotaxin receptors than blood eosinophils. This activation phenotype indicated by bronchoalveolar lavage eosinophil surface markers, as well as the release of eosinophil peroxidase by eosinophils in the bronchial mucosa, was maintained after mepolizumab. CONCLUSIONS Mepolizumab reduced airway eosinophil numbers but had a limited effect on airway eosinophil activation markers, suggesting that these cells retain functionality. This observation may explain why IL-5 neutralization reduces but does not completely eradicate asthma exacerbations. Clinical trial registered with www.clinicaltrials.gov (NCT00802438).
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Affiliation(s)
- Elizabeth A Kelly
- 1 Allergy, Pulmonary and Critical Care Medicine Division, Department of Medicine
| | - Stephane Esnault
- 1 Allergy, Pulmonary and Critical Care Medicine Division, Department of Medicine
| | - Lin Ying Liu
- 1 Allergy, Pulmonary and Critical Care Medicine Division, Department of Medicine
| | | | - Mats W Johansson
- 3 Department of Biomolecular Chemistry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sameer Mathur
- 1 Allergy, Pulmonary and Critical Care Medicine Division, Department of Medicine
| | - Deane F Mosher
- 3 Department of Biomolecular Chemistry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Loren C Denlinger
- 1 Allergy, Pulmonary and Critical Care Medicine Division, Department of Medicine
| | - Nizar N Jarjour
- 1 Allergy, Pulmonary and Critical Care Medicine Division, Department of Medicine
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60
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Wang G, Zhang X, Zhang HP, Wang L, Kang DY, Barnes PJ, Wang G. Corticosteroid plus β 2-agonist in a single inhaler as reliever therapy in intermittent and mild asthma: a proof-of-concept systematic review and meta-analysis. Respir Res 2017; 18:203. [PMID: 29207999 PMCID: PMC5718039 DOI: 10.1186/s12931-017-0687-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 11/05/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Current guidelines recommend a single inhaler maintenance and reliever therapy (SMART) regimen for moderate to severe asthma. However, evidence for the inhaled corticosteroid plus fast-onset-acting β2-agonist (ICS/FABA) as reliever therapy in management of intermittent and mild asthma patients is lacking. OBJECTIVE To systematically explore efficacy and safety of the proof-of-concept of the ICS plus FABA regimen in a single inhaler as reliever therapy across children and adults with intermittent and mild persistent asthma. METHODS We searched online bibliographic databases for randomized controlled trials (RCTs) involving the as-needed use of ICS/FABA as monotherapy in intermittent or mild asthma patients. The primary outcomes were exacerbations and the hazard ratio (HR) of the time to first exacerbation. RESULTS Six RCTs (n = 1300) met the inclusion criteria. Compared with the as-needed FABA regimen, the as-needed use of ICS/FABA as monotherapy statistically reduced exacerbations (RR = 0.56, P = 0.001). Compared with regular ICS regimen, the as-needed ICS/FABA therapy had slightly higher risk of exacerbations (RR = 1.39, P = 0.011). The HR for time to first exacerbations in the ICS/FABA regimen was significant lower when compared with FABA regimen (HR = 0.52, P = 0.002) but had no difference when compared with ICS regimen (HR = 1.30, P = 0.286). The corticosteroid exposure in the daily ICS regimen was 2- to 5-fold compared with as-needed use of ICS/FABA regimen. CONCLUSIONS Our analysis shows that the ICS/FABA as a symptom-driven therapy may be a promising alternative regimen for the patients with intermittent or mild asthma, but it needs further real-world RCTs to confirm these findings.
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Affiliation(s)
- Gang Wang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, 610041, People's Republic of China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.,West China School of Medicine, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xin Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, 610041, People's Republic of China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Hong Ping Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, 610041, People's Republic of China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Lei Wang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, 610041, People's Republic of China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - De Ying Kang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, China
| | - Peter J Barnes
- National Heart & Lung Institute, Imperial College, London, UK
| | - Gang Wang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, 610041, People's Republic of China. .,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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61
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Abstract
BACKGROUND This review is the first update of a previously published review in The Cochrane Library (Issue 7, 2015). Interleukin-5 (IL-5) is the main cytokine involved in the activation of eosinophils, which cause airway inflammation and are a classic feature of asthma. Monoclonal antibodies targeting IL-5 or its receptor (IL-5R) have been developed, with recent studies suggesting that they reduce asthma exacerbations, improve health-related quality of life (HRQoL) and lung function. These are being incorporated into asthma guidelines. OBJECTIVES To compare the effects of therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Rα) with placebo on exacerbations, health-related qualify of life (HRQoL) measures, and lung function in adults and children with chronic asthma, and specifically in those with eosinophilic asthma refractory to existing treatments. SEARCH METHODS We searched the Cochrane Airways Trials Register, clinical trials registries, manufacturers' websites, and reference lists of included studies. The most recent search was March 2017. SELECTION CRITERIA We included randomised controlled trials comparing mepolizumab, reslizumab and benralizumab versus placebo in adults and children with asthma. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by Cochrane. MAIN RESULTS Thirteen studies on 6000 participants met the inclusion criteria. Four used mepolizumab, four used reslizumab, and five used benralizumab. One study in benralizumab was terminated early due to sponsor decision and contributed no data. The studies were predominantly on people with severe eosinophilic asthma, which was similarly but variably defined. Eight included children over 12 years but these results were not reported separately. We deemed the risk of bias to be low, with all studies contributing data being of robust methodology. We considered the quality of the evidence for all comparisons to be high overall using the GRADE scheme, with the exception of intravenous mepolizumab because this is not currently a licensed delivery route.All of the anti-IL-5 treatments assessed reduced rates of 'clinically significant' asthma exacerbation (defined by treatment with systemic corticosteroids for three days or more) by approximately half in participants with severe eosinophilic asthma on standard of care (at least medium-dose inhaled corticosteroids (ICS)) with poorly controlled disease (either two or more exacerbations in the preceding year or Asthma Control Questionnaire (ACQ) 1.5 or more). Non-eosinophilic participants treated with benralizumab also showed a significant reduction in exacerbation rates, but no data were available for non-eosinophilic participants, and mepolizumab or reslizumab.We saw modest improvements in validated HRQoL scores with all anti-IL-5 agents in severe eosinophilic asthma. However these did not exceed the minimum clinically important difference for ACQ and Asthma Quality of Life Questionnaire (AQLQ), with St. George's Respiratory Questionnaire (SGRQ) only assessed in two studies. The improvement in HRQoL scores in non-eosinophilic participants treated with benralizumab, the only intervention for which data were available in this subset, was not statistically significant, but the test for subgroup difference was negative.All anti-IL-5 treatments produced a small but statistically significant improvement in mean pre-bronchodilator forced expiratory flow in one second (FEV1) of between 0.08 L and 0.11 L.There were no excess serious adverse events with any anti-IL-5 treatment, and indeed a reduction in favour of mepolizumab that could be due to a beneficial effect on asthma-related serious adverse events. There was no difference compared to placebo in adverse events leading to discontinuation with mepolizumab or reslizumab, but significantly more discontinued benralizumab than placebo, although the absolute numbers were small (36/1599 benralizumab versus 9/998 placebo).Mepolizumab, reslizumab and benralizumab all markedly reduced blood eosinophils, but benralizumab resulted in almost complete depletion, whereas a small number remained with mepolizumab and reslizumab. The implications for efficacy and/or adverse events are unclear. AUTHORS' CONCLUSIONS Overall our study supports the use of anti-IL-5 treatments as an adjunct to standard of care in people with severe eosinophilic asthma and poor control. These treatments roughly halve the rate of asthma exacerbations in this population. There is limited evidence for improved HRQoL scores and lung function, which may not meet clinically detectable levels. There were no safety concerns regarding mepolizumab or reslizumab, and no excess serious adverse events with benralizumab, although there remains a question over adverse events significant enough to prompt discontinuation.Further research is needed on biomarkers for assessing treatment response, optimal duration and long-term effects of treatment, risk of relapse on withdrawal, non-eosinophilic patients, children (particularly under 12 years), and comparing anti-IL-5 treatments to each other and, in people eligible for both, to anti-immunoglobulin E. For benralizumab, future studies should closely monitor rates of adverse events prompting discontinuation.
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Key Words
- adolescent
- adult
- child
- humans
- adrenal cortex hormones
- adrenal cortex hormones/administration & dosage
- anti‐asthmatic agents
- anti‐asthmatic agents/administration & dosage
- anti‐asthmatic agents/adverse effects
- antibodies, monoclonal, humanized
- antibodies, monoclonal, humanized/administration & dosage
- antibodies, monoclonal, humanized/adverse effects
- asthma
- asthma/etiology
- asthma/therapy
- disease progression
- injections, intravenous
- injections, subcutaneous
- interleukin‐5
- interleukin‐5/antagonists & inhibitors
- quality of life
- randomized controlled trials as topic
- receptors, interleukin‐5
- receptors, interleukin‐5/antagonists & inhibitors
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Affiliation(s)
| | - Amanda Wilson
- University of NewcastleSchool of Nursing and MidwiferyNewcastleAustralia
| | - Colin Powell
- Cardiff UniversityDepartment of Child Health, The Division of Population Medicine, The School of MedicineCardiffUK
| | - Lynne Bax
- Lancashire Care NHS Foundation TrustSceptre Point, Sceptre WayWalton SummitPrestonUKPR5 6AW
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Bush A, Fleming L, Saglani S. Severe asthma in children. Respirology 2017; 22:886-897. [PMID: 28543931 DOI: 10.1111/resp.13085] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/21/2017] [Accepted: 04/21/2017] [Indexed: 12/16/2022]
Abstract
Most children with asthma have their disease easily controlled if low-dose inhaled corticosteroids (ICSs) are regularly and correctly administered. If a child presents with asthma which is apparently resistant to therapy with high-dose ICS and other controllers, then they have problematic severe asthma. However, in light of the UK National Review of Asthma Deaths, definitions of severe asthma based solely on the levels of prescribed treatment are too narrow. A detailed assessment of all such children should be performed. First, the diagnosis of asthma should be confirmed, then co-morbidities assessed. Next, a nurse-led assessment further characterizes the problem, conventionally categorizing the child as either having difficult asthma or severe therapy-resistant asthma. Here, we reassess in particular the interactions between, and management of, these two categories, highlighting that this dichotomous classification may need reconsideration. We use bronchoscopy and an intramuscular steroid injection to determine if the child has steroid-resistant asthma, using a novel, multidomain approach because the adult definition does not apply to around half the children we see. Finally, we highlight some mechanistic data which have emerged from this protocol such as the absence of T-helper 2 (TH2) cytokines even in eosinophilic severe asthma and the potential role of the innate epithelial cytokine IL-33, novel data on lineage negative innate lymphoid cells, which we can measure in induced sputum, and demonstrating that intraepithelial neutrophils are associated with better, not worse asthma outcomes. Severe paediatric asthma is very different from severe asthma in adults, and approaches must not be uncritically extrapolated from adult disease to children.
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Affiliation(s)
- Andrew Bush
- Paediatric Respiratory Medicine, National Heart and Lung Institute, Imperial College and Royal Brompton Harefield NHS Foundation Trust, London, UK
| | - Louise Fleming
- Paediatric Respiratory Medicine, National Heart and Lung Institute, Imperial College and Royal Brompton Harefield NHS Foundation Trust, London, UK
| | - Sejal Saglani
- Paediatric Respiratory Medicine, National Heart and Lung Institute, Imperial College and Royal Brompton Harefield NHS Foundation Trust, London, UK
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Katial RK, Bensch GW, Busse WW, Chipps BE, Denson JL, Gerber AN, Jacobs JS, Kraft M, Martin RJ, Nair P, Wechsler ME. Changing Paradigms in the Treatment of Severe Asthma: The Role of Biologic Therapies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:S1-S14. [PMID: 28143691 DOI: 10.1016/j.jaip.2016.11.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 11/21/2016] [Accepted: 11/23/2016] [Indexed: 11/30/2022]
Abstract
Cytokine antagonists are monoclonal antibodies that offer new treatment options for refractory asthma but will also increase complexity because they are effective only for patients with certain asthma subtypes that remain to be more clearly defined. The clinical and inflammatory heterogeneity within refractory asthma makes it difficult to manage the disease and to determine which, if any, biologic therapy is suitable for a specific patient. The purpose of this article is to provide a data-driven discussion to clarify the use of biologic therapies in patients with refractory asthma. We first discuss the epidemiology and pathophysiology of refractory asthma. We then interpret current evidence for biomarkers of eosinophilic or type 2-high asthma so that clinicians can determine potential treatments for patients based on knowledge of their effectiveness in specific asthma phenotypes. We then assess clinical data on the efficacy, safety, and mechanisms of action of approved and pipeline biologic therapies. We conclude by discussing the potential of phenotyping or endotyping refractory asthma and how biologic therapies can play a role in treating patients with refractory asthma.
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Affiliation(s)
- Rohit K Katial
- Department of Medicine, Division of Allergy and Clinical Immunology, National Jewish Health, Denver, Colo.
| | - Greg W Bensch
- Allergy, Immunology and Asthma Medical Group, Stockton, Calif
| | - William W Busse
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Joshua L Denson
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colo; Division of Pulmonary Sciences and Critical Care Medicine, School of Medicine, University of Colorado at Denver, Anschutz Medical Campus, Aurora, Colo
| | - Anthony N Gerber
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colo; Department of Biomedical Research, National Jewish Health, Denver, Colo
| | - Joshua S Jacobs
- Allergy and Asthma Clinical Research, Inc., Walnut Creek, Calif
| | - Monica Kraft
- Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona Health Sciences, Tucson, Ariz
| | | | - Parameswaran Nair
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael E Wechsler
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colo
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