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Role of CD4 + T Cells in Allergic Airway Diseases: Learning from Murine Models. Int J Mol Sci 2020; 21:ijms21207480. [PMID: 33050549 PMCID: PMC7589900 DOI: 10.3390/ijms21207480] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 01/18/2023] Open
Abstract
The essential contribution of CD4+ T cells in allergic airway diseases has been demonstrated, especially by using various murine models of antigen-induced airway inflammation. In addition to antigen-immunized mouse models employing mast cell-deficient mice and CD4+ T cell-depleting procedure, antigen-specific CD4+ T cell transfer models have revealed the possible development of allergic inflammation solely dependent on CD4+ T cells. Regardless of the classical Th1/Th2 theory, various helper T cell subsets have the potential to induce different types of allergic inflammation. T cell receptor (TCR)-transgenic (Tg) mice have been used for investigating T cell-mediated immune responses. Besides, we have recently generated cloned mice from antigen-specific CD4+ T cells through somatic cell nuclear transfer. In contrast to TCR-Tg mice that express artificially introduced TCR, the cloned mice express endogenously regulated antigen-specific TCR. Upon antigen exposure, the mite antigen-reactive T cell-cloned mice displayed strong airway inflammation accompanied by bronchial hyperresponsiveness in a short time period. Antigen-specific CD4+ T cell-cloned mice are expected to be useful for investigating the detailed role of CD4+ T cells in various allergic diseases and for evaluating novel anti-allergic drugs.
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Ophthalmic manifestations and management of common and rare autoimmune syndromes. Curr Opin Allergy Clin Immunol 2020; 20:493-500. [DOI: 10.1097/aci.0000000000000674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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53
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Biologics for Severe Asthma: Treatment-Specific Effects Are Important in Choosing a Specific Agent. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1379-1392. [PMID: 31076056 DOI: 10.1016/j.jaip.2019.03.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 02/25/2019] [Accepted: 03/03/2019] [Indexed: 12/19/2022]
Abstract
Patients with uncontrolled severe persistent asthma have greater morbidity, greater use of health care resources, and more impairment in health-related quality of life when compared with their peers with well-controlled disease. Fortunately, since the introduction of biological therapeutics, patients with severe eosinophilic asthma now have beneficial treatment options that they did not have just a few years ago. In addition to anti-IgE therapy for allergic asthma, 3 new biological therapeutics targeting IL-5 and 1 targeting IL-4 and IL-13 signaling have recently been approved by the Food and Drug Administration for the treatment of severe eosinophilic asthma, and approval of more biological therapeutics is on the horizon. These medications decrease the frequency of asthma exacerbations, improve lung function, reduce corticosteroid usage, and improve health-related quality of life. This article reviews the mechanisms of action, specific indications, benefits, and side effects of each of the approved biological therapies for asthma. Furthermore, this article reviews how a clinician could use specific patient characteristics to decide which biologic treatment may be optimal for a given patient.
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The Role of Biologics and Precision-Based Medicine in Treating Atopic Diseases in Children. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00256-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Both asthma and anaphylaxis are recognized noncommunicable hypersensitivity conditions, which should be correctly diagnosed and treated/controlled in order to decrease avoidable deaths. Nevertheless, their association is not completely clear. We here propose to review the current and new evidence-based data of asthma and anaphylaxis in the view of the new knowledge in the field that can support the quality practice and empower allergists and health professionals in treating symptoms and preventing death. RECENT FINDINGS Hypersensitivity life-threatening conditions, such as anaphylaxis and asthma can coexist, mimic or worse each other. Asthma itself is not a strong predictor of more severe anaphylaxis. However, poor asthma control associated with more severe anaphylaxis reactions in all ages. In children, asthma is associated with the severity and recurrences of anaphylactic reactions. SUMMARY Although recent data point for the association between asthma and anaphylaxis, we still do not have harmonized evidence to confirm if we are dealing with two independent comorbidities one worsening each other. However, as far as this review is covering two relevant public health problems in the field of allergy, it is mandatory put in place decisions supporting recommendations to better manage the affected patients and reduce the risk.General strategies should include regular notification of this association, optimization of the classification and coding for anaphylaxis and asthma (new ICD 11 allergy codes) in order to harmonize epidemiological stratified data, early diagnosis of asthma in childhood, regular investigation of asthma in cases of anaphylaxis and optimization of the asthma control and lung function for all patients with indication to provocation tests, desensitization or allergen immunotherapy regardless to the trigger. Implementation of these strategies will involve national and international support for ongoing efforts in relationship with networks of centres of excellence to provide personalized management for the most at-risk patients and prevent death.
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Fu Z, Xu Y, Cai C. Efficacy and safety of omalizumab in children with moderate-to-severe asthma: a meta-analysis. J Asthma 2020; 58:1350-1358. [PMID: 32602383 DOI: 10.1080/02770903.2020.1789875] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of omalizumab in children with moderate-to-severe asthma.Data sources: We systematically searched MEDLINE, EMBASE, and Cochrane for randomized controlled trials (RCTs ) (inception to January 2020).Study selections: All RCTs which were conducted in childhood and adolescence with asthma and compared the efficacy or safety of omalizumab were adopted. RESULTS Three studies with four publications including 1380 pediatric patients met our criteria. For children with moderate-to-severe asthma, omalizumab decreased asthma exacerbations rate (OR 0.51, 95% CI: 0.44-0.58, p < 0.001) compared with placebo with no evidence of heterogeneity. Omalizumab reduced the rate of asthma exacerbations 0.58) with treatment period ≥30 weeks (p for heterogeneity = 0.03). Omalizumab treated patients had an excellent or good response rate of treatment effectiveness assessed by physicians (2.75, 2.45-3.09) and a bigger reduction in the dosage of inhaled corticosteroid (ICS) at the end of follow-up. For children with severe asthma, omalizumab also reduced the likelihood of asthma exacerbations and increased the odd of treatment effectiveness rated as excellent or good. Patients receiving omalizumab had a lower incidence of severe adverse events (0.36, 0.22-0.57). CONCLUSIONS These findings suggested that omalizumab had beneficial effects on moderate-to-severe asthma in children. Patients may benefit more from long-term use of omalizumab. In addition, omalizumab reduces the rate of serious adverse events requiring hospitalizations.
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Affiliation(s)
- Zhuo Fu
- Tianjin Medical University, Tianjin, PR China.,Respiratory Department, Tianjin Children's Hospital, Tianjin, PR China
| | - Yongsheng Xu
- Respiratory Department, Tianjin Children's Hospital, Tianjin, PR China
| | - Chunquan Cai
- Department of Neurosurgery, Tianjin Institute of Pediatrics, Tianjin Children's Hospital, Tianjin, PR China
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Abstract
PURPOSE OF REVIEW Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous inflammatory condition with different endotypes between patients from eastern or western countries. Targeted biologics are currently used to treat CRSwNP, but the outcomes widely vary. This review focuses on the present use of biologics for treating CRSwNP. RECENT FINDINGS Monoclonal biologics have been used as an innovative therapy for multiple allergic diseases and comorbid allergic conditions. Over the past several decades, numerous biomarkers have been investigated and were found to be closely correlated with CRSwNP, improving the understanding of inflammatory patterns and endotype classifications for CRSwNP and prompting discussion regarding the use of biologics in CRSwNP. Efficacies vary in reports of different research groups, but it has been found that patients with TH-2-driven inflammatory patterns respond better to the use of biologics than those with non-TH-2-driven CRSwNP. These findings suggest the importance and urgency of developing criteria for biologics in CRSwNP. SUMMARY Precisely determining patient criteria, identifying treatment biomarkers based on endotyping for CRSwNP and determinations of contraindications for long-term utilization may be useful for optimizing treatment strategies and improving the therapeutic efficacy of biologics to achieve long-term control starting at early stages.
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58
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Tison KL, Patrawala M, Blaiss MS. Monoclonal Antibody Therapy in Childhood Asthma. Curr Allergy Asthma Rep 2020; 20:26. [PMID: 32430808 DOI: 10.1007/s11882-020-00919-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW There has been an explosion of monoclonal antibodies in the treatment of severe uncontrolled adult asthma. Studies have now been published in severe pediatric asthma. There are numerous questions that need to be answered in determining whether these modalities are appropriate and safe in children. RECENT FINDINGS This is a narrative review examining the latest pediatric literature on monoclonal antibodies, both approved and in the pipeline, for uncontrolled asthma. Presently, all of the biologics are positioned to treat patients with underlying type 2 high disease. Two monoclonal antibodies are approved for children 6 years of age and older, omalizumab and mepolizumab, with more likely approved in the near future. The effect of these agents in controlling severe pediatric asthma is promising. Data is limited to long-term efficacy and safety, and whether any agent has an effect on the natural history of asthma.
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Affiliation(s)
- Katherine L Tison
- Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Meera Patrawala
- Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Michael S Blaiss
- Medical College of Georgia at Augusta University, Augusta, GA, USA. .,, Roswell, GA, USA.
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Agache I, Rocha C, Beltran J, Song Y, Posso M, Solà I, Alonso‐Coello P, Akdis C, Akdis M, Canonica GW, Casale T, Chivato T, Corren J, Del Giacco S, Eiwegger T, Firinu D, Gern JE, Hamelmann E, Hanania N, Mäkelä M, Martín IH, Nair P, O'Mahony L, Papadopoulos NG, Papi A, Park H, Pérez de Llano L, Quirce S, Sastre J, Shamji M, Schwarze J, Canelo‐Aybar C, Palomares O, Jutel M. Efficacy and safety of treatment with biologicals (benralizumab, dupilumab and omalizumab) for severe allergic asthma: A systematic review for the EAACI Guidelines - recommendations on the use of biologicals in severe asthma. Allergy 2020; 75:1043-1057. [PMID: 32064642 DOI: 10.1111/all.14235] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 01/01/2023]
Abstract
Allergic asthma is a frequent asthma phenotype. Both IgE and type 2 cytokines are increased, with some degree of overlap with other phenotypes. Systematic reviews assessed the efficacy and safety of benralizumab, dupilumab and omalizumab (alphabetical order) vs standard of care for patients with uncontrolled severe allergic asthma. PubMed, Embase and Cochrane Library were searched to identify RCTs and health economic evaluations, published in English. Critical and important asthma-related outcomes were evaluated. The risk of bias and the certainty of the evidence were assessed using GRADE. All three biologicals reduced with high certainty the annualized asthma exacerbation rate: benralizumab incidence rate ratios (IRR) 0.63 (95% CI 0.50 - 0.81); dupilumab IRR 0.58 (95%CI 0.47 - 0.73); and omalizumab IRR 0.56 (95%CI 0.42 - 0.73). Benralizumab and dupilumab improved asthma control with high certainty and omalizumab with moderate certainty; however, none reached the minimal important difference (MID). Both benralizumab and omalizumab improved QoL with high certainty, but only omalizumab reached the MID. Omalizumab enabled ICS dose reduction with high certainty. Benralizumab and omalizumab showed an increase in drug-related adverse events (AEs) with low to moderate certainty. All three biologicals had moderate certainty for an ICER/QALY value above the willingness to pay threshold. There was high certainty that in children 6-12 years old omalizumab decreased the annualized exacerbation rate [IRR 0.57 (95%CI 0.45-0.72)], improved QoL [relative risk 1.43 (95%CI 1.12 -1.83)], reduced ICS [mean difference (MD) -0.45 (95% CI -0.58 to -0.32)] and rescue medication use [ MD -0.41 (95%CI -0.66 to -0.15)].
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60
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Pajno GB, Castagnoli R, Arasi S, Licari A, Caminiti L, Marseglia GL. Pediatric use of omalizumab for allergic asthma. Expert Opin Biol Ther 2020; 20:695-703. [PMID: 32241196 DOI: 10.1080/14712598.2020.1751115] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Severe pediatric asthma is associated with significant morbidity as well as with a high economic burden. It represents a heterogeneous disease with multiple clinical phenotypes. Currently, physicians are facing the challenge to provide a 'personalized medicine approach', which is tailored to the diverse pathomechanisms underlying clinical presentations. Three main endotypes of airway inflammation have been described in children with severe asthma. While neutrophilic and paucigranulocytic inflammatory patterns are quite uncommon in childhood, type Th2 inflammation asthma with elevated IgE is the most prevalent in pediatric asthma. Considering the pivotal role of IgE in type Th2 inflammation asthma, the blockade of IgE using anti-IgE therapy represents a potent therapeutic option for severe pediatric asthma in children. AREAS COVERED This review aims to focus on the role of omalizumab as a treatment option in pediatric patients (aged six years and above) with severe allergic asthma. EXPERT OPINION The clinical efficacy and safety of omalizumab for the treatment of pediatric asthma is well documented in clinical trials and observational studies. Further studies are still required to characterize the potential benefit of anti-IgE therapy in airway remodeling, identify additional biomarkers of clinical response and address current unmet needs, including the limit on omalizumab use in children younger than six years.
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Affiliation(s)
| | - Riccardo Castagnoli
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
| | - Stefania Arasi
- Pediatric Allergology Unit, Bambino Gesù Hospital (IRCCS) , Rome, Italy
| | - Amelia Licari
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
| | - Lucia Caminiti
- Department of Pediatrics, Allergy Unit, University of Messina , Messina, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
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Hoshi M, Matsunaga M, Nogami K, Hamada K, Kobori T, Kainuma K, Nagao M, Fujisawa T. Three cases of severe adolescent asthma treated with mepolizumab: lung function trajectories. Asia Pac Allergy 2020; 10:e13. [PMID: 32411578 PMCID: PMC7203436 DOI: 10.5415/apallergy.2020.10.e13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/02/2020] [Indexed: 12/19/2022] Open
Abstract
Real-world experience with mepolizumab for pediatric asthma is still limited. We report 3 patients who were treated with mepolizumab for severe adolescent asthma. Two patients, a 12-year-old boy and a 14-year-old girl, responded well to mepolizumab and showed apparent improvement in lung function from a downward trend over time before treatment. The third patient, a 16-year-old boy, whose treatment was switched from omalizumab to mepolizumab, did not have satisfactory response. The 2 successful cases had eosinophil counts of 440 and 371/μL and multiple comorbid allergic diseases including food allergies. The clinical benefit to them included elimination of both exacerbation and exercise-induced asthma. Interestingly, the boy's food-induced gastrointestinal symptoms disappeared following start of mepolizumab treatment.
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Affiliation(s)
- Miyuki Hoshi
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Mayumi Matsunaga
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Kazutaka Nogami
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Kana Hamada
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Taiga Kobori
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Keigo Kainuma
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Mizuho Nagao
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Takao Fujisawa
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
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Lovinsky-Desir S. The use of biologic therapies for the management of pediatric asthma. Pediatr Pulmonol 2020; 55:803-808. [PMID: 31880870 PMCID: PMC7018587 DOI: 10.1002/ppul.24613] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/11/2019] [Indexed: 11/07/2022]
Abstract
With better understanding of the role of type 2 inflammation in allergic asthma, there has been progress made in the development of new biologic therapies targeting these specific pathways. This review will consider diagnostic criteria for using biologic therapies for pediatric asthma with special emphasis on populations that are likely to benefit the most from particular therapies. With the exception of the anti-immunoglobulin E, omalizumab, very few studies have been published on the efficacy and safety of biologic therapies in children, particularly anti-interleukin-5 (IL5) and anti-IL4/IL13 therapies. The review will highlight the scarcity of published data in pediatric-specific populations. In addition, we will consider the cost-effectiveness as well as potential long-term consequences of biologic therapies in pediatric asthma.
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Affiliation(s)
- Stephanie Lovinsky-Desir
- Division of Pediatric Pulmonology, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York
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63
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Castagnoli R, Marseglia A, Brambilla I, Marseglia GL, Licari A. Severe uncontrolled asthma in children: practical approach on diagnosis and management. Minerva Pediatr 2020; 72:196-205. [PMID: 32108455 DOI: 10.23736/s0026-4946.20.05818-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe uncontrolled asthma in children is a complex and heterogeneous disease and is considered a challenge for the pediatricians. Although nearly 5% of children with asthma present with a severe uncontrolled disease, these patients and their caregivers face a significant burden, including troublesome persistent symptoms, life-threatening acute attacks, medication side effects, impaired school performance, neuropsychological problems, and lower quality of life (QoL). Moreover, these patients also account for substantially higher healthcare resource use and costs than average patients with asthma. Thus, it is essential to accurately define and diagnose severe asthma in children as they potentially need close monitoring and additional treatment with advanced therapies. This review aims to update knowledge on diagnosis and management of severe uncontrolled asthma in childhood. We describe a practical approach to differentiate children with difficult-to-treat asthma from those with true severe therapy-resistant asthma. Moreover, the recent advances in the understanding of the pathogenetic mechanisms and inflammatory mediators involved in asthma have paved the way for the development of a precision medicine approach. In this context, we analyze approved personalized therapies for severe uncontrolled asthma, focusing on the pediatric indications.
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Affiliation(s)
- Riccardo Castagnoli
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy
| | - Alessia Marseglia
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy
| | - Ilaria Brambilla
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy
| | - Amelia Licari
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy -
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64
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Akar-Ghibril N, Casale T, Custovic A, Phipatanakul W. Allergic Endotypes and Phenotypes of Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:429-440. [PMID: 32037107 PMCID: PMC7569362 DOI: 10.1016/j.jaip.2019.11.008] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/30/2019] [Accepted: 11/16/2019] [Indexed: 12/12/2022]
Abstract
Allergic asthma is defined as asthma associated with sensitization to aeroallergens, which leads to asthma symptoms and airway inflammation. Allergic asthma is the most common asthma phenotype. The onset of allergic asthma is most often in childhood and is usually accompanied by other comorbidities including atopic dermatitis and allergic rhinitis. It is often persistent although there is a wide variation in disease severity. It is a TH2-driven process. Biomarkers have been identified to distinguish patients with allergic asthma, particularly serum IgE levels, tests to indicate sensitization to aeroallergens such as specific IgE or skin prick test positivity, blood and sputum eosinophil levels, fraction of exhaled nitric oxide, and periostin. Treatments for allergic asthma include environmental control measures, allergen immunotherapy, and glucocorticoids. Biologics, targeting the TH2 pathway, have been shown to be effective in the treatment of allergic asthma.
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Affiliation(s)
- Nicole Akar-Ghibril
- Division of Pediatric Allergy/Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Thomas Casale
- Division of Allergy and Immunology, University of South Florida Health Morsani College of Medicine, Tampa, Fla
| | - Adnan Custovic
- Respiratory Division, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Wanda Phipatanakul
- Division of Pediatric Allergy/Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
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65
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Licari A, Castagnoli R, Tondina E, Testa G, Parisi GF, Marseglia A, Brambilla I, Marseglia GL. Novel Biologics for the Treatment of Pediatric Severe Asthma. CURRENT RESPIRATORY MEDICINE REVIEWS 2020. [DOI: 10.2174/1573398x15666190521111816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Estimated to represent less than 5% of all asthmatic patients, children with severe asthma
experience troublesome persistent symptoms, life-threatening attacks and side effects by oral
corticosteroid treatment, that significantly impact on the quality of life and on economic costs. An
accurate understanding of the mechanisms of the disease has been crucial for the discovery and
development of biological therapies, for which children with severe asthma are candidates. The aim
of this review is to discuss the use of approved biologics for severe asthma, providing updated evidence
of novel targeted therapies in the pediatric age range.
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Affiliation(s)
- Amelia Licari
- S.C. Pediatria, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Enrico Tondina
- Department of Pediatrics, University of Pavia, Pavia, Italy
| | - Giorgia Testa
- S.C. Pediatria, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Fabio Parisi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Ilaria Brambilla
- S.C. Pediatria, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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66
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Pajor NM, Guilbert TW. Personalized Medicine and Pediatric Asthma. Immunol Allergy Clin North Am 2019; 39:221-231. [PMID: 30954172 DOI: 10.1016/j.iac.2018.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Asthma is a heterogeneous disorder described by a large number of clinical features. A growing body of literature on more specific asthma phenotypes provides evidence for a phenotype-based approach to management in which specific therapies are recommended based on patient and disease characteristics. This understanding, coupled with an increase in the number of available therapies for children with asthma, as well as emerging therapies and phenotypic markers, will allow for improved asthma management in the future.
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Affiliation(s)
- Nathan M Pajor
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH 45229, USA
| | - Theresa W Guilbert
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Pulmonary Division, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH 45229, USA.
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67
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Bayar Muluk N, Bafaqeeh SA, Cingi C. Anti-IgE treatment in allergic rhinitis. Int J Pediatr Otorhinolaryngol 2019; 127:109674. [PMID: 31526939 DOI: 10.1016/j.ijporl.2019.109674] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/08/2019] [Accepted: 09/05/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To review the efficacy of anti-IgE therapy in allergic rhinitis (AR). METHODS Literature search was performed using the PubMed and Proquest Central databases at Kırıkkale University Library. RESULTS Although the skin prick testing in patients suffering from AR is positive (indicating that antigen-specific Immunoglobulin E has been produced), there is no association with overall circulating IgE levels. Correlation was lacking between circulating IgE level and either skin prick tests or laboratory testing for specific IgE. Omalizumab binds to uncomplexed IgE in man more avidly than does Fc-epsilon. The effect of omalizumab is to lower the level of IgE and downgrade production of FceRI receptors (which bind IgE) in mast cells and basophils, causing less mast cell recruitment and responsivity and thus diminishing eosinophilic infiltration and activation. Anti-IgE therapy through omalizumab may shorten the lifetime of mast cells and causes dendritic cells to downgrade their production of FcεRI. There are reports indicating benefit from omalizumab in managing food allergies, nasal polyp formation, essential anaphylaxis, AR, venom allergy and eczema. Omalizumab acts to lessen circulating IgE levels, whilst reducing production of FceRI by mast cells and basophils. The fact that omalizumab influences how eosinophils respond may be down to disruption of the antigen-IgE-mast cell interactions, with mast cells being recruited at lower levels and thus chemotactic eosinophilic recruitment via cytokines being greatly reduced. Omalizumab has the effect in cases of perennial AR of blocking the increased eosinophilic recruitment and tissue infiltration initiated by seasonal antigens. Likewise, in omalizumab-treated cases, circulating unbound IgE levels showed significant decreases. For patients with perennial AR, the average daily nasal severity score was significantly reduced where omalizumab was administered, compared to placebo. CONCLUSION Omalizumab has efficacy in ameliorating symptoms and reduces the necessity for additional medication in both seasonal and perennial allergic rhinitis.
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Affiliation(s)
- Nuray Bayar Muluk
- Kirikkale University, Medical Faculty, Department of Otorhinolaryngology, Kirikkale, Turkey.
| | - Sameer Ali Bafaqeeh
- King Saud University, Faculty of Medicine, Department of Otorhinolaryngology, Riyadh, Saudi Arabia.
| | - Cemal Cingi
- Eskisehir Osmangazi University, Medical Faculty, Department of Otorhinolaryngology, Eskisehir, Turkey.
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Giovannini M, Mori F, Barni S, de Martino M, Novembre E. Omalizumab and mepolizumab in the landscape of biological therapy for severe asthma in children: how to choose? Ital J Pediatr 2019; 45:151. [PMID: 31779657 PMCID: PMC6883618 DOI: 10.1186/s13052-019-0737-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 10/15/2019] [Indexed: 12/17/2022] Open
Abstract
Severe asthma has a substantial epidemiological impact on children and biological treatments can be an option to take into account, as they target specific molecules and pathways involved in its pathogenesis. Modern medicine is continuously and progressively oriented towards tailored treatments designed specifically for the pathology patterns observed in individual patients and identified as endotypes with associated biomarkers. In this regard, biologic treatments in asthma are one of the best examples. Among the biological drugs currently available, omalizumab is the one with the greatest amount of data on efficacy and safety, and the one we have more real-life clinical experience with. However, mepolizumab will likely be accessible soon globally for clinical use. Moreover, research on biological drugs for the treatment of severe asthma is expanding rapidly, with some molecules currently used in adult patients that could be registered also for pediatric use and new molecules that could be available in the future. On the other hand, due to this potential abundance of therapeutic options, new criteria could become necessary to guide clinicians through an evidence-based choice between omalizumab and these new drugs. For the same reason, more data collected specifically from pediatric clinical trials are necessary. In this review we aim to analyze the factors that could help clinicians make their choice and to highlight the unmet need for a more evidence-based choice.
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Affiliation(s)
- Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy. .,Post-Graduate School of Pediatrics, Department of Health Sciences, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy
| | - Maurizio de Martino
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini 24, 50139, Florence, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy
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69
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Burg GT, Covar R, Oland AA, Guilbert TW. The Tempest: Difficult to Control Asthma in Adolescence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:738-748. [PMID: 29747981 DOI: 10.1016/j.jaip.2018.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/02/2018] [Accepted: 02/03/2018] [Indexed: 02/06/2023]
Abstract
Severe asthma is associated with significant morbidity and is a highly heterogeneous disorder. Severe asthma in adolescence has some unique elements compared with the features of severe asthma a medical provider would see in younger children or adults. A specific focus on psychological issues and adherence highlights some of the challenges in the management of asthma in adolescents. Treatment of adolescents with severe asthma now includes 3 approved biologic phenotype-directed therapies. Therapies available to adults may be beneficial to adolescents with severe asthma. Research into predictors of specific treatment response by phenotypes is ongoing. Optimal treatment strategies are not yet defined and warrant further investigation.
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Affiliation(s)
- Gregory T Burg
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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70
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Lou H, Wang C, Zhang L. Endotype-driven precision medicine in chronic rhinosinusitis. Expert Rev Clin Immunol 2019; 15:1171-1183. [PMID: 31600458 DOI: 10.1080/1744666x.2020.1679626] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Hongfei Lou
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Chengshuo Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Luo Zhang
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
- Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China
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71
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Niehues T, Özgür TT. The Efficacy and Evidence-Based Use of Biologics in Children and Adolescents: Using Monoclonal Antibodies and Fusion Proteins as Treatments. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:703-710. [PMID: 31711560 PMCID: PMC6891884 DOI: 10.3238/arztebl.2019.0703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 12/27/2018] [Accepted: 07/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Monoclonal antibodies (mAb) and fusion proteins (FP) are increasingly being used in children and adolescents. In this review, we analyze the evidence for their safety and efficacy in the treatment of the most common chronic inflammatory diseases. METHODS We systematically searched PubMed, AWMF.org, and other databases for high-quality trials (i.e., randomized controlled trials with clinical primary endpoints) and guidelines published at any time up to 10 December 2018 that dealt with mAb and FP that are approved for pediatric use. The search term was "monoclonal anti- body/fusion protein [e. g. adalimumab] AND children." RESULTS The 620 hits included 25 high-quality trials (20 of them manufacturer- sponsored) on 9 mAb/FP (omalizumab, adalimumab, etanercept, ustekinumab, infliximab, golimumab, anakinra, canakinumab, tocilizumab, and abatacept), as well as 6 guidelines (3 each of levels S3 and S2k) on the treatment of bronchial asthma, psoriasis, juvenile idopathic arthritis, and chronic inflammatory bowel diseases. For none of these conditions are mAb and FP the drugs of first choice. Adverse drug effects are rare but sometimes severe (infection, immune dysregulation, tumors). CONCLUSION The retrieved trials have deficiencies that make it difficult to reliably evaluate the efficacy, safety, and utility of mAb/FP for children and adolescents with chronic inflammatory diseases. mAb/FP nonetheless represent a treatment option to be considered in case conventional immune-modulating drugs are ineffective. Researcher-initiated, high-quality trials and manufacturer-independent, systematic long-term evaluations of adverse effects (e.g., tumors) are sorely needed.
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Affiliation(s)
- Tim Niehues
- Department of Pediatrics and Adolescent Medicine, HELIOS Klinikum Krefeld
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72
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Porcaro F, Cutrera R, Pajno GB. Options of immunotherapeutic treatments for children with asthma. Expert Rev Respir Med 2019; 13:937-949. [PMID: 31414917 DOI: 10.1080/17476348.2019.1656533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Asthma is the most common chronic disease in children. Avoiding triggers, and pharmacologic treatment with short acting beta-agonist, inhaler corticosteroids and anti-leukotriene are often enough to obtain symptoms control. Nevertheless, there is a subset of children with severe asthma and poor symptom control despite maximal therapy. In these patients, anti-IgE and anti-IL5 monoclonal antibodies are suggested as the fifth step of Global Initiative for Asthma guidelines. Area covered: Immunotherapeutic treatments are now suggested for asthma management. This article will discuss the available evidence on allergen immunotherapy and biologic drugs in pediatric asthma treatment. Expert opinion: Previously published studies demonstrated a good efficacy and safety profile of Allergen Immunotherapy in patients with mild-moderate asthma and sensitization to one main allergen. New understanding of mechanisms underlying severe asthma inflammation has allowed the identifications of specific biomarkers guiding the clinician in the choice of patient specific drug. Among the suggested immunotherapeutic options, omalizumab (blocking IgE) remains the first choice for atopic 'early onset' asthma in patients aged over 6 years. Instead, mepolizumab (blocking the IL5 ligand) should be considered for 'eosinophilic' asthma. Other biologic drugs are under consideration but data on the pediatric population are still lacking.
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Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Hospital , Rome , Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Hospital , Rome , Italy
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Omalizumab Treatment Patterns Among Patients with Asthma in the US Medicare Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:507-515.e10. [PMID: 31336178 DOI: 10.1016/j.jaip.2019.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Asthma in older adults is associated with high rates of morbidity and mortality; similarly, asthma can be severe enough among younger adults to warrant disability benefits. Reasons for poor outcomes in both groups of patients may include discontinuation and lack of adherence to controller therapies. OBJECTIVE To examine characteristics and treatment patterns of US Medicare patients initiating omalizumab for asthma, and factors associated with its discontinuation and adherence. METHODS A retrospective claims database analysis of Medicare beneficiaries with asthma initiating omalizumab treatment was carried out. The primary outcomes were omalizumab discontinuation (gap in use ≥90 days) and adherence (proportion of days covered ≥0.8) over a 12-month follow-up. Multivariable regressions were used to examine factors associated with omalizumab discontinuation and adherence. RESULTS Of the 3058 Medicare patients initiating omalizumab for asthma (mean age, 62.7 years), 36.9% discontinued omalizumab and 60.6% were adherent. Discontinuation rates were 32.7% and 42.8%, and adherence rates were 65.4% and 53.9%, for disabled and older Medicare patients, respectively. Patients aged 65 to 69 years and 70 to 74 years had significantly lower odds of discontinuation (odds ratios [95% CI], 0.66 [0.46-0.93] and 0.62 [0.43-0.89], respectively) and higher odds of adherence than did patients aged 80 years or older. Compared with patients receiving low-income subsidy, patients not receiving low-income subsidy had lower odds of discontinuation (0.66 [0.52-0.83]) and higher odds of adherence (1.52 [1.20-1.93]). Greater numbers of preindex evaluation and management physician visits and comorbid rhinitis were associated with lower odds of discontinuation and higher odds of adherence. CONCLUSIONS More than 60% of Medicare patients with asthma continued and were adherent to omalizumab over a 12-month follow-up. Patient age, low-income subsidy status, and the numbers of evaluation and management physician visits were among factors associated with treatment adherence and discontinuation.
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74
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Giallongo A, Parisi GF, Licari A, Pulvirenti G, Cuppari C, Salpietro C, Marseglia GL, Leonardi S. Novel therapeutic targets for allergic airway disease in children. Drugs Context 2019; 8:212590. [PMID: 31391855 PMCID: PMC6668505 DOI: 10.7573/dic.212590] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 12/22/2022] Open
Abstract
The aim of precision medicine is setting up targeted therapies for selected patients that would ideally have high effectiveness and few side effects. This is made possible by targeted therapy drugs that selectively act on a specific pathway. Precision medicine is spreading to many medical specialties, and there is increasing interest in the context of allergic airway diseases, such as allergic rhinitis, chronic rhinosinusitis, and asthma. This review is an update of new targets in the treatment of childhood allergic upper airway diseases and asthma, including the most recent biologic drugs that have already been licensed or are in the pipeline to be tested with children.
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Affiliation(s)
- Alessandro Giallongo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giuseppe Fabio Parisi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Amelia Licari
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Giulio Pulvirenti
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Caterina Cuppari
- Department of Human Pathology of the Adult and Developmental Age 'Gaetano Barresi,' Unit of Pediatric Emergency, University of Messina, Messina, Italy
| | - Carmelo Salpietro
- Department of Human Pathology of the Adult and Developmental Age 'Gaetano Barresi,' Unit of Pediatric Emergency, University of Messina, Messina, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Salvatore Leonardi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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Folqué M, Lozano J, Riggioni C, Piquer M, Álvaro M, Machinena A, Giner M, Domínguez O, Jiménez-Feijoo R, Dias da Costa M, Plaza A. 'Real-life' experience in asthmatic children treated with omalizumab up to six-years follow-up. Allergol Immunopathol (Madr) 2019; 47:336-341. [PMID: 30509559 DOI: 10.1016/j.aller.2018.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 09/04/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Omalizumab is present in international guidelines for the control of severe asthma, but data on the long-term effects in children are limited. Our objective was to perform a 'real-life' long-term trial of omalizumab in children with allergic asthma. MATERIALS AND METHODS An observational single center 'real-life' study was performed. Data for treatment, lung function, side effect, asthma exacerbations and hospitalizations were recorded at six months and annually. RESULTS Forty-eight patients <18 years of age were enrolled. Median treatment period was 2.9 (0.5-6). Fluticasone dose for the maintenance treatment decreases significantly at six months (452mcg/day to 329.89mcg/day, respectively). This difference was maintained throughout the follow-up. Nobody used oral corticosteroid after six months. The rate of hospital admissions and visits to the emergency department for asthma exacerbations decreased significantly in the third years and fourth years follow-up, respectively. There was an improvement in lung function. Mean values of FEV1 and FEF25-75% before treatment were 79.88 and 62.94, respectively; after six months of treatment a statistically significant change was seen with a mean FEV1 of 92.29 and FEF25-75% of 76.31 (p=0.0001). Lung function values were above normal throughout the six years of treatment. No side effects were reported. CONCLUSIONS Overall in 'real life' omalizumab in children reduces asthma exacerbations and hospitalizations, improves lung function, and decreases the maintenance therapy. It is shown to be safe for up to six years of treatment in children.
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76
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Saeki M, Nishimura T, Kitamura N, Hiroi T, Mori A, Kaminuma O. Potential Mechanisms of T Cell-Mediated and Eosinophil-Independent Bronchial Hyperresponsiveness. Int J Mol Sci 2019; 20:ijms20122980. [PMID: 31216735 PMCID: PMC6627885 DOI: 10.3390/ijms20122980] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 12/14/2022] Open
Abstract
Bronchial asthma is a chronic disease characterized by reversible airway obstruction, mucus production, and bronchial hyperresponsiveness (BHR). Although Th2 cell-mediated eosinophilic inflammation is an important disease mechanism in the majority of patients with bronchial asthma, recent studies suggest the possible development of Th2-independent airway inflammation and BHR. These non-Th2 endotype patients seem to consist of multiple subgroups, and often do not respond to inhaled corticosteroids. Therefore, to understand the pathogenesis of asthma, it is important to characterize these non-Th2 subgroups. Recently, we demonstrated that Th9 cells induce eosinophil infiltration and eosinophil-independent BHR, and Th9 cells-mediated BHR may be resistant to glucocorticoid. In this review, we summarize the contribution of several T cell subsets in the development of bronchial asthma and introduce our recent study demonstrating Th9 cell-mediated and eosinophil-independent BHR.
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Affiliation(s)
- Mayumi Saeki
- Allergy and Immunology Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan.
| | - Tomoe Nishimura
- Allergy and Immunology Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan.
| | - Noriko Kitamura
- Allergy and Immunology Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan.
| | - Takachika Hiroi
- Allergy and Immunology Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan.
| | - Akio Mori
- Allergy and Immunology Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan.
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa 252-0392, Japan.
| | - Osamu Kaminuma
- Allergy and Immunology Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan.
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa 252-0392, Japan.
- Department of Disease Model, Research Institute of Radiation Biology and Medicine, Hiroshima University, Hiroshima 734-0037, Japan.
- Center for Life Science Research, University of Yamanashi, Yamanashi 400-8510, Japan.
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77
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Kennedy JL, Pham S, Borish L. Rhinovirus and Asthma Exacerbations. Immunol Allergy Clin North Am 2019; 39:335-344. [PMID: 31284924 DOI: 10.1016/j.iac.2019.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Rhinovirus (RV) is ubiquitous and typically causes only minor upper respiratory symptoms. However, especially in children and adolescent asthmatics, RV is responsible for most exacerbations. This ability of RV to drive exacerbations typically requires the concomitant presence of exposure to a bystander allergen. Susceptibility to RV-mediated exacerbations is also related to the genetic background of the host, which contributes to greater infectivity, more severe infections, altered immune responses, and to greater inflammation and loss of asthma control. Given these responses, there are several treatments available or being developed that should improve the control of exacerbations related to RV infection.
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Affiliation(s)
- Joshua L Kennedy
- Department of Pediatrics, University of Arkansas for Medical Sciences, 13 Children's Way, Slot 512-13, Little Rock, AR 72202, USA; Department of Internal Medicine, University of Arkansas for Medical Sciences, 13 Children's Way, Slot 512-13, Little Rock, AR 72202, USA; Arkansas Children's Research Institute, University of Arkansas for Medical Sciences, 13 Children's Way, Slot 512-13, Little Rock, AR 72202, USA.
| | - Sarah Pham
- Department of Pediatrics, University of Arkansas for Medical Sciences, 13 Children's Way, Slot 512-13, Little Rock, AR 72202, USA
| | - Larry Borish
- Department of Medicine, University of Virginia Health Systems, MR4 Building Room 5041, 409 Lane Road, Charlottesville, VA 22903, USA; Department of Microbiology, University of Virginia Health Systems, MR4 Building Room 5041, 409 Lane Road, Charlottesville, VA 22903, USA; Carter Immunology Center, University of Virginia Health Systems, MR4 Building Room 5041, 409 Lane Road, Charlottesville, VA 22903, USA
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78
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van de Veen W, Akdis M. The use of biologics for immune modulation in allergic disease. J Clin Invest 2019; 129:1452-1462. [PMID: 30882368 DOI: 10.1172/jci124607] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The rising prevalence of allergies represents an increasing socioeconomic burden. A detailed understanding of the immunological mechanisms that underlie the development of allergic disease, as well as the processes that drive immune tolerance to allergens, will be instrumental in designing therapeutic strategies to treat and prevent allergic disease. Improved characterization of individual patients through the use of specific biomarkers and improved definitions of disease endotypes are paving the way for the use of targeted therapeutic approaches for personalized treatment. Allergen-specific immunotherapy and biologic therapies that target key molecules driving the Th2 response are already used in the clinic, and a wave of novel drug candidates are under development. In-depth analysis of the cells and tissues of patients treated with such targeted interventions provides a wealth of information on the mechanisms that drive allergies and tolerance to allergens. Here, we aim to deliver an overview of the current state of specific inhibitors used in the treatment of allergy, with a particular focus on asthma and atopic dermatitis, and provide insights into the roles of these molecules in immunological mechanisms of allergic disease.
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Affiliation(s)
- Willem van de Veen
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.,Christine Kühne - Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
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79
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Chung LP, Paton JY. Two Sides of the Same Coin?-Treatment of Chronic Asthma in Children and Adults. Front Pediatr 2019; 7:62. [PMID: 30915319 PMCID: PMC6421287 DOI: 10.3389/fped.2019.00062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/18/2019] [Indexed: 12/17/2022] Open
Abstract
Globally, asthma is one of the most common chronic conditions that affect individuals of all ages. When poorly controlled, it negatively impacts patient's ability to enjoy life and work. At the population level, effective use of recommended strategies in children and adults can reduce symptom burden, improve quality of life and significantly reduce the risk of exacerbation, decline of lung function and asthma-related death. Inhaled corticosteroid as the initial maintenance therapy, ideally started within 2 years of symptom onset, is highly effective in both children and adults and across various degrees of asthma severity. If asthma is not controlled, the choice of subsequent add-on therapies differs between children and adults. Evidence supporting pharmacological approach to asthma management, especially for those with more severe disease, is more robust in adults compared to children. This is, in part, due to various challenges in the diagnosis of asthma, in the recruitment into clinical trials and in the lack of objective outcomes in children, especially those in the preschool age group. Nevertheless, where evidence is emerging for younger children, it seems to mirror the observations in adults. Clinicians need to develop strategies to implement guideline-based recommendations while taking into consideration individual variations in asthma clinical phenotypes, pathophysiology and treatment responses at different ages.
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Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - James Y. Paton
- School of Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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80
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Lanz MJ, Gilbert I, Szefler SJ, Murphy KR. Can early intervention in pediatric asthma improve long-term outcomes? A question that needs an answer. Pediatr Pulmonol 2019; 54:348-357. [PMID: 30609252 PMCID: PMC6590791 DOI: 10.1002/ppul.24224] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although many children with asthma do not experience persistence into adulthood, recent studies have suggested that poorly controlled asthma in childhood may be associated with significant airflow obstruction in adulthood. However, data regarding disease progression are lacking, and clinicians are not yet able to predict the course of a child's asthma. The goal of this article was to assess the current understanding of childhood asthma treatment and progression and to highlight gaps in information that remain. DATA SOURCES Nonsystematic PubMed literature search and authors' expertise. STUDY SELECTION Articles were selected at the authors' discretion based on areas of interest in childhood asthma treatment and progression into adulthood. RESULTS Uncontrolled asthma in early childhood can potentially have lasting effects on lung development, but it is unclear whether traditional interventions in very young children preserve lung function. Although not all children respond to standard interventions, certain asthma phenotypes have been identified that can help to understand which children may respond to a particular treatment. CONCLUSION Clinicians should monitor children's asthma control and pulmonary function over time to assess the long-term impact of an intervention and to minimize the effect of uncontrolled asthma, especially exacerbations, on lung development. New biologic therapies have shown promise in treating adults with severe, uncontrolled asthma, and some of these therapies are approved in the United States for children as young as age 6. However, knowledge gaps regarding the efficacy and safety of these treatments in younger children hamper our understanding of their effect on long-term outcomes.
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Affiliation(s)
- Miguel J Lanz
- Allergy and Asthma, AAADRS Clinical Research Center, Coral Gables, Florida
| | | | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Just J, Deschildre A, Lejeune S, Amat F. New perspectives of childhood asthma treatment with biologics. Pediatr Allergy Immunol 2019; 30:159-171. [PMID: 30444939 DOI: 10.1111/pai.13007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 01/01/2023]
Abstract
Asthma is no longer considered as a single disease but rather as a syndrome corresponding to different entities and pathophysiologic pathways. A targeted strategy is part of personalized medicine which aims to better define each patient's phenotype and endotype so as to prescribe the most suitable treatment at an individual level. Omalizumab and, more recently, mepolizumab are the first biologics approved for children (6-18 years). Omalizumab is now widely used to treat severe allergic asthma in children and is highly effective for asthma exacerbations and asthma control with a good safety profile. Moreover, several other drugs-lebrikizumab, dupilumab, tezepelumab, mepolizumab, reslizumab, benralizumab-are used or are being studied in both teenagers and adults and could benefit younger children in the near future. We hypothesize that defining the asthma phenotype/endotype regarding the type and intensity of inflammation, association with allergic or non-allergic comorbidities, and airway remodeling should contribute to the choice of a specific biologic. Pediatric specificities have to be addressed and validated by studies in children. Long-term effectiveness and particularly the impact on the natural history of asthma should also be investigated. Severe asthma in children is a complex disease, and patients have to be referred to a specialized pediatric asthma center to confirm diagnosis and initiate the best treatment strategy which could include biologics while taking into account their high cost.
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Affiliation(s)
- Jocelyne Just
- Department of Allergology-Centre de l'Asthme et des Allergies, Hôpital d'Enfants Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France.,UMR-S 1136, Equipe EPAR, INSERM Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Antoine Deschildre
- CHU Lille, Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, Université Nord de France, Lille, France
| | - Stéphanie Lejeune
- CHU Lille, Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, Université Nord de France, Lille, France
| | - Flore Amat
- Department of Allergology-Centre de l'Asthme et des Allergies, Hôpital d'Enfants Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France.,UMR-S 1136, Equipe EPAR, INSERM Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
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82
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Fang L, Wang X, Sun Q, Papakonstantinou E, S'ng C, Tamm M, Stolz D, Roth M. IgE Downregulates PTEN through MicroRNA-21-5p and Stimulates Airway Smooth Muscle Cell Remodeling. Int J Mol Sci 2019; 20:ijms20040875. [PMID: 30781615 PMCID: PMC6412688 DOI: 10.3390/ijms20040875] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/04/2019] [Accepted: 02/14/2019] [Indexed: 12/14/2022] Open
Abstract
The patho-mechanism leading to airway wall remodeling in allergic asthma is not well understood and remodeling is resistant to therapies. This study assessed the effect of immunoglobulin E (IgE) in the absence of allergens on human primary airway smooth muscle cell (ASMC) remodeling in vitro. ASMCs were obtained from five allergic asthma patients and five controls. Proliferation was determined by direct cell counts, mitochondrial activity by expression of cytochrome c, protein expression by immunoblotting and immuno-fluorescence, cell migration by microscopy imaging, and collagen deposition by cell based ELISA and RNA expression by real time PCR. Non-immune IgE activated two signaling pathways: (i) signal transducer and activator of transcription 3 (STAT3)→miR-21-5p→downregulating phosphatase and tensin homolog (PTEN) expression, and (ii) phosphatidylinositol 3-kinases (PI3K)→protein kinase B (Akt)→mammalian target of rapamycin (mTOR)→ribosomal protein S6 kinase beta-1 (p70s6k)→peroxisome proliferator-activated receptor gamma coactivator 1-α (PGC1-α)→peroxisome proliferator-activated receptor-γ (PPAR-γ)→cyclooxygenase-2 (COX-2)→mitochondrial activity, proliferation, migration, and extracellular matrix deposition. Reduced PTEN expression correlated with enhanced PI3K signaling, which upregulated ASMC remodeling. The inhibition of microRNA-21-5p increased PTEN and reduced mTOR signaling and remodeling. Mimics of microRNA-21-5p had opposing effects. IgE induced ASMC remodeling was significantly reduced by inhibition of mTOR or STAT3. In conclusion, non-immune IgE alone is sufficient for stimulated ASMC remodeling by upregulating microRNA-21-5p. Our findings suggest that the suppression of micoRNA-21-5p may present a therapeutic target to reduce airway wall remodeling.
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Affiliation(s)
- Lei Fang
- Pneumology & Pulmonary Cell Research, Departments of Internal Medicine & Biomedicine, University & University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
| | - Xinggang Wang
- Gynecological Endocrinology, Department of Biomedicine, University & University Hospital Basel, Hebelstrasse 20, CH-4031 Basel, Switzerland.
| | - Qingzhu Sun
- Pneumology & Pulmonary Cell Research, Departments of Internal Medicine & Biomedicine, University & University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
- College of Animal Science and Technology, Northwest A&F University, Yangling 712100, China.
| | - Eleni Papakonstantinou
- Pneumology & Pulmonary Cell Research, Departments of Internal Medicine & Biomedicine, University & University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
- Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece.
| | | | - Michael Tamm
- Pneumology & Pulmonary Cell Research, Departments of Internal Medicine & Biomedicine, University & University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
| | - Daiana Stolz
- Pneumology & Pulmonary Cell Research, Departments of Internal Medicine & Biomedicine, University & University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
| | - Michael Roth
- Pneumology & Pulmonary Cell Research, Departments of Internal Medicine & Biomedicine, University & University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
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83
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Katsaounou P, Buhl R, Brusselle G, Pfister P, Martínez R, Wahn U, Bousquet J. Omalizumab as alternative to chronic use of oral corticosteroids in severe asthma. Respir Med 2019; 150:51-62. [PMID: 30961951 DOI: 10.1016/j.rmed.2019.02.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/21/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
Systemic/oral corticosteroids (OCS) have been used for decades in the management of acute asthma exacerbations and chronically in patients with uncontrolled severe asthma. However, while OCS are effective at treating acute exacerbations, there is only empirical evidence regarding the efficacy of OCS at reducing the rate of exacerbations. Evidence, although scarce, is suggestive of high exacerbation rates in severe asthma patients even when receiving maintenance treatment with OCS. In addition, use of OCS is associated with undesirable effects. Despite all this, physicians have continued to use OCS for managing severe asthma and acute exacerbation due to the lack of availability of effective alternatives. Fortunately, in the last decade several biologics have been proven safe and effective for patients with uncontrolled severe asthma. This has led to the Global Initiative for Asthma (GINA) recommending the use of biologics, instead of maintenance OCS, in patients with severe asthma (GINA Step 5). These include one biologic targeting immunoglobulin E (IgE) (omalizumab), and different biologics targeting interleukin-5 (IL-5), the IL-5 receptor (IL-5R) or IL-4 receptor α-unit (IL-4R α), including mepolizumab (subcutaneous), reslizumab (intravenous), benralizumab (subcutaneous) and dupilumab (subcutaneous). Omalizumab for the treatment of severe allergic asthma reduces exacerbations, irrespective of blood eosinophil levels. Anti-IL-5/IL-5R biologics are indicated in patients with severe eosinophilic asthma and repetitive exacerbations, irrespective of the presence or absence of allergy. Recently, an anti-IL4Rα biologic has been approved by the FDA for eosinophilic phenotype or oral corticosteroid-dependent asthma. Finally, physicians should consider using biologics as an alternative to chronic OCS therapy.
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Affiliation(s)
- Paraskevi Katsaounou
- School of Medicine, National and Kapodistrian University of Athens, 1st ICU Evangelismos Hospital, Athens, Greece.
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany.
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, De Pintelaan, Ghent, Belgium; Department of Epidemiology and Respiratory Medicine, Erasmus MC Rotterdam, Rotterdam, the Netherlands.
| | - Pascal Pfister
- Global Medical Department, Novartis Pharma AG, Basel, Switzerland.
| | - Rafael Martínez
- Global Medical Department, Novartis Pharma AG, Basel, Switzerland
| | - Ulrich Wahn
- Department of Paediatric Pneumology & Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Jean Bousquet
- Service des Maladies Respiratoires, Hôpital Arnaud de Villeneuve, Montpellier, France.
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84
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Nishima S, Kozawa M, Milligan KL, Papadopoulos NG. Omalizumab and unmet needs in severe asthma and allergic comorbidities in Japanese children. Asia Pac Allergy 2019; 9:e7. [PMID: 30740355 PMCID: PMC6365659 DOI: 10.5415/apallergy.2019.9.e7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 01/17/2019] [Indexed: 01/20/2023] Open
Abstract
Childhood asthma is one condition within a family of allergic diseases, which includes allergic rhinitis, atopic dermatitis, and food allergy, among others. Omalizumab is an anti-IgE antibody therapy that was approved in Japan for children with asthma and added to the Japanese pediatric asthma guidelines in 2017. This review highlights the Japanese clinical perspectives in pediatric allergic asthma, and consideration for allergic comorbidities, and reflects on omalizumab clinical trials in progress to present comprehensive future opportunities.
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Affiliation(s)
- Sankei Nishima
- National Hospital Organization, Fukuoka National Hospital, Fukuoka, Japan
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85
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Crisafulli G, Caminiti L, Chiera F, Arasi S, Salzano G, Panasiti I, Barbalace A, Pajno GB. Omalizumab in children with severe allergic disease: a case series. Ital J Pediatr 2019; 45:13. [PMID: 30642367 PMCID: PMC6332555 DOI: 10.1186/s13052-019-0602-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/03/2019] [Indexed: 02/08/2023] Open
Abstract
Background Currently, severe allergic asthma and food allergy in children represent an important public health problem with medical, psychosocial and economic impacts. Omalizumab is a humanized monoclonal anti-IgE antibody, approved for refractory allergic asthma and chronic urticaria. It has been widely used in clinical practice as add-on therapy in patients with severe uncontrolled allergic asthma. In recent years there has seen the emergence of an allergic epidemic with increasing food allergy, which represents the main cause of anaphylaxis in children. The standard of care for food allergy is strictly dietary allergen avoidance and emergency treatment, but recent clinical trials have suggested that omalizumab may have a role to play as an adjuvant to oral immunotherapy (OIT). We present a case series of patients treated at our institution with omalizumab for severe allergic asthma and food allergy. Methods Patients received omalizumab according to a standard reference nomogram after failing standard therapies. In children with comorbid severe food allergy, omalizumab was administered in conjunction with an oral immunotherapy protocol. Results Omalizumab was effective in controlling symptoms of allergic asthma, allergic rhinitis and rhinosinusitis, but not eosinophilic esophagitis, while aiding successful oral desensitization of comorbid severe food allergies. Conclusions Omalizumab appears to be an excellent therapeutic option in children with inadequately controlled severe allergic asthma, allergic rhinitis and rhinosinusitis, with or without food allergy.
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Affiliation(s)
- Giuseppe Crisafulli
- Department of Pediatrics, Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, 98124, Messina, Italy
| | - Lucia Caminiti
- Department of Pediatrics, Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, 98124, Messina, Italy
| | - Fernanda Chiera
- Department of Pediatrics, Pediatric Unit, San Giovanni di Dio Hospital, Crotone, Italy
| | - Stefania Arasi
- Pediatric Allergology Unit, Bambino Gesù Hospital (IRCCS), Rome, Italy
| | - Giuseppina Salzano
- Department of Pediatrics, Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, 98124, Messina, Italy
| | - Ilenia Panasiti
- Department of Pediatrics, Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, 98124, Messina, Italy
| | - Andrea Barbalace
- Department of Pediatrics, Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, 98124, Messina, Italy
| | - Giovanni Battista Pajno
- Department of Pediatrics, Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, 98124, Messina, Italy.
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86
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Zhou H, Lu Y, Wu B, Che D. Cost-effectiveness of omalizumab for the treatment of inadequately controlled severe allergic asthma in Chinese children. J Asthma 2018; 57:87-94. [PMID: 30507328 DOI: 10.1080/02770903.2018.1544642] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The addition of omalizumab to standard therapy has proven to be efficacious in children with severe allergic asthma. The goal of this study was to assess the cost-effectiveness of adding omalizumab to standard treatment for asthma in Chinese pediatric patients.Methods: A Markov model was constructed to project the health and economic outcomes in pediatric patients with severe allergic asthma. Model inputs were obtained from the literature. Cost and quality-adjusted life-years (QALYs) were measured over a five-year time horizon. One-way and probabilistic sensitivity analyses were conducted.Results: For the base-case analysis, the addition of omalizumab to standard therapy yielded an incremental cost of $49,047 for 0.232 incremental QALY, led to an incremental cost-effectiveness ratio of $211,217/QALY. Sensitivity analyses were robust for these results.Conclusions: This study found that the addition of omalizumab is not a cost-effective strategy compared with standard therapy for children with severe allergic asthma in China due to its high cost.
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Affiliation(s)
- Hua Zhou
- Department of VIP, Shanghai Children's Hospital, affiliated with the School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yanming Lu
- Department of Pediatrics, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Bin Wu
- Medical decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Datian Che
- Department of VIP, Shanghai Children's Hospital, affiliated with the School of Medicine, Shanghai Jiaotong University, Shanghai, China
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87
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Durrani SR, Mukkada VA, Guilbert TW. Eosinophilic Esophagitis: an Important Comorbid Condition of Asthma? Clin Rev Allergy Immunol 2018; 55:56-64. [PMID: 29455359 DOI: 10.1007/s12016-018-8670-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Eosinophilic esophagitis and asthma are frequently found as comorbid conditions in children and adults along with other manifestations of atopic diathesis. These two conditions have similar T helper 2 responses-driven pathophysiology and share common management strategies such as using systemic corticosteroids and targeted anti-cytokine biologic therapies. Review of the literature finds that asthma is often a comorbid condition in eosinophilic esophagitis in both children and adults; however, the EoE-asthma relationship remains poorly characterized mechanistically and clinically. EoE and asthma commonly share several comorbid conditions such as allergic rhinitis and gastroesophageal reflux disease; therefore, addressing these comorbid conditions has the potential to improve and/or maintain control in both diseases. Similar to asthma, patients with EoE frequently demonstrate elevations in serum markers of atopy, including serum IgE levels, peripheral eosinophil counts, and T helper 2-related cytokines. Gastroesophageal reflux disease is thought to affect asthma through microaspirations, airway hyperresponsiveness, and increased vagal tone. The understanding of the relationship between gastroesophageal reflux and EoE is still evolving but seems to be bidirectional and interactive. In terms of treatment, similar classes of medications have been used in both EoE and asthma. In both children and adults, EoE remission can be achieved by food trigger avoidance and use of corticosteroids and biologic therapies. Asthma control is mostly achieved through inhaled corticosteroids, and long but biologic therapies are increasingly used in severe subsets of the disease. Significant clinical and mechanistic work needs to be accomplished to better understand the relationship between asthma, EoE, and their interaction with other allergic diseases. Understanding whether shared mechanisms exist can lead to the development of new diagnostic and therapeutic strategies. The following review examines the existing literature regarding prevalence, common comorbidities, and potential therapeutic approach and identifies gaps in knowledge and future directions.
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Affiliation(s)
- Sandy R Durrani
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA. .,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Vincent A Mukkada
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Theresa W Guilbert
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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88
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Abrams EM, Becker AB, Szefler SJ. Current State and Future of Biologic Therapies in the Treatment of Asthma in Children. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2018; 31:119-131. [PMID: 30283711 DOI: 10.1089/ped.2018.0901] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/26/2018] [Indexed: 02/06/2023]
Abstract
There is increasing recognition of phenotypic variability in pediatric asthma, providing the opportunity for a more personalized approach to therapy. Increasingly biologic therapies, in particular those targeting the "allergic" (or T helper 2) pathway, are being considered for children with severe asthma. However, there is a great deal of variability in the extent these biologic therapies have been studied in children, as well as efficacy of results thus far. The goal of this article is to review the mechanism of action, efficacy, and potential predictive and monitoring biomarkers of the biologic medications focusing on the pediatric population, in an effort to establish a more personalized approach to asthma in the pediatric population for the 21st century.
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Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Allan B Becker
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Stanley J Szefler
- Department of Pediatrics, Section of Pulmonary Medicine, Breathing Institute, University of Colorado School of Medicine, Aurora, Colorado
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89
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Bernstein JA, Mansfield L. Step-up and step-down treatments for optimal asthma control in children and adolescents. J Asthma 2018; 56:758-770. [PMID: 29972079 DOI: 10.1080/02770903.2018.1490752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To review therapeutic options for stepwise management of pediatric asthma in the context of this population's unique needs such as potential effects of asthma, treatments, or both on growth and psychosocial development, and caregiver involvement. DATA SOURCES AND STUDY SELECTION We conducted PubMed searches to identify relevant articles then reviewed resultant articles, guidelines for asthma management in children, and articles from personal files. RESULTS Stepwise management of asthma, similar to adults, is recommended for children in current global and US guidelines. Treatment may be stepped up or stepped down temporarily or long-term based on response over time. Inhaled corticosteroids remain the recommended treatment for persistent childhood asthma and any potential small effects on growth are considered relatively minor compared with their benefit. Controller medication options for patients <18 years old are limited, especially for Global Initiative for Asthma Steps 2-5. The long-acting antimuscarinic antagonist tiotropium (Steps 4/5, patients aged ≥12 years) and in certain circumstances (Step 5), anti-immunoglobulin E (aged ≥6 years) and interleukin-5 antibodies (aged ≥12 years) are newer treatment options. Tiotropium is indicated in the United States and Europe for patients ≥6 years old. Stepping down treatment, which is recommended but infrequently practiced, can maintain symptom control and minimize adverse events while substantially reducing costs. Patient education and better monitoring remain important for self-management and optimum outcomes. CONCLUSION A need exists to target individual treatment goals for children with asthma by using step-up and step-down approaches to maximize treatment benefits and minimize potential adverse effects.
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Affiliation(s)
- Jonathan A Bernstein
- a University of Cincinnati, College of Medicine , Cincinnati , OH , USA.,b Clinical Research for the Division of Immunology , Cincinnati , Ohio , USA.,c The Bernstein Allergy Group/Clinical Research Center , Cincinnati , OH , USA
| | - Lyndon Mansfield
- d Pediatrics, Paul L. Foster School of Medicine , El Paso , Texas , USA.,e Department of Pediatrics, Paul Foster School of Medicine , El Paso , TX , USA
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90
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Maitra A. Severe Asthma: Challenges and Pitfalls in Management. Indian J Pediatr 2018; 85:763-772. [PMID: 29736695 DOI: 10.1007/s12098-018-2686-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 01/03/2023]
Abstract
A small but significant subset of asthmatic children show a lack of response to standard management, resulting in further intensification of therapy to optimise symptom control and may remain symptomatic despite maximal therapy. Severe asthma results in increased risk of adverse outcomes whilst contributing significantly to the economic burden on the nation's health resources. The ERS / ATS guidelines were published in 2014 and form the basis of identifying, evaluating and managing severe asthmatic children. However, much of this evidence is extrapolated from adult studies and may be inappropriate in children as unlike adults, children have a more atopic phenotype. Severe asthma is an umbrella term and may represent several overlapping heterogeneous wheezing entities. This chapter aims at discussing the strategies employed in managing severe asthmatic children with particular focus on diagnostic challenges and management pitfalls. Particular emphasis is put into the logical and systematic approach to a child with severe asthma and describes the multidisciplinary approach to manage these children. Finally, this chapter describes the novel therapies available in children and in adults in managing this challenging condition.
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Affiliation(s)
- Anirban Maitra
- Pediatric Respiratory Medicine, Royal Manchester Children's Hospital, Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK.
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91
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Kaur S, Singh V. Asthma and Medicines - Long-Term Side-Effects, Monitoring and Dose Titration. Indian J Pediatr 2018; 85:748-756. [PMID: 29306991 DOI: 10.1007/s12098-017-2553-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/22/2017] [Indexed: 01/30/2023]
Abstract
Asthma is a major pediatric respiratory morbidity requiring long-term management. A thorough knowledge of long-term medication side-effects in children is, thus, essential for every physician dealing with childhood asthma. Establishing diagnosis and initiating treatment is just a beginning of the journey. Ongoing monitoring is an essential component of comprehensive asthma management programme. Monitoring includes not only assessment of asthma control but also checking for adherence to treatment, technique of inhaler device use, associated co-morbities, if any, and potential environmental exposure. Various tools - both subjective and objective - are available for assessment of asthma control. However, evidence for their optimum use in different settings and patient groups is lacking and monitoring has to be customized depending on available resources and individual patient characteristics. Patient education is an important component of long-term asthma therapy. The ultimate aim is to achieve optimum asthma control i.e., achieve and maintain control of clinical symptoms, decrease future risk to patients (risk of exacerbations, progressive loss of lung function and development of fixed airflow obstruction, adverse effects of medications) and enabling the child to lead a life without restrictions, at lowest possible dose of drugs. This article reviews the side-effects of medications used for long-term management of asthma and discusses current literature on asthma monitoring and dose titration in pediatric population to help the asthma therapist not only prescribe the drugs rationally but also help the family make right choices for treatment.
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Affiliation(s)
- Satnam Kaur
- Department of Pediatrics, Vardhman Mahavir Medical College and Associated Safdarjung Hospital, New Delhi, India
| | - Varinder Singh
- Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India.
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92
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Tortajada-Girbés M, Bousquet R, Bosque M, Carrera Martínez JJ, Ibáñez MD, Moreira A, Nieto A, Plaza AM, Rivas C, Requena G, Sánchez-Solis M, Tabar A, Torres-Borrego J, Zapatero L. Efficacy and effectiveness of omalizumab in the treatment of childhood asthma. Expert Rev Respir Med 2018; 12:745-754. [PMID: 30141696 DOI: 10.1080/17476348.2018.1507740] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Omalizumab is a monoclonal antibody that binds and inhibits free serum immunoglobulin E, a mediator involved in the clinical manifestations of allergic asthma. Evidence for its efficacy and safety in the treatment of moderate-to-severe allergic asthma is based primarily on studies in adolescents and adults. However, there is increasing evidence of its utility in children with allergic asthma aged 6-12 years. Areas covered: This article reviews efficacy, safety, and effectiveness of omalizumab in the treatment of moderate-to-severe allergic asthma in children aged 6-12 years in clinical trials and in studies in clinical practice. Pharmacoeconomic aspects of its use among this population and the positioning of omalizumab in pediatric asthma management guidelines are also discussed. Additionally, an algorithm for the management of poorly controlled severe pediatric asthma in children older than 6 years is proposed. Electronic databases, such as PubMed, were searched for terms Asthma and Omalizumab and for asthma management guidelines. Expert commentary: Add-on omalizumab is an effective maintenance therapy in children aged 6-12 years with poorly controlled moderate-to-severe allergic asthma treated with medium-high inhaled corticosteroids doses and inhaled long-acting β2-agonists. Omalizumab appears safe in children in both clinical trials and real-life setting and may be cost-effective.
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Affiliation(s)
- Miguel Tortajada-Girbés
- a Department of Pediatrics, Obstetrics and Gynecology , University of Valencia , Valencia , Spain.,b Pediatric Pulmonology and Allergy Unit , Dr. Peset University Hospital , Valencia , Spain
| | - Rosa Bousquet
- c Pediatric Pulmonology and Allergy Unit, Pediatric Service , Hospital del Mar , Barcelona , Spain
| | - Montserrat Bosque
- d Pediatric Allergy and Pulmonology Unit , Hospital Universitario Parc Taulí , Sabadell , Spain
| | | | | | - Ana Moreira
- g Medical Advisor Xolair-Asma, Novartis , Barcelona , Spain
| | - Antonio Nieto
- h Pediatric Pulmonology and Allergy Unit , Children's Hospital la Fe , Valencia , Spain
| | - Ana María Plaza
- i Allergy and Clinical Immunology Service , Hospital Sant Joan de Déu , Barcelona , Spain
| | - Cristina Rivas
- j Pediatric Service , Hospital de Sagunto , Valencia , Spain
| | - Gloria Requena
- k Allergy Department , Hospital Vithas-Xanit Internacional , Málaga , Spain
| | - Manuel Sánchez-Solis
- l Pediatric Pulmonology Unit, University Hospital Virgen de la Arrixaca , IMIB Bio-Health Research Institute , Murcia , Spain
| | - Ana Tabar
- m Allergology Service , Complejo Hospitalario de Navarra , Pamplona , Spain
| | - Javier Torres-Borrego
- n Pediatric Allergy and Pulmonology Unit , Children´s University Hospital Reina Sofía , Córdoba , Spain
| | - Lydia Zapatero
- o Pediatric Allergy Unit , Maternal and Child Hospital Gregorio Marañón , Madrid , Spain
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93
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Generoso A, Muglia-Chopra C, Oppenheimer J. Prospects for Monoclonal Antibody Therapy in Pediatric Asthma. Curr Allergy Asthma Rep 2018; 18:45. [PMID: 29992472 DOI: 10.1007/s11882-018-0799-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The profile of biologic therapies for asthma is growing rapidly. We discuss how to match the proper pediatric patient with the most effective therapy. RECENT FINDINGS Currently available biologic therapies are most effective in patients with T2 high asthma. Newer drugs are currently being studied which target TSLP and interleukin 33. These newer drugs may provide options for asthmatics who do not respond to the current anti-IgE, anti-IL5, and anti-IL4/13 therapies. Asthma is a heterogeneous disease which can be driven by different inflammatory mediators in different patients. To select the most effective biologic therapy for a pediatric patient, the asthma phenotype must first be determined. The steep cost of biologics limits their use, which makes proper pairing of patient to therapy even more crucial. Presently, several therapies exist for T2 high asthma, but it is hoped in the future that development of drugs effective for T2 low asthmatics will be available as well.
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Affiliation(s)
- August Generoso
- Rutgers New Jersey Medical School, The State University of New Jersey, 90 Bergen Street, Newark, NJ, 07103, USA
| | - Christine Muglia-Chopra
- Rutgers New Jersey Medical School, The State University of New Jersey, 90 Bergen Street, Newark, NJ, 07103, USA
| | - John Oppenheimer
- Rutgers New Jersey Medical School, The State University of New Jersey, 90 Bergen Street, Newark, NJ, 07103, USA.
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94
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Amat F, Labbé A. Biomarkers for severe allergic asthma in children: could they be useful to guide disease control and use of omalizumab? Expert Rev Respir Med 2018; 12:475-482. [PMID: 29741411 DOI: 10.1080/17476348.2018.1475233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Although symptom controls in asthmatic children can be achieved through compliant use of conventional medication, some children have uncontrolled severe persistent asthma, especially if they are allergic. For these children, omalizumab (approved by the EMA and FDA in children aged > 6 years) could be a therapeutic option. However, response to omalizumab varies from one child to another. Predictive biomarkers of omalizumab effectiveness could be useful to monitor response to treatment. Area covered: The authors searched in the PubMed database for publications related to the use of biomarkers in allergic asthma. Supported by their own experience in phenotyping asthma in children, they analyzed whether these biomarkers could be useful in assessing response to omalizumab. Expert commentary: Th2 inflammation in children with allergic asthma can be assessed by measuring several biomarkers (blood eosinophil, serum ECP or periostin, FeNO). While a single measurement may be insufficient, a combination of biomarkers assessments may improve the follow-up of children treated by omalizumab.
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Affiliation(s)
- Flore Amat
- a Department of Allergology-Centre de l'Asthme et des Allergies, Hôpital d'Enfants Armand Trousseau, Assistance Publique-Hôpitaux de Paris; UPMC Univ Paris 06,Sorbonne Universités; Equipe EPAR , Institut Pierre Louis d'Epidémiologie et de Santé Publique , Paris , France
| | - André Labbé
- b Pediatric Emergency Department , CHU , Clermont-Ferrand , France
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95
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Naja AS, Permaul P, Phipatanakul W. Taming Asthma in School-Aged Children: A Comprehensive Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:726-735. [PMID: 29747980 PMCID: PMC5953205 DOI: 10.1016/j.jaip.2018.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 12/14/2022]
Abstract
Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity as measured by school absences, emergency department visits, and hospitalizations. Multiple factors play a role in the development, treatment and prevention of childhood asthma including racial/ethnic and socioeconomic disparities, both the home and school environments, and medication use. The goals of this review are to summarize these aspects of asthma in school-aged children and to present an updated review of medications as it relates to treatment strategies that will help in the care of these children. We conclude that phenotypic heterogeneity and appropriate environmental assessments and interventions are important considerations in the management of childhood asthma.
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Affiliation(s)
- Ahmad Salaheddine Naja
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass; Lebanese American University, Beirut, Lebanon
| | - Perdita Permaul
- Harvard Medical School, Boston, Mass; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital for Children, Boston, Mass
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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96
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Chipps BE, Bacharier LB, Farrar JR, Jackson DJ, Murphy KR, Phipatanakul W, Szefler SJ, Teague WG, Zeiger RS. The pediatric asthma yardstick: Practical recommendations for a sustained step-up in asthma therapy for children with inadequately controlled asthma. Ann Allergy Asthma Immunol 2018; 120:559-579.e11. [PMID: 29653238 DOI: 10.1016/j.anai.2018.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/31/2018] [Accepted: 04/03/2018] [Indexed: 12/29/2022]
Abstract
Current asthma guidelines recommend a control-based approach to management involving assessment of impairment and risk followed by implementation of treatment strategies individualized according to the patient's needs and preferences. However, for children with asthma, achieving control can be elusive. Although tools are available to help children (and families) track and manage day-to-day symptoms, when and how to implement a longer-term step-up in care is less clear. Furthermore, treatment is challenged by the 3 age groups of childhood-adolescence (12-18 years old), school age (6-11 years old), and young children (≤5 years old)-and what works for 1 age group might not be the best approach for another. The Pediatric Asthma Yardstick provides an in-depth assessment of when and how to step-up therapy for the child with not well or poorly controlled asthma. Development of this tool follows others in the Yardstick series, presenting patient profiles and step-up strategies based on current guidance documents, but modified according to newer data and the authors' combined clinical experience. The objective is to provide clinicians who treat children with asthma practical and clinically relevant recommendations for each step-up and each intervention, with the intent of helping practitioners better treat their pediatric patients with asthma, particularly those who do not always respond to recommended therapies.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri
| | | | - Daniel J Jackson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin R Murphy
- Boys Town National Research Hospital, Boys Town, Nebraska
| | - Wanda Phipatanakul
- Allergy, Asthma, Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital of Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - W Gerald Teague
- Division of Pediatric Respiratory Medicine and Allergy, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Robert S Zeiger
- Department of Allergy and Research and Evaluation, Kaiser Permanente Southern California Region, San Diego and Pasadena, California
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97
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Tabatabaian F, Ledford DK. Omalizumab for severe asthma: toward personalized treatment based on biomarker profile and clinical history. J Asthma Allergy 2018; 11:53-61. [PMID: 29662320 PMCID: PMC5892947 DOI: 10.2147/jaa.s107982] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Asthma is a heterogeneous syndrome with numerous underlining molecular and inflammatory mechanisms contributing to the wide spectrum of clinical phenotypes. Multiple therapies targeting severe asthma with type 2 (T2) high inflammation are or soon will be available. T2 high inflammation is defined as inflammation associated with atopy or eosinophilia or an increase in cytokines associated with T-helper 2 lymphocytes. Omalizumab is a humanized anti-IgE monoclonal antibody and the first biologic therapy approved for moderate-severe allergic asthma. Despite the specificity of biologic therapies like omalizumab, clinical response is variable, with approximately 50% of treated patients achieving the primary outcome. A prior identification of the ideal candidate for therapy would improve patient outcomes and optimize the use of health care resources. As the number of biologic therapies for asthma increases, the goal is identification of biomarkers or clinical phenotypes likely to respond to a specific therapy. This review focuses on potential biomarkers and clinical history that may identify responders to omalizumab therapy for asthma.
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Affiliation(s)
- Farnaz Tabatabaian
- Division of Allergy and Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Dennis K Ledford
- Division of Allergy and Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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98
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Role of biologics targeting type 2 airway inflammation in asthma: what have we learned so far? Curr Opin Pulm Med 2018; 23:3-11. [PMID: 27820746 DOI: 10.1097/mcp.0000000000000343] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Severe asthma is a heterogeneous syndrome that can be classified into distinct phenotypes and endotypes. In the type 2 (T2)-high endotype, multiple cytokines are produced that lead to eosinophilic inflammation. These cytokines and their receptors are targets for biologic therapies in patients with severe asthma who do not respond well to standard therapy with inhaled corticosteroids. RECENT FINDINGS In the last decade, an increasing number of biologic therapies have been developed targeting T2 inflammation. Clinical trials of therapies targeting immunoglobulin E as well as the T2 cytokines interleukin (IL)-4, IL-5, and IL-13 have demonstrated that these treatments improve asthma-related clinical outcomes and/or have steroid-sparing properties. The use of biomarkers of T2 inflammation can help to identify the subset of patients in whom these therapies may be most efficacious. Multiple biologic agents that are directed at other targets are currently in development, including thymic stromal lymphopoietin (TSLP), prostaglandin (PG)D2 receptor, IL-25, and IL-33. SUMMARY Biologics are emerging as a key component of severe asthma management. In patients with T2-high severe asthma, the addition of treatments targeting immunoglobulin E and IL-5 to standard therapy may lead to improvement in clinical outcomes. Other biologic therapies have shown promising preliminary results and need to be studied in further clinical trials. These biologic therapies in conjunction with biomarkers will lead to tailored therapy for asthma.
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99
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Managing problematic severe asthma: beyond the guidelines. Arch Dis Child 2018; 103:392-397. [PMID: 28903951 DOI: 10.1136/archdischild-2016-311368] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 08/17/2017] [Accepted: 08/19/2017] [Indexed: 01/26/2023]
Abstract
This review discusses issues related to managing problematic severe asthma in children and young people. A small minority of children have genuinely severe asthma symptoms which are difficult to control. Children with genuinely severe asthma need investigations and treatments beyond those described within conventional guidelines. However, the majority of children with poor symptom control despite high-intensity treatment achieve improvement in their asthma control once attention has been paid to the basics of asthma management. Basic asthma management requires optimisation of inhaler technique and treatment adherence, avoidance of environmental triggers and self-management education. It is also important that clinicians recognise risk factors that predispose patients to asthma exacerbations and potentially life-threatening attacks. These correctable issues need to be tackled in partnership with children and young people and their families. This requires a coordinated approach between professionals across healthcare settings. Establishing appropriate infrastructure for coordinated asthma care benefits not only those with problematic severe asthma, but also the wider asthma population as similar correctable issues exist for children with asthma of all severities. Investigation and management of genuine severe asthma requires specialist multidisciplinary expertise and a systematic approach to characterising patients' asthma phenotypes and delivering individualised care. While inhaled corticosteroids continue to play a leading role in asthma therapy, new treatments on the horizon might further support phenotype-specific therapy.
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100
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Uses of biologics in allergic diseases: What to choose and when. Ann Allergy Asthma Immunol 2018; 120:357-366. [PMID: 29499367 DOI: 10.1016/j.anai.2018.02.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 01/09/2023]
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