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Nixon J, Newbold P, Mustelin T, Anderson GP, Kolbeck R. Monoclonal antibody therapy for the treatment of asthma and chronic obstructive pulmonary disease with eosinophilic inflammation. Pharmacol Ther 2016; 169:57-77. [PMID: 27773786 DOI: 10.1016/j.pharmthera.2016.10.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Eosinophils have been linked with asthma for more than a century, but their role has been unclear. This review discusses the roles of eosinophils in asthma and chronic obstructive pulmonary disease (COPD) and describes therapeutic antibodies that affect eosinophilia. The aims of pharmacologic treatments for pulmonary conditions are to reduce symptoms, slow decline or improve lung function, and reduce the frequency and severity of exacerbations. Inhaled corticosteroids (ICS) are important in managing symptoms and exacerbations in asthma and COPD. However, control with these agents is often suboptimal, especially for patients with severe disease. Recently, new biologics that target eosinophilic inflammation, used as adjunctive therapy to corticosteroids, have proven beneficial and support a pivotal role for eosinophils in the pathology of asthma. Nucala® (mepolizumab; anti-interleukin [IL]-5) and Cinquair® (reslizumab; anti-IL-5), the second and third biologics approved, respectively, for the treatment of asthma, exemplifies these new treatment options. Emerging evidence suggests that eosinophils may contribute to exacerbations and possibly to lung function decline for a subset of patients with COPD. Here we describe the pharmacology of therapeutic antibodies inhibiting IL-5 or targeting the IL-5 receptor, as well as other cytokines contributing to eosinophilic inflammation. We discuss their roles as adjuncts to conventional therapeutic approaches, especially ICS therapy, when disease is suboptimally controlled. These agents have achieved a place in the therapeutic armamentarium for asthma and COPD and will deepen our understanding of the pathogenic role of eosinophils.
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Affiliation(s)
| | | | | | - Gary P Anderson
- Lung Health Research Centre, University of Melbourne, Melbourne, Victoria, Australia
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152
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Abstract
INTRODUCTION Diagnosing eosinophilic asthma is important, because uncontrolled eosinophilic airway inflammation is associated with reduced response to glucocorticoids and increased risk of severe exacerbations. AREAS COVERED Currently, the diagnosis of eosinophilic asthma is based on measurements of sputum eosinophils, which is time consuming and requires specific technical expertise. Therefore, biomarkers such as blood eosinophils, FeNO, serum IgE and periostin are being used as surrogates. These biomarkers can be used separately or in combination, and their accuracy to detect sputum eosinophilia depends on cut-off values. The demonstration of eosinophils in sputum is no guarantee for response to treatment with current biological agents targeting Type 2 inflammation, because several molecular pathways may lead to eosinophilic inflammation. In the near future, the results of large trials using 'omics' technologies will certainly identify new, more 'upstream' biomarkers of eosinophilic inflammation, that will ultimately lead to the ideal targeted treatment for patients with eosinophilic asthma. Expert commentary: Of currently used surrogate markers to diagnose eosinophilic asthma, blood eosinophils and FeNO have the highest diagnostic accuracy, in particular if used in combination to rule in or rule out eosinophilic asthma. For patients who cannot be classified by these biomarkers alone, the clinical profile may be of help.
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Affiliation(s)
- Hanneke Coumou
- a Department of Respiratory Medicine, Academic Medical Centre , University of Amsterdam , Amsterdam , The Netherlands
| | - Elisabeth H Bel
- a Department of Respiratory Medicine, Academic Medical Centre , University of Amsterdam , Amsterdam , The Netherlands
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153
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Zeiger RS, Schatz M, Dalal AA, Chen W, Sadikova E, Suruki RY, Kawatkar AA, Qian L. Blood Eosinophil Count and Outcomes in Severe Uncontrolled Asthma: A Prospective Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:144-153.e8. [PMID: 27665383 DOI: 10.1016/j.jaip.2016.07.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/11/2016] [Accepted: 07/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Severe uncontrolled asthma (SUA) is associated with increased asthma exacerbations. Whether high blood eosinophil counts are related to this burden is uncertain. OBJECTIVES To determine the relationship of blood eosinophil counts to asthma exacerbations, utilization, and cost in patients with SUA. METHODS Patients with persistent asthma (age ≥ 12 years) were identified administratively with SUA in phase I by evidencing (1) 2 or more asthma exacerbations; (2) 6 or more medium- or high-dose dispensed canisters of inhaled corticosteroid (ICS) as monotherapy or with long-acting β2-agonist; and (3) 3 or more dispensed non-ICS controllers. Of the 541 patients with SUA invited to participate in the prospective phase II follow-up study, 261 (48.2%) had blood tests (index date) to determine eosinophil count and other atopic biomarkers. The relationship of blood eosinophil cutoff points to asthma exacerbations and direct costs 1 year after the index date were determined by multivariable regression. RESULTS A blood eosinophil cutoff point of greater than or equal to 400 cells/mm3 compared with less than 400 cells/mm3, but not 150 cells/mm3 or 300 cells/mm3, was a risk factor in the outcome year in adjusted analyses for 2 or more asthma exacerbations (risk ratio, 1.55; 95% CI, 1.02-2.35; P =.04) and any asthma emergency department visit or hospitalization (risk ratio, 2.29; 95% CI, 1.16-4.55; P =.02), but not for rate of asthma exacerbations or incremental total direct asthma costs per patient ($202; 95% CI, -286 to 691). CONCLUSIONS A high blood eosinophil count was an independent risk factor for 2 or more asthma exacerbations or any asthma emergency department visit or hospitalization, but not direct costs in patients with SUA, possibly constrained by limited power.
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Affiliation(s)
- Robert S Zeiger
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif.
| | - Michael Schatz
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | | | - Wansu Chen
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | - Ekaterina Sadikova
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | | | - Aniket A Kawatkar
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | - Lei Qian
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
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154
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Chung KF. Neutrophilic asthma: a distinct target for treatment? THE LANCET RESPIRATORY MEDICINE 2016; 4:765-767. [PMID: 27574789 DOI: 10.1016/s2213-2600(16)30232-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 08/01/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Kian Fan Chung
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK; Biomedical Research Unit, Royal Brompton and Harefield NHS Trust, London, UK.
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155
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Agache I, Strasser DS, Klenk A, Agache C, Farine H, Ciobanu C, Groenen PMA, Akdis CA. Serum IL-5 and IL-13 consistently serve as the best predictors for the blood eosinophilia phenotype in adult asthmatics. Allergy 2016; 71:1192-202. [PMID: 27060452 DOI: 10.1111/all.12906] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Molecular biomarkers that identify the phenotype of blood eosinophilia were evaluated in adult asthmatics, and their relationship with clinically significant asthma outcomes was assessed. Patients were clustered based on their molecular fingerprint. METHODS At inclusion, 64 patients were evaluated for phenotypic traits, sputum and blood eosinophilia, exhaled NO, serum cytokines and chemokines, total serum IgE, lung function (LF), and airway hyper-responsiveness (AHR). Within-patient changes were evaluated in 44 patients 6 weeks later. RESULTS Lung function, asthma control, and monocyte chemotactic protein-1 (MCP-1) were identified as the most important distinguisher and blood eosinophilia as second most important identifier in principal component analysis. A robust relationship was observed between blood eosinophilia and IL-5, IL-13, and eosinophil-derived neurotoxin (EDN), which stayed consistent after 6 weeks. Serum IL-5 and IL-13 were the two best, followed by EDN as separators of high vs low blood eosinophilia. Periostin did not identify blood or sputum eosinophilia, even after stratification for total IgE, and did not correlate with IL-5, IL-13, eotaxin, or EDN. IL-5 and IL-13 showed strong correlations with AHR and monocyte chemoattractant protein (MCP)-1 with asthma severity and fast LF decline. The presence of high or low expression of MCP-1, eotaxin, and IL-8 identified two separate blood eosinophilia patient clusters linked to asthma severity. CONCLUSION Serum IL-5 and IL-13 are reliable biomarkers for the blood eosinophilia asthma phenotype. High or low expression of MCP-1, eotaxin, and IL-8 discriminates between eosinophilic asthma severity clusters.
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Affiliation(s)
- I. Agache
- Transylvania University Brasov; Brasov Romania
| | - D. S. Strasser
- Department of Translational Science; Actelion Pharmaceuticals Ltd.; Davos Switzerland
| | - A. Klenk
- Information Management Drug Discovery; Actelion Pharmaceuticals Ltd.; Davos Switzerland
| | - C. Agache
- Theramed Medical Center; Brasov Romania
- Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - H. Farine
- Department of Translational Science; Actelion Pharmaceuticals Ltd.; Davos Switzerland
| | | | - P. M. A. Groenen
- Department of Translational Science; Actelion Pharmaceuticals Ltd.; Davos Switzerland
| | - C. A. Akdis
- Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
- Swiss Institute for Allergy and Asthma Research (SIAF); University of Zurich; Davos Switzerland
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156
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Swedin L, Saarne T, Rehnberg M, Glader P, Niedzielska M, Johansson G, Hazon P, Catley MC. Patient stratification and the unmet need in asthma. Pharmacol Ther 2016; 169:13-34. [PMID: 27373855 DOI: 10.1016/j.pharmthera.2016.06.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 06/14/2016] [Indexed: 02/07/2023]
Abstract
Asthma is often described as an inflammatory disease of the lungs and in most patients symptomatic treatment with bronchodilators or inhaled corticosteroids is sufficient to control disease. Unfortunately there are a proportion of patients who fail to achieve control despite treatment with the best current treatment. These severe asthma patients have been considered a homogeneous group of patients that represent the unmet therapeutic need in asthma. Many novel therapies have been tested in unselected asthma patients and the effects have often been disappointing, particularly for the highly specific monoclonal antibody-based drugs such as anti-IL-13 and anti-IL-5. More recently, it has become clear that asthma is a syndrome with many different disease drivers. Clinical trials of anti-IL-13 and anti-IL-5 have focused on biomarker-defined patient groups and these trials have driven the clinical progression of these drugs. Work on asthma phenotyping indicates that there is a group of asthma patients where T helper cell type 2 (Th2) cytokines and inflammation predominate and these type 2 high (T2-high) patients can be defined by biomarkers and response to therapies targeting this type of immunity, including anti-IL-5 and anti-IL-13. However, there is still a subset of T2-low patients that do not respond to these new therapies. This T2-low group will represent the new unmet medical need now that the T2-high-targeting therapies have made it to the market. This review will examine the current thinking on patient stratification in asthma and the identification of the T2-high subset. It will also look at the T2-low patients and examine what may be the drivers of disease in these patients.
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Affiliation(s)
- Linda Swedin
- Respiratory, Inflammation and Autoimmunity iMED, Translational Biology, AstraZeneca R&D Gothenburg, Sweden
| | - Tiiu Saarne
- Respiratory, Inflammation and Autoimmunity iMED, Translational Biology, AstraZeneca R&D Gothenburg, Sweden
| | - Maria Rehnberg
- Respiratory, Inflammation and Autoimmunity iMED, Translational Biology, AstraZeneca R&D Gothenburg, Sweden
| | - Pernilla Glader
- Respiratory, Inflammation and Autoimmunity iMED, Translational Biology, AstraZeneca R&D Gothenburg, Sweden
| | - Magdalena Niedzielska
- Respiratory, Inflammation and Autoimmunity iMED, Translational Biology, AstraZeneca R&D Gothenburg, Sweden
| | - Gustav Johansson
- Respiratory, Inflammation and Autoimmunity iMED, Translational Biology, AstraZeneca R&D Gothenburg, Sweden
| | - Petra Hazon
- Respiratory, Inflammation and Autoimmunity iMED, Translational Biology, AstraZeneca R&D Gothenburg, Sweden
| | - Matthew C Catley
- Respiratory, Inflammation and Autoimmunity iMED, Translational Biology, AstraZeneca R&D Gothenburg, Sweden.
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157
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Negewo NA, McDonald VM, Baines KJ, Wark PA, Simpson JL, Jones PW, Gibson PG. Peripheral blood eosinophils: a surrogate marker for airway eosinophilia in stable COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:1495-504. [PMID: 27445469 PMCID: PMC4936821 DOI: 10.2147/copd.s100338] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Sputum eosinophilia occurs in approximately one-third of stable chronic obstructive pulmonary disease (COPD) patients and can predict exacerbation risk and response to corticosteroid treatments. Sputum induction, however, requires expertise, may not always be successful, and does not provide point-of-care results. Easily applicable diagnostic markers that can predict sputum eosinophilia in stable COPD patients have the potential to progress COPD management. This study investigated the correlation and predictive relationship between peripheral blood and sputum eosinophils. It also examined the repeatability of blood eosinophil counts. Methods Stable COPD patients (n=141) were classified as eosinophilic or noneosinophilic based on their sputum cell counts (≥3%), and a cross-sectional analysis was conducted comparing their demographics, clinical characteristics, and blood cell counts. Receiver operating characteristic curve analysis was used to assess the predictive ability of blood eosinophils for sputum eosinophilia. Intraclass correlation coefficient was used to examine the repeatability of blood eosinophil counts. Results Blood eosinophil counts were significantly higher in patients with sputum eosinophilia (n=45) compared to those without (0.3×109/L vs 0.15×109/L; P<0.0001). Blood eosinophils correlated with both the percentage (ρ=0.535; P<0.0001) and number of sputum eosinophils (ρ=0.473; P<0.0001). Absolute blood eosinophil count was predictive of sputum eosinophilia (area under the curve =0.76, 95% confidence interval [CI] =0.67–0.84; P<0.0001). At a threshold of ≥0.3×109/L (specificity =76%, sensitivity =60%, and positive likelihood ratio =2.5), peripheral blood eosinophil counts enabled identification of the presence or absence of sputum eosinophilia in 71% of the cases. A threshold of ≥0.4×109/L had similar classifying ability but better specificity (91.7%) and higher positive likelihood ratio (3.7). In contrast, ≥0.2×109/L offered a better sensitivity (91.1%) for ruling out sputum eosinophilia. There was a good agreement between two measurements of blood eosinophil count over a median of 28 days (intraclass correlation coefficient =0.8; 95% CI =0.66–0.88; P<0.0001). Conclusion Peripheral blood eosinophil counts can help identify the presence or absence of sputum eosinophilia in stable COPD patients with a reasonable degree of accuracy.
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Affiliation(s)
- Netsanet A Negewo
- Priority Research Centre for Healthy Lungs, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia; School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia
| | - Katherine J Baines
- Priority Research Centre for Healthy Lungs, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia
| | - Peter Ab Wark
- Priority Research Centre for Healthy Lungs, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Jodie L Simpson
- Priority Research Centre for Healthy Lungs, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia
| | - Paul W Jones
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
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158
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Peters MC, McGrath KW, Hawkins GA, Hastie AT, Levy BD, Israel E, Phillips BR, Mauger DT, Comhair SA, Erzurum SC, Johansson MW, Jarjour NN, Coverstone AM, Castro M, Holguin F, Wenzel SE, Woodruff PG, Bleecker ER, Fahy JV. Plasma interleukin-6 concentrations, metabolic dysfunction, and asthma severity: a cross-sectional analysis of two cohorts. THE LANCET. RESPIRATORY MEDICINE 2016; 4:574-584. [PMID: 27283230 PMCID: PMC5007068 DOI: 10.1016/s2213-2600(16)30048-0] [Citation(s) in RCA: 332] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/25/2016] [Accepted: 04/08/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Severe asthma is a complex heterogeneous disease associated with older age and obesity. The presence of eosinophilic (type 2) inflammation in some but not all patients with severe asthma predicts responsiveness to current treatments, but new treatment approaches will require a better understanding of non-type 2 mechanisms of severe asthma. We considered the possibility that systemic inflammation, which arises in subgroups of obese and older patients, increases the severity of asthma. Interleukin-6 (IL-6) is a biomarker of systemic inflammation and metabolic dysfunction, and we aimed to explore the association between IL-6 concentrations, metabolic dysfunction, and asthma severity. METHODS In this cross-sectional analysis, patients were recruited from two cohorts: mainly non-severe asthmatics from the University of California San Francisco (UCSF) and mainly severe asthmatics from the Severe Asthma Research Program (SARP). We generated a reference range for plasma IL-6 in a cohort of healthy control patients. We compared the clinical characteristics of asthmatics with plasma IL-6 concentrations above (IL-6 high) and below (IL-6 low) the upper 95% centile value for plasma IL-6 concentration in the healthy cohort. We also compared how pulmonary function, frequency of asthma exacerbations, and frequency of severe asthma differed between IL-6 low and IL-6 high asthma populations in the two asthma cohorts. FINDINGS Between Jan 1, 2005, and Dec 31, 2014, we recruited 249 patients from UCSF and between Nov 1, 2012, and Oct 1, 2014, we recruited 387 patients from SARP. The upper 95th centile value for plasma IL-6 concentration in the healthy cohort (n=93) was 3·1 pg/mL, and 14% (36/249) of UCSF cohort and 26% (102/387) of the SARP cohort had plasma IL-6 concentrations above this upper limit. The IL-6 high patients in both asthma cohorts had a significantly higher average BMI (p<0·0001) and a higher prevalence of hypertension (p<0·0001) and diabetes (p=0·04) than the IL-6 low patients. IL-6 high patients also had significantly worse lung function and more frequent asthma exacerbations than IL-6 low patients (all p values <0·0001). Although 80% (111/138) of IL-6 high asthmatic patients were obese, 62% (178/289) of obese asthmatic patients were IL-6 low. Among obese patients, the forced expiratory volume in 1 s (FEV1) was significantly lower in IL-6 high than in IL-6 low patients (mean percent predicted FEV1=70·8% [SD 19·5] vs 78·3% [19·7]; p=0·002), and the percentage of patients reporting an asthma exacerbation in the past 1-2 years was higher in IL-6 high than in IL-6 low patients (66% [73/111] vs 48% [85/178]; p=0·003). Among non-obese asthmatics, FEV1 values and the frequency of asthma exacerbations within the past 1-2 years were also significantly worse in IL-6 high than in IL-6 low patients (mean FEV1 66·4% [SD 23·1] vs 83·2% [20·4] predicted; p<0·0001; 59% [16/27] vs 34% [108/320]; p=0·01). INTERPRETATION Systemic IL-6 inflammation and clinical features of metabolic dysfunction, which occur most commonly in a subset of obese asthma patients but also in a small subset of non-obese patients, are associated with more severe asthma. These data provide strong rationale to undertake clinical trials of IL-6 inhibitors or treatments that reduce metabolic dysfunction in a subset of patients with severe asthma. Plasma IL-6 is a biomarker that could guide patient stratification in these trials. FUNDING NIH and the Parker B Francis Foundation.
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Affiliation(s)
- Michael C Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Kelly Wong McGrath
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Gregory A Hawkins
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University Winston-Salem, NC, USA
| | - Annette T Hastie
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University Winston-Salem, NC, USA
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Brenda R Phillips
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, PA, USA
| | - David T Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, PA, USA
| | - Suzy A Comhair
- Department of Pathobiology, Cleveland Clinic, Cleveland, OH, USA
| | - Serpil C Erzurum
- Department of Pathobiology, Cleveland Clinic, Cleveland, OH, USA
| | - Mats W Johansson
- Department of Biomolecular Chemistry, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Nizar N Jarjour
- Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Andrea M Coverstone
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Pediatrics, Washington University, St Louis, MO, USA
| | - Fernando Holguin
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sally E Wenzel
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Prescott G Woodruff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University Winston-Salem, NC, USA
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA.
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Abstract
Noneosinophilic airway inflammation occurs in approximately 50% of patients with asthma. It is subdivided into neutrophilic or paucigranulocytic inflammation, although the proportion of each subtype is uncertain because of variable cut-off points used to define neutrophilia. This article reviews the evidence for noneosinophilic inflammation being a target for therapy in asthma and assesses clinical trials of licensed drugs, novel small molecules and biologics agents in noneosinophilic inflammation. Current symptoms, rate of exacerbations and decline in lung function are generally less in noneosinophilic asthma than eosinophilic asthma. Noneosinophilic inflammation is associated with corticosteroid insensitivity. Neutrophil activation in the airways and systemic inflammation is reported in neutrophilic asthma. Neutrophilia in asthma may be due to corticosteroids, associated chronic pulmonary infection, altered airway microbiome or delayed neutrophil apoptosis. The cause of poorly controlled noneosinophilic asthma may differ between patients and involve several mechanism including neutrophilic inflammation, T helper 2 (Th2)-low or other subtypes of airway inflammation or corticosteroid insensitivity as well as noninflammatory pathways such as airway hyperreactivity and remodelling. Smoking cessation in asthmatic smokers and removal from exposure to some occupational agents reduces neutrophilic inflammation. Preliminary studies of 'off-label' use of licensed drugs suggest that macrolides show efficacy in nonsmokers with noneosinophilic severe asthma and statins, low-dose theophylline and peroxisome proliferator-activated receptor gamma (PPARγ) agonists may benefit asthmatic smokers with noneosinophilic inflammation. Novel small molecules targeting neutrophilic inflammation, such as chemokine (CXC) receptor 2 (CXCR2) antagonists reduce neutrophils, but do not improve clinical outcomes in studies to date. Inhaled phosphodiesterase (PDE)4 inhibitors, dual PDE3 and PDE4 inhibitors, p38MAPK (mitogen-activated protein kinase) inhibitors, tyrosine kinase inhibitors and PI (phosphoinositide) 3kinase inhibitors are under development and these compounds may be of benefit in noneosinophilic inflammation. The results of clinical trials of biological agents targeting mediators associated with noneosinophilic inflammation, such as interleukin (IL)-17 and tumor necrosis factor (TNF)-α are disappointing. Greater understanding of the mechanisms of noneosinophilic inflammation in asthma should lead to improved therapies.
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Affiliation(s)
- Neil C Thomson
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 0YN, UK
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160
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Diagnostic Utility of Total IgE in Foods, Inhalant, and Multiple Allergies in Saudi Arabia. J Immunol Res 2016; 2016:1058632. [PMID: 27314052 PMCID: PMC4897674 DOI: 10.1155/2016/1058632] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 04/04/2016] [Accepted: 04/28/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. To assess the diagnostic significance of total IgE in foods, inhalant, and multiple allergies. Methods. Retrospective review of the laboratory records of patients who presented with clinical suspicion of food or inhalant allergy between January 2013 and December 2014. Total IgE level was defined as positive for a value >195 kU/L; and diagnosis was confirmed by the detection of specific IgE (golden standard) for at least one food or inhalant allergen and at least two allergens in multiple allergies. Results. A total of 1893 (male ratio = 0.68, mean age = 39.0 ± 19.2 years) patients were included. Total IgE had comparable sensitivity (55.8% versus 59.6%) and specificity (83.9% versus 84.4%) in food versus inhalant allergy, respectively, but a superior PPV in inhalant allergy (79.1% versus 54.4%). ROC curve analysis showed a better diagnostic value in inhalant allergies (AUC = 0.817 (95% CI = 0.796-0.837) versus 0.770 (95% CI = 0.707-0.833)). In multiple allergies, total IgE had a relatively good sensitivity (78.6%), while negative IgE testing (<195 kU/L) predicted the absence of multiple allergies with 91.5% certitude. Conclusion. Total IgE assay is not efficient as a diagnostic test for foods, inhalant, or multiple allergies. The best strategy should refer to specific IgE testing guided by a comprehensive atopic history.
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161
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Fingleton J, Braithwaite I, Travers J, Bowles D, Strik R, Siebers R, Holweg C, Matthews J, Weatherall M, Beasley R. Serum periostin in obstructive airways disease. Eur Respir J 2016; 47:1383-91. [PMID: 26917610 PMCID: PMC4851937 DOI: 10.1183/13993003.01384-2015] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 01/15/2016] [Indexed: 12/11/2022]
Abstract
Serum periostin is a potential biomarker of response to therapies that target type 2 inflammation in asthma. The objectives of this study were to describe: 1) the distribution of serum periostin levels in adults with symptomatic airflow obstruction; 2) its relationship with other variables, including type 2 biomarkers; and 3) the effect of inhaled corticosteroids on periostin levels.Serum periostin levels were measured in a cross-sectional study exploring phenotypes and biomarkers in 386 patients aged 18-75 years who reported wheeze and breathlessness in the past 12 months. In 49 ICS-naïve patients, periostin levels were measured again after 12 weeks of budesonide (800 μg·day(-1)).The distribution of serum periostin levels was right skewed (mean±sd 57.3±18.6 ng·mL(-1), median (interquartile range) 54.0 (45.1-65.6) ng·mL(-1), range 15.0-164.7 ng·mL(-1)). Periostin was positively associated with exhaled nitric oxide (Spearman's rho=0.22, p<0.001), blood eosinophil count (Spearman's rho=0.21, p<0.001), and total IgE (Spearman's rho=0.14, p=0.007). The Hodges-Lehmann estimator (95% CI) of change in periostin level after ICS therapy was -4.8 (-6.7- -3.2) ng·mL(-1) (p<0.001).These findings provide data on the distribution of serum periostin in adults with symptomatic airflow obstruction, the weak associations between periostin and other type 2 markers, and the reduction in periostin with inhaled corticosteroid therapy.
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Affiliation(s)
- James Fingleton
- Medical Research Institute of New Zealand, Wellington, New Zealand Capital and Coast District Health Board, Wellington, New Zealand Victoria University of Wellington, Wellington, New Zealand
| | | | - Justin Travers
- Medical Research Institute of New Zealand, Wellington, New Zealand Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Darren Bowles
- Medical Research Institute of New Zealand, Wellington, New Zealand Capital and Coast District Health Board, Wellington, New Zealand
| | - Rianne Strik
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Rob Siebers
- University of Otago Wellington, Wellington, New Zealand
| | | | | | - Mark Weatherall
- Capital and Coast District Health Board, Wellington, New Zealand University of Otago Wellington, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand Capital and Coast District Health Board, Wellington, New Zealand Victoria University of Wellington, Wellington, New Zealand
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162
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Clinically relevant outcome measures for new therapies of asthma using pharmaceutical and biologic agents. Curr Opin Allergy Clin Immunol 2016; 15:213-9. [PMID: 25899693 DOI: 10.1097/aci.0000000000000165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To determine the benefits of new asthma drugs or therapies, they should be assessed with regard to their effects on relevant clinical outcomes. RECENT FINDINGS The most frequently used outcomes have been symptoms, rescue medication needs and pulmonary function tests, although others such as quality of life, exacerbations and impairment of activities have also been identified as important ones. Improvements in our understanding of basic mechanisms of asthma have led to the development of new sets of outcomes including inflammatory markers and a rapidly increasing number of biomarkers, which however require validation, and assessment of their clinical usefulness. Many studies have not only looked at induced sputum cell differentials or FENO to phenotype asthma but also as treatment efficacy markers. Periostin is considered a marker of TH2-induced airway inflammation and a predictor of response to drugs such as anti-IL13 and omalizumab, although at the individual level, such prediction remains imperfect. SUMMARY There is a need to develop new markers of activity of the disease, with a prognostic value with regard to the benefits of new treatments.
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163
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Gitomer SA, Fountain CR, Kingdom TT, Getz AE, Sillau SH, Katial RK, Ramakrishnan VR. Clinical Examination of Tissue Eosinophilia in Patients with Chronic Rhinosinusitis and Nasal Polyposis. Otolaryngol Head Neck Surg 2016; 155:173-8. [PMID: 26980909 DOI: 10.1177/0194599816637856] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/17/2016] [Indexed: 01/21/2023]
Abstract
OBJECTIVE (1) Describe clinical and histopathologic findings in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). (2) Determine if tissue and serum eosinophilia predicts disease severity in CRSwNP. STUDY DESIGN Case series with chart review. SETTING Academic hospital specializing in respiratory and allergic disease. SUBJECTS Patients with CRSwNP treated from 2008 to 2010. METHODS Clinical data were collected; sinus computed tomography (CT) scans were scored according to the Lund-Mackay system; and surgical specimens were evaluated for degree of tissue eosinophilia. Statistical analysis was performed to compare eosinophilia with indicators of disease severity. RESULTS Seventy CRSwNP patients were included, with a mean Lund-Mackay score of 16.7; 62.1% of patients had severe asthma, and 62.9% were aspirin sensitive. Elevated tissue eosinophil level did not correlate with medication usage, olfactory symptoms, or Lund-Mackay scores, nor did it correlate with presence of asthma or aspirin-sensitivity (P = .09). Patients with mild asthma had significantly more tissue eosinophils versus patients with severe asthma, possibly because of the high amount of chronic corticosteroid use in severe asthmatics. There was no correlation between tissue and serum eosinophil counts (P = .97), but there was a significant positive correlation between CT score and peripheral eosinophil level (P < .05). CONCLUSIONS Higher serum eosinophil levels may indicate more extensive mucosal disease as measured on CT scan. Neither serum nor tissue eosinophilia predicted disease severity in our retrospective analysis of CRSwNP patients, and serum eosinophil level did not serve as a marker of tissue eosinophilia.
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Affiliation(s)
- Sarah A Gitomer
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Cynthia R Fountain
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Todd T Kingdom
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anne E Getz
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Stefan H Sillau
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rohit K Katial
- National Jewish Health, Division of Allergy and Immunology, Denver, Colorado, USA
| | - Vijay R Ramakrishnan
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
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164
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Emprm V, Rajanandh MG, Nageswari AD. Periostin - A Novel Systemic Biomarker for Eosinophilic Airway Inflammation: A Case Control Study. J Clin Diagn Res 2016; 10:OC01-4. [PMID: 27054127 DOI: 10.7860/jcdr/2016/14553.7166] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 11/02/2015] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chronic airway inflammation and remodelling are fundamental features of asthma. The molecular phenotypes in asthma are Th2 high and Th2 low. Serum periostin is a biomarker which aid in understanding Th2 high eosinophilic asthma. AIM The present study aimed to identify whether or not serum periostin is a systemic biomarker for eosinophilic airway inflammation in asthmatics. MATERIALS AND METHODS The study was designed as a prospective, case control study. Patients who presented with consistent symptoms of asthma and confirmed by spirometry with reversibility were the cases. The controls were healthy subjects who had no history of lung disease with normal lung function. The sputum and blood samples were collected from both the groups. Sputum eosinophils, Absolute Eosinophil Counts (AEC) and serum periostin levels were compared between the groups. RESULTS The study comprised of 101 participants in which 30 were controls and 71 were cases. In the study group, mean post FEV1 was 64.45. There was a positive correlation of sputum eosinophils with severity of obstruction. The ROC curve analysis showed the cut-off value of 24.556 for serum periostin with the p-value of <0.001. As the severity of obstruction increased, the serum periostin levels were also found to be increased. Serum periostin had a sensitivity and specificity of 97.18% and 86.67% with a diagnostic accuracy of 94.06%. CONCLUSION Serum periostin appears to be a more sensitive tool for detection of airflow limitation in asthmatic patients with a Th2 high eosinophilic phenotype when compared to AEC and sputum eosinophils.
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Affiliation(s)
- Viswanathan Emprm
- ESI Post Graduate Institute of Medical Sciences and Research (PGIMSR) , Rajajinagar, Bengaluru, India
| | - M G Rajanandh
- Department of Pharmacy Practice, Faculty of Pharmacy, Sri Ramachandra University , Porur, Chennai, Tamil Nadu, India
| | - A D Nageswari
- Professor and Head, Department of TB and Chest Diseases, Tagore Medical College & Hospital , Chennai, Tamil Nadu, India
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165
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Sim DW, Lee JH. Biomarkers of adult asthma and personalized medicine. ALLERGY ASTHMA & RESPIRATORY DISEASE 2016. [DOI: 10.4168/aard.2016.4.1.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Da Woon Sim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Hyun Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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166
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Price DB, Rigazio A, Campbell JD, Bleecker ER, Corrigan CJ, Thomas M, Wenzel SE, Wilson AM, Small MB, Gopalan G, Ashton VL, Burden A, Hillyer EV, Kerkhof M, Pavord ID. Blood eosinophil count and prospective annual asthma disease burden: a UK cohort study. THE LANCET. RESPIRATORY MEDICINE 2015; 3:849-58. [PMID: 26493938 DOI: 10.1016/s2213-2600(15)00367-7] [Citation(s) in RCA: 380] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/04/2015] [Accepted: 09/11/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Elevated sputum eosinophil counts predict asthma exacerbations and responsiveness to inhaled corticosteroids but are impractical to measure in primary care. We investigated the relation between blood eosinophil count and prospective annual asthma outcomes for a large UK cohort. METHODS This historical cohort study used anonymised medical record data to identify primary care patients with asthma aged 12-80 years with 2 years of continuous records, including 1 year before (baseline) and 1 year after (outcome) their most recent eosinophil count. Negative binomial regression was used to compare outcome exacerbation rates and logistic regression to compare odds of asthma control for patients with blood eosinophil counts of 400 cells per μL or less versus greater than 400 cells per μL, adjusting for age, sex, body-mass index, smoking status, and Charlson comorbidity index. The study is registered at ClinicalTrials.gov, number NCT02140541. FINDINGS Overall, 20 929 (16%) of 130 248 patients had blood eosinophil counts greater than 400 cells per μL. During the outcome year, these patients experienced significantly more severe exacerbations (adjusted rate ratio [RR] 1·42, 95% CI 1·36-1·47) and acute respiratory events (RR 1·28, 1·24-1·33) than those with counts of 400 cells per μL or less. They also had significantly lower odds of achieving overall asthma control (OR 0·74, 95% CI 0·72-0·77), defined as limited reliever use and no asthma-related hospital attendance or admission, acute course of oral corticosteroids, or prescription for antibiotics. Exacerbation rates increased progressively with nine ascending categories of blood eosinophil count as compared with a reference category of 200 cells per μL or less. INTERPRETATION Patients with asthma and blood eosinophil counts greater than 400 cells per μL experience more severe exacerbations and have poorer asthma control. Furthermore, a count-response relation exists between blood eosinophil counts and asthma-related outcomes. Blood eosinophil counts could add predictive value to Global Initiative for Asthma control-based risk assessment. FUNDING Teva Pharmaceuticals.
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Affiliation(s)
- David B Price
- Academic Primary Care, University of Aberdeen, Aberdeen, UK; Research in Real-Life, Cambridge, UK.
| | | | - Jonathan D Campbell
- Department of Clinical Pharmacy, Pharmaceutical Outcomes Research, University of Colorado School of Pharmacy, Aurora, CO, USA
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Mike Thomas
- Primary Care and Population Sciences, and NIHR Southampton Respiratory Biomedical Research Unit, University of Southampton, Southampton, UK
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute at UPMC, Division of Pulmonary, Allergy and Critical Care Medicine, Pittsburgh, PA, USA
| | - Andrew M Wilson
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mary Buatti Small
- Respiratory, Global Medical Affairs, TEVA Pharmaceuticals, Frazer, PA, USA
| | - Gokul Gopalan
- Respiratory, Global Medical Affairs, TEVA Pharmaceuticals, Frazer, PA, USA
| | | | | | | | | | - Ian D Pavord
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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167
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Liu T, Wu J, Zhao J, Wang J, Zhang Y, Liu L, Cao L, Liu Y, Dong L. Type 2 innate lymphoid cells: A novel biomarker of eosinophilic airway inflammation in patients with mild to moderate asthma. Respir Med 2015; 109:1391-6. [PMID: 26459159 DOI: 10.1016/j.rmed.2015.09.016] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/27/2015] [Accepted: 09/30/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eosinophilic airway inflammation can predict the exacerbation of asthma, and we can improve the management of asthma by monitoring the eosinophilic airway inflammation. Although induced sputum and sputum eosinophil count is the gold standard test for diagnosing eosinophilic asthma, a more accessible and receptive method is needed for clinical practice. Type 2 innate lymphoid cells (ILC2) have recently been proposed to play a crucial role in eosinophilic inflammation and have been identified in peripheral blood from patients with asthma. OBJECTIVES We sought to identify simple and feasible biomarkers which can predict eosinophilic airway inflammation in asthmatic patients. METHODS Sputum was induced for the assessment of eosinophils in 150 asthmatic patients. In parallel, the proportion of ILC2s of peripheral blood lymphocytes (%ILC2), blood eosinophil counts, total immunoglobulin E (IgE), fractional exhaled nitric oxide (FeNO) and lung function tests were measured. 42 healthy donors served as controls. RESULTS 126 patients finished sputum induction and produced adequate sputum. The ILC2 level was significantly increased in eosinophilic asthmatic patients compared with non-eosinophilic asthmatic patients (0.117 ± 0.090versus0.035 ± 0.021, p < 0.001). A multiple regression model, including age, sex, BMI, blood eosinophil counts, FeNO, IgE and %ILC2, showed that %ILC2, blood eosinophil counts and FeNO were correlative factors of sputum eosinophil counts (p < 0.001, p = 0.037, p < 0.001, respectively) and %ILC2 was the most significant subset of airway eosinophilic inflammation (Estimate = 11.385). A receiver operating characteristic (ROC) analysis showed a sensitivity of 67.7% and a specificity of 95.3% for %ILC2 of 0.076 to distinguish eosinophilic asthmatic patients from non-eosinophilic asthmatic patients. CONCLUSION ILC2 is a surrogate marker of airway eosinophilic inflammation in patients with mild to moderate asthma and has great potential advantages for selecting the asthmatic patients most likely to benefit from therapeutics targeting Th2 inflammation.
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Affiliation(s)
- Tian Liu
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China
| | - Jinxiang Wu
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China
| | - Jiping Zhao
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China
| | - Junfei Wang
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China
| | - Yuanyuan Zhang
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China
| | - Lin Liu
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China
| | - Liuzhao Cao
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China
| | - Yahui Liu
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China
| | - Liang Dong
- Dept. of Pulmonary Medicine, Qilu Hospital of Shandong University, Jinan 250012, PR China.
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168
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Abstract
PURPOSE OF REVIEW This review examines the association between airway neutrophilia and severe asthma, potential mechanisms, and the effect on asthma control of therapies directed at reducing airway neutrophil numbers or activity. RECENT FINDINGS The majority of studies that observe an association between airway neutrophilia and severe asthma are cross-sectional in nature, and the intensity of neutrophilia is low and may be a reflection of the age of the patients, effect of tobacco smoke exposure, or the high doses of corticosteroids used to treat their asthma. There may be a small proportion of patients who may have abnormal innate immune responses that may lead to airway neutrophilia. However, these neutrophils may not be any more activated than in patients with milder asthma. Novel strategies using small molecule antagonists against the interleukin-8 receptor, CXCR2, are able to reduce airway neutrophilia, and their clinical efficacies are being investigated. SUMMARY Although cross-sectional studies suggest that airway neutrophilia may be observed in some patients with severe asthma, it is not clearly established if this is a consequence of treatment with corticosteroids or if it contributes directly to asthma pathobiology and severity. New therapies such as anti-CXCR2 provide an opportunity to investigate the contribution of neutrophils to asthma severity.
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169
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Westerhof GA, Korevaar DA, Amelink M, de Nijs SB, de Groot JC, Wang J, Weersink EJ, ten Brinke A, Bossuyt PM, Bel EH. Biomarkers to identify sputum eosinophilia in different adult asthma phenotypes. Eur Respir J 2015; 46:688-96. [PMID: 26113672 DOI: 10.1183/09031936.00012415] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 04/15/2015] [Indexed: 01/22/2023]
Abstract
Several biomarkers have been used to assess sputum eosinophilia in asthma. It has been suggested that the diagnostic accuracy of these biomarkers might differ between asthma phenotypes. We investigated the accuracy of biomarkers in detecting sputum eosinophilia (≥3%) in different adult asthma phenotypes.Levels of eosinophils in blood and sputum, exhaled nitric oxide fraction (FeNO) and total immunoglobulin (Ig)E from 336 adult patients, enrolled in three prospective observational clinical trials and recruited at five pulmonology outpatient departments, were analysed. Areas under the receiver operating characteristics curves (AUC) for detecting sputum eosinophilia were calculated and compared between severe and mild, obese and nonobese, atopic and nonatopic and (ex-)smoking and never-smoking asthma patients.Sputum eosinophilia was present in 116 patients (35%). In the total group the AUC was 0.83 (95% CI 0.78-0.87) for blood eosinophils, 0.82 (0.77-0.87) for FeNO and 0.69 (0.63-0.75) for total IgE. AUCs were similar for blood eosinophils and FeNO between different phenotypes. Total IgE was less accurate in detecting sputum eosinophilia in atopic and obese patients than in nonatopic and nonobese patients.Blood eosinophils and FeNO had comparable diagnostic accuracy (superior to total IgE) in identifying sputum eosinophilia in adult asthma patients, irrespective of asthma phenotype such as severe, nonatopic, obese and smoking-related asthma.
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Affiliation(s)
- Guus A Westerhof
- Department of Respiratory Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Daniël A Korevaar
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - Marijke Amelink
- Department of Respiratory Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Selma B de Nijs
- Department of Respiratory Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jantina C de Groot
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Junfeng Wang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - Els J Weersink
- Department of Respiratory Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Anneke ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - Elisabeth H Bel
- Department of Respiratory Medicine, Academic Medical Centre, Amsterdam, the Netherlands
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170
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Zhang XY, Simpson JL, Powell H, Yang IA, Upham JW, Reynolds PN, Hodge S, James AL, Jenkins C, Peters MJ, Lin JT, Gibson PG. Full blood count parameters for the detection of asthma inflammatory phenotypes. Clin Exp Allergy 2015; 44:1137-45. [PMID: 24849076 DOI: 10.1111/cea.12345] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 03/04/2014] [Accepted: 04/14/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND In asthma, the airway inflammatory phenotype influences clinical characteristics and treatment response. Although induced sputum is the gold standard test for phenotyping asthma, a more accessible method is needed for clinical practice. OBJECTIVE To investigate whether white blood cell counts and/or their derived ratios can predict sputum eosinophils or neutrophils in uncontrolled asthma. METHODS This cross-sectional study evaluated 164 treated but uncontrolled asthmatic patients with sputum induction and blood collection. Receiver-operating characteristic (ROC) curves were used to assess the relationship between blood and sputum parameters. RESULTS There was a significant positive relationship between blood eosinophil parameters and the percentage of sputum eosinophil count. A weak but significant correlation was found between sputum neutrophil percentage and blood neutrophil percentage (r = 0.219, P = 0.005). ROC curve analysis identified that blood eosinophil percentage count was the best predictor for eosinophilic asthma, with an area under the curve (AUC) of 0.907 (P < 0.001). The optimum cut-point for blood eosinophil percentage was 2.7%, and this yielded a sensitivity of 92.2% and a specificity of 75.8%. The absolute blood eosinophil count was also highly predictive with an AUC of 0.898 (P < 0.0001) at a blood eosinophil cut-off of 0.26 × 10(9) /L. The blood eosinophil/lymphocyte ratio (ELR) and eosinophil/neutrophil ratio (ENR) were increased in eosinophilic asthma, and the neutrophil/lymphocyte ratio (NLR) was increased in neutrophilic asthma. Neutrophilic asthma could also be detected by blood neutrophil percentages and NLR, but with less accuracy. CONCLUSIONS AND CLINICAL RELEVANCE Blood eosinophil counts and derived ratios (ELR and ENR) can accurately predict eosinophilic asthma in patients with persistent uncontrolled asthma despite treatment. Blood neutrophil parameters are poor surrogates for the proportion of sputum neutrophils. Blood counts may be a useful aid in the monitoring of uncontrolled asthma.
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Affiliation(s)
- X-Y Zhang
- Department of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Graduate School, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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171
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Khatry DB, Gossage DL, Geba GP, Parker JM, Jarjour NN, Busse WW, Molfino NA. Discriminating sputum-eosinophilic asthma: Accuracy of cutoffs in blood eosinophil measurements versus a composite index, ELEN. J Allergy Clin Immunol 2015; 136:812-814.e2. [PMID: 25913197 DOI: 10.1016/j.jaci.2015.03.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 02/19/2015] [Accepted: 03/13/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | | | | | | | - Nizar N Jarjour
- Allergy, Pulmonary and Critical Care Division, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wis
| | - William W Busse
- Allergy, Pulmonary and Critical Care Division, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wis
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Korevaar DA, Westerhof GA, Wang J, Cohen JF, Spijker R, Sterk PJ, Bel EH, Bossuyt PMM. Diagnostic accuracy of minimally invasive markers for detection of airway eosinophilia in asthma: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2015; 3:290-300. [PMID: 25801413 DOI: 10.1016/s2213-2600(15)00050-8] [Citation(s) in RCA: 182] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Eosinophilic airway inflammation is associated with increased corticosteroid responsiveness in asthma, but direct airway sampling methods are invasive or laborious. Minimally invasive markers for airway eosinophilia could present an alternative method, but estimates of their accuracy vary. METHODS We did a systematic review and searched Medline, Embase, and PubMed for studies assessing the diagnostic accuracy of markers against a reference standard of induced sputum, bronchoalveolar lavage, or endobronchial biopsy in patients with asthma or suspected asthma (for inception to Aug 1, 2014). Unpublished results were obtained by contacting authors of studies that did not report on diagnostic accuracy, but had data from which estimates could be calculated. We assessed risk of bias with QUADAS-2. We used meta-analysis to produce summary estimates of accuracy. FINDINGS We included 32 studies: 24 in adults and eight in children. Of these, 26 (81%) showed risk of bias in at least one domain. In adults, three markers had extensively been investigated: fraction of exhaled nitric oxide (FeNO) (17 studies; 3216 patients; summary area under the receiver operator curve [AUC] 0·75 [95% CI 0·72-0·78]); blood eosinophils (14 studies; 2405 patients; 0·78 [0·74-0·82]); total IgE (seven studies; 942 patients; 0·65 [0·61-0·69]). In children, only FeNO (six studies; 349 patients; summary AUC 0·81 [0·72-0·89]) and blood eosinophils (three studies; 192 patients; 0·78 [0·71-0·85]) had been investigated in more than one study. Induced sputum was most frequently used as the reference standard. Summary estimates of sensitivity and specificity in detecting sputum eosinophils of 3% or more in adults were: 0·66 (0·57-0·75) and 0·76 (0·65-0·85) for FeNO; 0·71 (0·65-0·76) and 0·77 (0·70-0·83) for blood eosinophils; and 0·64 (0·42-0·81) and 0·71 (0·42-0·89) for IgE. INTERPRETATION FeNO, blood eosinophils, and IgE have moderate diagnostic accuracy. Their use as a single surrogate marker for airway eosinophilia in patients with asthma will lead to a substantial number of false positives or false negatives. FUNDING None.
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Affiliation(s)
- Daniël A Korevaar
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands.
| | - Guus A Westerhof
- Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Junfeng Wang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Jérémie F Cohen
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands; Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris, France; Department of Pediatrics, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - René Spijker
- Medical Library, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Elisabeth H Bel
- Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Patrick M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
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Lim HF, Nair P. Efficacy and safety of reslizumab in patients with moderate to severe eosinophilic asthma. Expert Rev Respir Med 2015; 9:135-42. [PMID: 25578680 DOI: 10.1586/17476348.2015.1000867] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Reslizumab, a neutralizing anti-IL-5 monoclonal antibody, is a promising adjunctive treatment for severe eosinophilic asthma. Monthly intravenous 3.0 mg/kg reslizumab had resulted in improvements in lung function and asthma control. It is well tolerated and common adverse events include headache, nasopharyngitis and upper respiratory tract infection. Rebound eosinophilia after cessation of reslizumab and attenuation of the treatment response with repeated dosing had been reported. Stringent selection of patients with a high eosinophil burden, who are poorly controlled despite moderate to high doses of inhaled corticosteroid, confers the most significant treatment response. Future trials should compare the dose, delivery platform, frequency of dosing and study combinations with other biologics, which will affect its maximal clinical efficacy.
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Affiliation(s)
- Hui Fang Lim
- Department of Medicine, Division of Respiratory and Critical Care Medicine, National University Health System, NUHS Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore
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174
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Blood eosinophil count is a useful biomarker to identify patients with severe eosinophilic asthma. Ann Am Thorac Soc 2015; 11:531-6. [PMID: 24606022 DOI: 10.1513/annalsats.201310-354oc] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
RATIONALE Measurement of sputum or blood eosinophils may allow identification of a severe eosinophilic asthma population responsive to mepolizumab. OBJECTIVES The primary objective was assessment of a single blood eosinophil measurement to predict future eosinophil measurements in the following year versus using multiple blood eosinophil measurements. In addition, we examined whether a single sputum or blood eosinophil measurement was a useful biomarker for predicting treatment response to mepolizumab. METHODS Based on data from placebo subjects (n = 155), we determined whether a blood eosinophil count of 150/μl or greater at screening remained on average above this level during the following year. The rate of exacerbation reduction in the sputum substudy population based on the screening blood eosinophil count and sputum eosinophils was evaluated. MEASUREMENTS AND MAIN RESULTS Of 115 patients with eosinophils 150/μl or greater at screening, 98 (85%) remained above this level in their post-screening average. Using the average of two, three or four measurements 150/μl or greater, 97 (85%), 103 (90%), and 105 (92%) have postscreening averages above 150/μl. Mepolizumab reduced exacerbations by 69% (95% confidence interval [CI] = 41-83%) in subjects with baseline sputum eosinophils of 3% or greater compared with 66% (95% CI = 7-87%) in subjects with baseline sputum eosinophils under 3%. The reduction was 72% (95% CI = 41-83%) in subjects with blood eosinophils of 150/μl or greater compared with 30% (95% CI = -134 to 79%) in subjects with blood eosinophils under 150/μl. CONCLUSIONS A single measurement of 150/μl or greater predicted the average of subsequent measurements being 150/μl or greater in 85% of this population. Using an average of multiple measurements only marginally increases the sensitivity. Sputum eosinophils did not predict treatment response with mepolizumab.
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175
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Thomson NC. Novel therapies targeting eosinophilic inflammation in asthma. Clin Exp Allergy 2014; 44:462-8. [PMID: 24666518 DOI: 10.1111/cea.12268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- N C Thomson
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
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176
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Bartminski G, Crossley M, Turcanu V. Novel biomarkers for asthma stratification and personalized therapy. Expert Rev Mol Diagn 2014; 15:415-30. [PMID: 25479456 DOI: 10.1586/14737159.2015.988613] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A stepwise pharmacological treatment is currently recommended for all asthma patients and is personalized mainly on disease severity, aiming for the lowest disease-controlling step. Nevertheless, asthma comprises several related pathologies with similar clinical manifestations resulting from distinct underlying mechanisms. Therefore novel biomarkers could lead to asthma stratification and thus improve upon the current stepwise approach. The aim of this review is to update the reader with regard to different assays proposed in the recent asthma literature for measuring potential biomarkers for patient stratification and treatment personalization. Promising biomarkers are sputum eosinophils, serum periostin and exhaled nitric oxide. Periostin could differentiate between Th2-high and Th2-low asthma (Th2-high patients are more responsive to glucocorticoids) and the less-defined asthma types which often present a therapeutic challenge. Several other biomarkers, mainly cytokines, leukotrienes and exhaled air components, can be quantified in body fluids and exhaled breath and could also be useful for asthma stratification.
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Affiliation(s)
- Grzegorz Bartminski
- Department of Asthma, Allergy and Lung Biology, King's College London 5th floor Tower Wing, Guy's Hospital, London Bridge, SE1 9RT, UK
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177
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Wagener AH, de Nijs SB, Lutter R, Sousa AR, Weersink EJM, Bel EH, Sterk PJ. External validation of blood eosinophils, FE(NO) and serum periostin as surrogates for sputum eosinophils in asthma. Thorax 2014; 70:115-20. [PMID: 25422384 DOI: 10.1136/thoraxjnl-2014-205634] [Citation(s) in RCA: 316] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Monitoring sputum eosinophils in asthma predicts exacerbations and improves management of asthma. Thus far, blood eosinophils and FE(NO) show contradictory results in predicting eosinophilic airway inflammation. More recently, serum periostin was proposed as a novel biomarker for eosinophilic inflammation. OBJECTIVES Quantifying the mutual relationships of blood eosinophils, FE(NO), and serum periostin with sputum eosinophils by external validation in two independent cohorts across various severities of asthma. METHODS The first cohort consisted of 110 patients with mild to moderate asthma (external validation cohort). The replication cohort consisted of 37 patients with moderate to severe asthma. Both cohorts were evaluated cross-sectionally. Sputum was induced for the assessment of eosinophils. In parallel, blood eosinophil counts, serum periostin concentrations and FENO were assessed. The diagnostic accuracy of these markers to identify eosinophilic asthma (sputum eosinophils ≥3%) was calculated using receiver operating characteristics area under the curve (ROC AUC). RESULTS In the external validation cohort, ROC AUC for blood eosinophils was 89% (p<0.001) and for FE(NO) level 78% (p<0.001) to detect sputum eosinophilia ≥3%. Serum periostin was not able to distinguish eosinophilic from non-eosinophilic airway inflammation (ROC AUC=55%, p=0.44). When combining these three variables, no improvement was seen. The diagnostic value of blood eosinophils was confirmed in the replication cohort (ROC AUC 85%, p<0.001). CONCLUSIONS In patients with mild to moderate asthma, as well as patients with more severe asthma, blood eosinophils had the highest accuracy in the identification of sputum eosinophilia in asthma. The use of blood eosinophils can facilitate individualised treatment and management of asthma. TRIAL REGISTRATION NTR1846 and NTR2364.
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Affiliation(s)
- A H Wagener
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands
| | - S B de Nijs
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands
| | - R Lutter
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands Department of Experimental Immunology, Academic Medical Center (AMC), University of Amsterdam, The Netherlands
| | - A R Sousa
- Respiratory Therapy Unit, GlaxoSmithKline, London, UK
| | - E J M Weersink
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands
| | - E H Bel
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands
| | - P J Sterk
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands
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178
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Fowler SJ, Tavernier G, Niven R. High blood eosinophil counts predict sputum eosinophilia in patients with severe asthma. J Allergy Clin Immunol 2014; 135:822-4.e2. [PMID: 25445828 DOI: 10.1016/j.jaci.2014.09.034] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/19/2014] [Accepted: 09/24/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Stephen J Fowler
- University of Manchester, Manchester Academic Health Science Centre, and NIHR Translational Research Facility in Respiratory Medicine, University Hospital of South Manchester, Manchester, United Kingdom; Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom.
| | - Gaël Tavernier
- University of Manchester, Manchester Academic Health Science Centre, and NIHR Translational Research Facility in Respiratory Medicine, University Hospital of South Manchester, Manchester, United Kingdom
| | - Robert Niven
- University of Manchester, Manchester Academic Health Science Centre, and NIHR Translational Research Facility in Respiratory Medicine, University Hospital of South Manchester, Manchester, United Kingdom
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Abstract
PURPOSE OF REVIEW The importance and functional contribution of eosinophils to the pathogenesis of severe asthma was questioned when adult studies reported neutrophilic inflammation and Th17 cells were central to disease. RECENT FINDINGS Eosinophilic inflammation, atopic sensitization and airway remodelling are the hallmark features of severe asthma in children. Contrary to adult reports, neutrophils, Th17 and Th2 cytokines are rarely detected in children with severe disease who are prescribed high-dose steroids. Type 2 innate lymphoid cells (ILCs), which are induced by the epithelial cytokine interleukin (IL)-33, and also release the Th2 cytokines IL-5 and IL-13, have been shown to be important in mediating asthma, and specifically, ILCs have a role in mediating eosinophil homeostasis. A direct link between IL-33, airway remodelling and steroid resistance in paediatric severe asthma suggests the steroid-resistant eosinophilia may be mediated by ILCs rather than classical Th2 lymphocytes. SUMMARY Data from children with severe asthma have shown that findings from adults cannot be translated to children, and that steroid-resistant eosinophilic inflammation appears central to the pathogenesis of paediatric disease. Age-appropriate experimental models and use of airway samples from children are critical to understanding the underlying mechanisms and identifying novel therapeutic targets.
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180
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Belsky DW, Shalev I, Sears MR, Hancox RJ, Lee Harrington H, Houts R, Moffitt TE, Sugden K, Williams B, Poulton R, Caspi A. Is chronic asthma associated with shorter leukocyte telomere length at midlife? Am J Respir Crit Care Med 2014; 190:384-91. [PMID: 24956257 DOI: 10.1164/rccm.201402-0370oc] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
RATIONALE Asthma is prospectively associated with age-related chronic diseases and mortality, suggesting the hypothesis that asthma may relate to a general, multisystem phenotype of accelerated aging. OBJECTIVES To test whether chronic asthma is associated with a proposed biomarker of accelerated aging, leukocyte telomere length. METHODS Asthma was ascertained prospectively in the Dunedin Multidisciplinary Health and Development Study cohort (n = 1,037) at nine in-person assessments spanning ages 9-38 years. Leukocyte telomere length was measured at ages 26 and 38 years. Asthma was classified as life-course-persistent, childhood-onset not meeting criteria for persistence, and adolescent/adult-onset. We tested associations between asthma and leukocyte telomere length using regression models. We tested for confounding of asthma-leukocyte telomere length associations using covariate adjustment. We tested serum C-reactive protein and white blood cell counts as potential mediators of asthma-leukocyte telomere length associations. MEASUREMENTS AND MAIN RESULTS Study members with life-course-persistent asthma had shorter leukocyte telomere length as compared with sex- and age-matched peers with no reported asthma. In contrast, leukocyte telomere length in study members with childhood-onset and adolescent/adult-onset asthma was not different from leukocyte telomere length in peers with no reported asthma. Adjustment for life histories of obesity and smoking did not change results. Study members with life-course-persistent asthma had elevated blood eosinophil counts. Blood eosinophil count mediated 29% of the life-course-persistent asthma-leukocyte telomere length association. CONCLUSIONS Life-course-persistent asthma is related to a proposed biomarker of accelerated aging, possibly via systemic eosinophilic inflammation. Life histories of asthma can inform studies of aging.
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Affiliation(s)
- Daniel W Belsky
- 1 Center for The Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
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181
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Nair P, Zhang Q, Brennan JD. A perspective on point-of-care tests to detect eosinophilic bronchitis. J Asthma 2014; 52:254-61. [PMID: 25272185 DOI: 10.3109/02770903.2014.966110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Approximately 50% of asthma exacerbations and a third of COPD exacerbations are associated with an eosinophilic bronchitis. Quantitative cell counts reliably identify the number of eosinophils in sputum and treatment strategies that are guided by sputum eosinophil counts lead to significantly better outcomes than strategies guided by conventional assessments of symptoms and airflow. However, cell counts are not widely available and the results are not available in real time. Similarly, more sophisticated detection methods using immunoassays or genetic analysis via polymerase chain reaction are too costly and thus not amenable to rapid point-of-care diagnosis. Blood eosinophil counts and fraction of exhaled nitric oxide correlate poorly with airway eosinophilia, particularly in patients with severe airway diseases who are on corticosteroid therapy. Point of care assessments of eosinophil-specific activity may be provided by breathomics that employ metabolomics profiling of volatile compounds in breath. However, it is too early to decide if this would provide quantitative data to monitor therapy and disease activities longitudinally. Herein we provide a perspective on the potential for developing simple point-of-care tests with special emphasis on the potential for a bio-active paper diagnostic test to quantitatively assay the amount of eosinophil peroxidase in sputum samples by employing different types of detection systems.
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Affiliation(s)
- Parameswaran Nair
- Department of Medicine, St Joseph's Healthcare and McMaster University , Hamilton, Ontario , Canada and
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182
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Enumeration of circulating fibrocytes for clinical use in asthma by an optimized single-platform flow cytometry assay. BBA CLINICAL 2014; 1:52-8. [PMID: 26673636 PMCID: PMC4633918 DOI: 10.1016/j.bbacli.2014.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/04/2014] [Accepted: 06/09/2014] [Indexed: 11/23/2022]
Abstract
Background Elevated numbers of circulating fibrocytes are associated with inadequately controlled asthma, poor response to available therapies, and increased risk of adverse outcomes. The lack of reliable and clinically-applicable assays precludes a proper evaluation of blood fibrocyte count as a prognostic biomarker in asthma. This report concerns the use of a multiparameter flow cytometry assay for the enumeration of fibrocytes in the whole blood. Methods Consenting fibrocyte donors were 19 patients with asthma well controlled by current treatment, 16 patients with treatment-resistant asthma, 9 patients with transiently uncontrolled asthma and 14 age-matched normal individuals. Blood sampling was performed once in patients with transiently uncontrolled asthma and twice, at an interval of one week, in the other subjects. The assay was performed in 100 μl of whole blood and involved a sequential gating strategy and absolute fibrocyte counting with a single instrument (single-platform assay). Results The quantification of circulating fibrocytes by this assay was analytically and clinically valid. In individuals with stable clinical conditions, the repeatability of blood fibrocyte counts over one week was good. The intraclass correlation coefficient was 0.939 and 96.88% of the total variability reflected on-average differences among the tested subjects. Stabilized blood samples could be stored at 4 °C for up to 96 h before processing. Conclusions The novel assay for the enumeration of fibrocytes in the whole blood is reliable and clinically applicable. General significance This report demonstrates the validity and reliability of the first optimized assay for the enumeration of circulating fibrocytes in multicenter clinical trials. Elevated blood fibrocyte count is an emerging prognostic biomarker in asthma. The lack of reliable, clinically-applicable assays precludes further evaluation. An optimized whole-blood single-platform flow cytometry assay is described here. The assay is analytically and clinically valid and provides reproducible measures. Stabilized blood samples can be stored for 96 h at 4 °C before processing.
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Key Words
- 7-AAD, 7-amino-actinomycin-D
- AF, Alexa Fluor
- Asthma
- BMC, blood mononuclear cell
- Biomarker
- CCC, concordance correlation coefficient
- CI, confidence interval
- COL1, type I collagen
- CT, threshold cycle
- Clinical outcome
- ET-1, endothelin-1
- FSC, forward scatter
- Fibrocyte enumeration
- Flow cytometry
- ICC, intraclass correlation coefficient
- MFI, mean fluorescence intensity
- PB, Pacific Blue
- SD, standard deviation
- SS, sum of squares
- SSC, side scatter
- Single-platform assay
- α-SMA, α-smooth muscle actin
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Moore WC, Hastie AT, Li X, Li H, Busse WW, Jarjour NN, Wenzel SE, Peters SP, Meyers DA, Bleecker ER. Sputum neutrophil counts are associated with more severe asthma phenotypes using cluster analysis. J Allergy Clin Immunol 2014; 133:1557-63.e5. [PMID: 24332216 PMCID: PMC4040309 DOI: 10.1016/j.jaci.2013.10.011] [Citation(s) in RCA: 429] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/04/2013] [Accepted: 10/11/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical cluster analysis from the Severe Asthma Research Program (SARP) identified 5 asthma subphenotypes that represent the severity spectrum of early-onset allergic asthma, late-onset severe asthma, and severe asthma with chronic obstructive pulmonary disease characteristics. Analysis of induced sputum from a subset of SARP subjects showed 4 sputum inflammatory cellular patterns. Subjects with concurrent increases in eosinophil (≥2%) and neutrophil (≥40%) percentages had characteristics of very severe asthma. OBJECTIVE To better understand interactions between inflammation and clinical subphenotypes, we integrated inflammatory cellular measures and clinical variables in a new cluster analysis. METHODS Participants in SARP who underwent sputum induction at 3 clinical sites were included in this analysis (n = 423). Fifteen variables, including clinical characteristics and blood and sputum inflammatory cell assessments, were selected using factor analysis for unsupervised cluster analysis. RESULTS Four phenotypic clusters were identified. Cluster A (n = 132) and B (n = 127) subjects had mild-to-moderate early-onset allergic asthma with paucigranulocytic or eosinophilic sputum inflammatory cell patterns. In contrast, these inflammatory patterns were present in only 7% of cluster C (n = 117) and D (n = 47) subjects who had moderate-to-severe asthma with frequent health care use despite treatment with high doses of inhaled or oral corticosteroids and, in cluster D, reduced lung function. The majority of these subjects (>83%) had sputum neutrophilia either alone or with concurrent sputum eosinophilia. Baseline lung function and sputum neutrophil percentages were the most important variables determining cluster assignment. CONCLUSION This multivariate approach identified 4 asthma subphenotypes representing the severity spectrum from mild-to-moderate allergic asthma with minimal or eosinophil-predominant sputum inflammation to moderate-to-severe asthma with neutrophil-predominant or mixed granulocytic inflammation.
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Affiliation(s)
- Wendy C Moore
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC.
| | - Annette T Hastie
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - Xingnan Li
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - Huashi Li
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - William W Busse
- University of Wisconsin School of Medicine and Public Health, Allergy, Pulmonary and Critical Care Division, Madison, Wis
| | - Nizar N Jarjour
- University of Wisconsin School of Medicine and Public Health, Allergy, Pulmonary and Critical Care Division, Madison, Wis
| | - Sally E Wenzel
- University of Pittsburgh School of Medicine, Pulmonary, Allergy and Critical Care Medicine, Pittsburgh, Pa
| | - Stephen P Peters
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - Deborah A Meyers
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - Eugene R Bleecker
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
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184
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Tran TN, Khatry DB, Ke X, Ward CK, Gossage D. High blood eosinophil count is associated with more frequent asthma attacks in asthma patients. Ann Allergy Asthma Immunol 2014; 113:19-24. [PMID: 24846699 DOI: 10.1016/j.anai.2014.04.011] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/04/2014] [Accepted: 04/15/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND The clinical importance of eosinophils in asthma has been shown by the observation of frequent exacerbation in patients with high sputum eosinophil counts and a corresponding decrease in exacerbations when anti-inflammatory therapy was adjusted to maintain low sputum eosinophil percentages. However, less is known of the relation between blood eosinophilia and asthma exacerbation. OBJECTIVE To examine whether patients with asthma and a higher blood eosinophil count have more asthma attacks than those with a lower count. METHODS The authors analyzed data from the National Health and Nutrition Examination Survey, an annual cross-sectional survey of the US general population. Patients with asthma and asthma attacks were identified based on participants' self-report or parental report. A high blood eosinophil count was defined using 200, 300, or 400 cells/μL as cutoffs. The primary analysis used data from 2001 through 2010 after adjusting for demographic variables, obesity, smoking, neutrophil level, and past treatment for wheezing. A secondary analysis used data from 2007 through 2010 and included recent treatment for asthma and fraction of exhaled nitric oxide level as additional adjustment variables. RESULTS In survey years 2001 through 2010, 3,162 patients with asthma had blood eosinophil data and approximately half (54% of children and 52% of adults) reported an asthma attack in the previous year. In the primary analysis, higher blood eosinophil counts were associated with more asthma attacks in children but not in adults. The secondary analysis suggested an association in both children and adults. CONCLUSION Patients with asthma with higher blood eosinophil counts experienced more asthma attacks than those with lower eosinophil counts.
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Affiliation(s)
- Trung N Tran
- Observational Research Center, AstraZeneca, Gaithersburg, Maryland.
| | | | - Xiongkan Ke
- Observational Research Center, AstraZeneca, Gaithersburg, Maryland
| | | | - David Gossage
- Clinical Development, MedImmune, Gaithersburg, Maryland
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185
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Walford HH, Doherty TA. Diagnosis and management of eosinophilic asthma: a US perspective. J Asthma Allergy 2014; 7:53-65. [PMID: 24748808 PMCID: PMC3990389 DOI: 10.2147/jaa.s39119] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Eosinophilic asthma is now recognized as an important subphenotype of asthma based on the pattern of inflammatory cellular infiltrate in the airway. Eosinophilic asthma can be associated with increased asthma severity, atopy, late-onset disease, and steroid refractoriness. Induced sputum cell count is the gold standard for identifying eosinophilic inflammation in asthma although several noninvasive biomarkers, including fractional exhaled nitric oxide and periostin, are emerging as potential surrogates. As novel therapies and biologic agents become increasingly available, there is an increased need for specific phenotype-directed treatment strategies. Greater recognition and understanding of the unique immunopathology of this asthma phenotype has important implications for management of the disease and the potential to improve patient outcomes. The present review provides a summary of the clinical features, pathogenesis, diagnosis, and management of eosinophilic asthma.
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Affiliation(s)
- Hannah H Walford
- Department of Medicine, University of California, La Jolla, CA, USA ; Department of Pediatrics, University of California, La Jolla, CA, USA
| | - Taylor A Doherty
- Department of Medicine, University of California, La Jolla, CA, USA
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187
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Apter AJ. Advances in adult asthma diagnosis and treatment in 2013. J Allergy Clin Immunol 2014; 133:49-56. [PMID: 24369799 DOI: 10.1016/j.jaci.2013.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Abstract
In 2013, several themes emerged: (1) a dedicated search for new therapies using new mechanisms; (2) the importance of the plasticity of the immune system (eg, that molecules that mediate inflammation in one setting can promote its resolution and return to homeostasis in other circumstances); (3) the complex role of viruses in asthma exacerbations; (4) the similarities and differences among asthma, asthma in smokers, and chronic obstructive pulmonary disease; and (5) the importance of understanding asthma phenotypes and their stability over time. Once new therapeutics pass the initial clinical trials, patient-oriented and real-world research will be needed.
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Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pa.
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188
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Loutsios C, Farahi N, Porter L, Lok LSC, Peters AM, Condliffe AM, Chilvers ER. Biomarkers of eosinophilic inflammation in asthma. Expert Rev Respir Med 2014; 8:143-50. [PMID: 24460178 DOI: 10.1586/17476348.2014.880052] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Eosinophils are mediators of allergic inflammation and are implicated in the pathogenesis of numerous conditions including asthma, parasitic infections, neoplasms, hyper-eosinophilic syndromes, vasculitic disorders, and organ-specific conditions. Assessing eosinophilic inflammation is therefore important in establishing a diagnosis, in monitoring and assessing response to treatment, and in testing novel therapeutics. Clinical markers of atopy and eosinophilic inflammation include indirect tests such as lung function, exhaled breath condensate analysis, fractional exhaled nitric oxide, serum immunoglobulin E levels and serum periostin. Direct measures, which quantify but do not anatomically localise inflammation include blood eosinophil counts, serum or plasma eosinophil cationic protein and sputum eosinophil levels. Cytology from bronchoalveolar lavage and histology from endobronchial and transbronchial biopsies are better at localising inflammation but are more invasive. Novel approaches using radiolabelled eosinophils with single-photon emission computed tomography, offer the prospect of non-invasive methods to localise eosinophilic inflammation.
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Affiliation(s)
- Chrystalla Loutsios
- Department of Medicine, Division of Respiratory Medicine, University of Cambridge, School of Clinical Medicine, Cambridge, UK
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189
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Moore WC, Bleecker ER. Asthma heterogeneity and severity-why is comprehensive phenotyping important? THE LANCET RESPIRATORY MEDICINE 2013; 2:10-1. [PMID: 24461885 DOI: 10.1016/s2213-2600(13)70288-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Wendy C Moore
- Center for Genomics and Personalized Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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190
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Genuneit J. Interaction between atopy and blood eosinophils in the development of childhood wheeze. J Allergy Clin Immunol 2013; 132:1237-1239.e5. [PMID: 23993881 DOI: 10.1016/j.jaci.2013.06.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/23/2013] [Accepted: 06/28/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Jon Genuneit
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
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191
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What is an "eosinophilic phenotype" of asthma? J Allergy Clin Immunol 2013; 132:81-3. [PMID: 23727039 DOI: 10.1016/j.jaci.2013.05.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/07/2013] [Indexed: 11/21/2022]
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