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Hojo M, Mizutani T, Iikura M, Hirano S, Kobayashi N, Sugiyama H. Asthma Control Can Be Maintained after Fixed-Dose, Budesonide/Formoterol Combination Inhaler Therapy is Stepped Down from Medium to Low Dose. Allergol Int 2015; 62:91-98. [PMID: 28942990 DOI: 10.2332/allergolint.12-oa-0444] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 07/02/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In cases using a budesonide/formoterol combination inhaler, many patients are started on fixed-dose treatment at 640/18 μg (4 puffs) daily, but there are no guidelines yet regarding the step-down method when control has been maintained. METHODS Patients with moderate asthma treated with either budesonide 400 μg and salmeterol 100 μg (GINA step3 group) or salmeterol/fluticasone 250 at 2 puffs (GINA step4 group) were enrolled and started on therapy of budesonide/formoterol 4 puffs. Thereafter, step-down to 2 puffs was performed if either of the following criteria was met at 8-week intervals: fractional exhaled nitric oxide (FeNO)≤28 ppb plus asthma control test (ACT) score≥22, or ACT score≥24 at 3 consecutive visits regardless of FeNO level. Thereafter, changes in ACT score, the number of acute exacerbations and reliever use, and FeNO level were monitored through 48th week. RESULTS Fifty-one patients, 27 in step3 group and 24 in step4 group, underwent step-down. ACT scores and the number of reliever use remained stable in both groups even after step-down. In contrast, FeNO levels increased gradually in step4 group, whereas in the step3 group they increased immediately after step-down. Step-down was considered to be safely performed because the numbers of reliever use and those of moderate or more severe exacerbations during the 48-week period has not changed significantly compared to before step-down. CONCLUSIONS If complete control of asthma, not only of clinical symptoms but also airway inflammation, is achieved by 3-6 months of fixed-dose budesonide/formoterol 4 puffs/day, it should be possible to safely perform step-down to 2 puffs/day.
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Affiliation(s)
- Masayuki Hojo
- Division of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan..
| | - Tomonori Mizutani
- Division of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Motoyasu Iikura
- Division of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Satoshi Hirano
- Division of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nobuyuki Kobayashi
- Division of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Haruhito Sugiyama
- Division of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
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152
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Birring SS, Kavanagh J, Lai K, Chang AB. Adult and paediatric cough guidelines: Ready for an overhaul? Pulm Pharmacol Ther 2015; 35:137-44. [PMID: 25681276 DOI: 10.1016/j.pupt.2015.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 01/31/2015] [Indexed: 11/17/2022]
Abstract
Cough is one of the most common reasons that patients seek medical attention. Cough guidelines from numerous countries and societies are available to assist the clinician to investigate and manage patients with cough. We review some of the recent progress in the field of cough that may lead to revision of these guidelines. In adults with chronic cough, new causes such as obstructive sleep apnoea have been identified. A new terminology, cough hypersensitivity syndrome (CHS), has been proposed for patients with chronic cough, which emphasises cough reflex hypersensitivity as a key feature. New therapeutic options are now available, particularly for patients with refractory or idiopathic chronic cough, which include gabapentin, speech pathology management and morphine. There has been great progress in the assessment of cough with the development of validated quality of life questionnaires and cough frequency monitoring tools. In children, common aetiologies differ from adults and those managed according to guidelines have better outcomes compared to usual care. New diagnostic entities such as protracted bacterial bronchitis have been described. Paediatric-specific cough assessment tools such as the Parent/Child Quality of Life Questionnaire will help improve the assessment of patients. Further research is necessary to improve the evidence base for future clinical guideline recommendations. Guidelines in future should also aim to reach a wider audience that includes primary care physicians, non-specialists and patients.
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Affiliation(s)
- Surinder S Birring
- King's College London, Division of Asthma, Allergy and Lung Biology, Denmark Hill Campus, London, United Kingdom
| | - Joanne Kavanagh
- King's College London, Division of Asthma, Allergy and Lung Biology, Denmark Hill Campus, London, United Kingdom.
| | - Kefang Lai
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, 1st Affiliated Hospital, Guangzhou Medical College, GZ, China
| | - Anne B Chang
- Dept of Respiratory and Sleep Medicine, Queensland Children's Medical Research Institute, Children's Health Queensland; and Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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153
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Gemicioglu B, Musellim B, Dogan I, Guven K. Fractional exhaled nitric oxide (FeNo) in different asthma phenotypes. ALLERGY & RHINOLOGY 2015; 5:157-61. [PMID: 25565052 PMCID: PMC4275462 DOI: 10.2500/ar.2014.5.0099] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fractioned exhaled nitric oxide (FeNO) is a noninvasive marker of inflammation in asthmatic patients. FeNO can be used to monitor airway inflammation, but individual responses make tailored interventions based on FeNO difficult. The correlation between the asthma control test (ACT), FEV1, and FeNO was evaluated in this study to ascertain the correct usage of FeNO with different asthma phenotypes regarding their control, allergy, comorbidity, obesity, age, smoking status, and severity. ACT, pulmonary function, and FeNO in 416 asthmatic patients on combined therapy were retrospective evaluated. Correlations between these parameters and the FeNO levels in different asthma phenotypes were calculated. In the study population, FeNO was 31.8 ± 28.5 parts per billion (ppb), FEV1 was 83.4 ± 19% and ACT was 19 ± 5.2. ACT scores were negatively correlated with FeNO (r = -0.31; p = 0.002). FeNO was different in patients with positive and negative skin-prick test (p < 0.05), with and without allergic rhinitis (p < 0.01), and with and without allergic conjunctivitis (p < 0.01). Significantly higher FeNO levels were found with logistic regression analysis only in patients with a history of emergency room visits (ERVs) (p = 0.024). The rate of the ERV of the patients with an ACT score more than or equal to 20 and with a FeNO value of more than 35 ppb was 22.9%, but with a FeNO value of less than 35 ppb was 6.5% (p = 0.004). Allergy and allergic comorbidities may lead to an increase in FeNO levels. Patients with a history of ERV have markedly higher FeNO levels, although they have an ACT score more than or equal to 20.
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Affiliation(s)
- Bilun Gemicioglu
- Department of Pulmonary Diseases, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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154
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Lu M, Wu B, Che D, Qiao R, Gu H. FeNO and asthma treatment in children: a systematic review and meta-analysis. Medicine (Baltimore) 2015; 94:e347. [PMID: 25634163 PMCID: PMC4602963 DOI: 10.1097/md.0000000000000347] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 11/06/2014] [Accepted: 11/08/2014] [Indexed: 11/25/2022] Open
Abstract
Traditional asthma treatments are typically adjusted in children with asthma using symptoms and spirometry. Treatments tailored in accordance to inflammatory markers, such as fraction of exhaled nitric oxide (FeNO) or sputum eosinophils, are increasing in use. This meta-analysis evaluated the potential benefit of incorporating the use of monitoring FeNO with guideline-based management in treating children with asthma. PubMed and Cochrane CENTRAL databases were searched until November 2013 for randomized control trials that investigated the use of FeNO compared with conventional monitoring in managing asthma in children. Included studies had at least 2 intervention groups: one that utilized FeNO and the other that utilized only conventional or standard methods (eg, spirometry, symptoms, and others) to guide treatment. Six studies were included in the meta-analysis comprising 506 subjects whose treatment was monitored using FeNO and 511 subjects who were managed using conventional methods. We found no difference between the FeNO and the conventional groups in FeNO value (95% confidence interval [CI]: -0.31, 0.1), change from baseline in FEV1 (95% CI: -0.07, 0.20), or steroid use (95% CI: -0.67, 1.80). However, the FeNO group was associated with a lower frequency of >1 asthma exacerbation (95% CI: 0.532, 0.895). This meta-analysis suggests that using FeNO to guide treatment decisions has little clinical benefit, although may result in a decrease in asthma exacerbations. Our findings support the use of guideline-based asthma management and diagnosis.
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Affiliation(s)
- Min Lu
- From the Department of Pulmonary Medicine (ML, BRW, DTC, HXG); and Department of Digestive Medicine (RQ), Children's Hospital of Shanghai, Jiaotong University School of Medicine, Shanghai, China
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155
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Rawy AM, Mansour AI. Fraction of exhaled nitric oxide measurement as a biomarker in asthma and COPD compared with local and systemic inflammatory markers. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2014.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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156
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Fractional Exhaled Nitric Oxide: Indications and Interpretation. DIAGNOSTIC TESTS IN PEDIATRIC PULMONOLOGY 2015. [DOI: 10.1007/978-1-4939-1801-0_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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157
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Pedersen F, Holz O, Kanniess F, Zielen S, Schulze J, Gillissen A, von Berg A, Berdel D, Beier J, Beeh K, Schnoor M, Magnussen H. Longitudinal measurement of airway inflammation over one year in children and adults with intermittent asthma. BMC Res Notes 2014; 7:925. [PMID: 25515668 PMCID: PMC4301900 DOI: 10.1186/1756-0500-7-925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 11/21/2014] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Asthma is an inflammatory disease of the airways, but in clinical practice inflammation is rarely monitored. The aim of this study was to assess the level of airway inflammation in steroid naïve adult and pediatric patients with intermittent asthma over one year. METHODS 54 children and 50 adults with intermittent asthma (GINA step 1) were included. On up to 6 visits lung function, airway hyperresponsiveness to methacholine (PC20FEV1), sputum eosinophils and exhaled nitric oxide (FeNO) were assessed. RESULTS 36 pediatric and 34 adult patients were able to produce at least three adequate sputum samples over the study period and were included into the analysis.In 8 children (22%) the percentage of sputum eosinophils was always below 2.5%. A higher level of eosinophils (>2.5%) was found on at least one visit in 16 (44%) and always >2.5% in 12 children (33%). In the adult group the respective numbers were 14 patients (41%) with always low (<2.5%), 17 (50%) with at least once over 2.5% and three patients (9%) were always above the threshold of 2.5% sputum eosinophils. CONCLUSION These results demonstrate that a substantial number of children and adults with intermittent asthma under ß-agonist treatment only, have variable or persistently high levels of eosinophilic airway inflammation. Long-term studies are needed to observe the progression of asthma severity in such patient populations.
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Affiliation(s)
- Frauke Pedersen
- />LungClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research, Wöhrendamm 80, 22927 Großhansdorf, Germany
- />Pulmonary Research Institute at LungClinic Grosshansdorf, Wöhrendamm 80, 22927 Großhansdorf, Germany
| | - Olaf Holz
- />Fraunhofer ITEM, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research, Feodor-Lynen-Str. 15, 30625 Hannover, Germany
| | - Frank Kanniess
- />Pulmonary Research Institute at LungClinic Grosshansdorf, Wöhrendamm 80, 22927 Großhansdorf, Germany
- />Practice for Allergy and Family Medicine, Raiffeisenpassage 15, 23858 Reinfeld, Germany
| | - Stefan Zielen
- />University Hospital Frankfurt, Center for children and adolescents, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Johannes Schulze
- />University Hospital Frankfurt, Center for children and adolescents, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Adrian Gillissen
- />Robert Koch Klinik, Pneumologie Zentrum, Nikolai-Rumjanzew-Str. 100, 04207 Leipzig, Germany
- />Department of Pulmonary Medicine, Hospital Kassel, Mönchebergstr. 41-43, 34125 Kassel, Germany
| | - Andrea von Berg
- />Marienhospital Wesel, Klinik für Kinder und Jugendmedizin, Pastor-Janssen-Str. 8-38, 46483 Wesel, Germany
| | - Dietrich Berdel
- />Marienhospital Wesel, Klinik für Kinder und Jugendmedizin, Pastor-Janssen-Str. 8-38, 46483 Wesel, Germany
| | - Jutta Beier
- />insaf - Respiratory Research Institute GmbH, Biebricher Allee 34, 65187 Wiesbaden, Germany
| | - Kai Beeh
- />insaf - Respiratory Research Institute GmbH, Biebricher Allee 34, 65187 Wiesbaden, Germany
| | - Maike Schnoor
- />Department of Social Medicine, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, house 50, 23552 Lübeck, Germany
| | - Helgo Magnussen
- />Pulmonary Research Institute at LungClinic Grosshansdorf, Wöhrendamm 80, 22927 Großhansdorf, Germany
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158
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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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159
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Dinh-Xuan AT, Annesi-Maesano I, Berger P, Chambellan A, Chanez P, Chinet T, Degano B, Delclaux C, Demange V, Didier A, Garcia G, Magnan A, Mahut B, Roche N. Contribution of exhaled nitric oxide measurement in airway inflammation assessment in asthma. A position paper from the French Speaking Respiratory Society. Rev Mal Respir 2014; 32:193-215. [PMID: 25704902 DOI: 10.1016/j.rmr.2014.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 08/27/2014] [Indexed: 01/06/2023]
Abstract
Nitric oxide (NO) is both a gas and a ubiquitous inter- and intracellular messenger with numerous physiological functions. As its synthesis is markedly increased during inflammatory processes, NO can be used as a surrogate marker of acute and/or chronic inflammation. It is possible to quantify fractional concentration of NO in exhaled breath (FENO) to detect airway inflammation, and thus improve the diagnosis of asthma by better characterizing asthmatic patients with eosinophilic bronchial inflammation, and eventually improve the management of targeted asthmatic patients. FENO measurement can therefore be viewed as a new, reproducible and easy to perform pulmonary function test. Measuring FENO is the only non-invasive pulmonary function test allowing (1) detecting, (2) quantifying and (3) monitoring changes in inflammatory processes during the course of various respiratory disorders, including corticosensitive asthma.
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Affiliation(s)
- A T Dinh-Xuan
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de physiologie-explorations fonctionnelles, université Paris-Descartes, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| | - I Annesi-Maesano
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Inserm et université de médecine Pierre-et-Marie-Curie, 75571 Paris cedex 12, France
| | - P Berger
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Centre de recherche cardio-thoracique Inserm U1045, université de Bordeaux, 33076 Bordeaux cedex, France
| | - A Chambellan
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Inserm UMR 1087, institut du thorax, 44007 Nantes cedex, France
| | - P Chanez
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de pneumologie, hôpital Nord, chemin des Bourrelly, 13015 Marseille, France
| | - T Chinet
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de pneumologie, CHU Ambroise-Paré, 92104 Boulogne, France
| | - B Degano
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Explorations fonctionnelles, hôpital Jean-Minjoz, centre hospitalier régional universitaire, 25000 Besançon, France
| | - C Delclaux
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France
| | - V Demange
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Département épidémiologie en entreprise, INRS, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France
| | - A Didier
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de pneumologie, CHU de Toulouse, 24, chemin de Pouvourville - TSA, 31059 Toulouse cedex 9, France
| | - G Garcia
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de physiologie, hôpital Bicêtre, Assistance publique-Hôpitaux de Paris, 94275 Le Kremlin-Bicêtre, France
| | - A Magnan
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Inserm UMR 915, institut du thorax, CHU de Nantes, 44007 Nantes cedex, France
| | - B Mahut
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Cabinet de pédiatrie, 4, avenue de la Providence, 92160 Antony, France
| | - N Roche
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de pneumologie et soins intensifs respiratoires, Hôtel Dieu, groupe hospitalier Cochin-Broca, 75014 Paris, France
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Lin CH, Hsu JY, Hsiao YH, Tseng CM, Su VYF, Chen YH, Yang SN, Lee YC, Su KC, Perng DW. Budesonide/formoterol maintenance and reliever therapy in asthma control: acute, dose-related effects and real-life effectiveness. Respirology 2014; 20:264-72. [PMID: 25366969 DOI: 10.1111/resp.12425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/18/2014] [Accepted: 09/15/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE The efficacy of budesonide/formoterol maintenance and reliever therapy (BFMRT) in asthma control is well documented in large randomized controlled trials. However, the acute reliever effects and real-life effectiveness are seldom reported. METHODS This multicenter trial enrolled steroid-naïve, symptomatic asthmatics with baseline exhaled nitric oxide (eNO) of ≥ 40 ppb. There were 120 eligible patients who were randomized and received a dose of inhaled budesonide/formoterol 320/9 μg (lower dose budesonide/formoterol), 640/18 μg (higher dose budesonide/formoterol (HDBF)), or terbutaline (TERB) 1 mg. Inflammatory cells and mediators in induced sputum, eNO and lung function were measured at baseline and 6 h (acute phase). Subsequently, all patients used BFMRT as real-life practice for 24 weeks (maintenance phase). RESULTS In the acute phase, the degree of post-treatment reduction in total eosinophil counts, interleukin-8 and matrix metalloproteinase-9 in induced sputum were significantly greater in group HDBF (vs TERB, P < 0.05). The increase in forced expiratory volume in first second (FEV1 ) in group HDBF was significantly higher (vs LDBF and TERB, P < 0.05) 3 h after dosing. In the maintenance phase, significant improvement of asthma control (presented by eNO, FEV1 and a five-item asthma control questionnaire) in real-life settings was observed at 4 weeks and sustained to the end of study. The rate of patients who followed scheduled visits declined over time (87% at week 4 and 42% at week 24). CONCLUSIONS Budesonide/formoterol as reliever exerts acute, dose-related anti-inflammatory effects and FEV1 improvement in symptomatic asthmatics. BFMRT is effective in asthma control. However, the decrease in long-term follow-up rate remains an issue to overcome in real-life settings.
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Affiliation(s)
- Ching-Hsiung Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan; Department of Respiratory Care, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Wechsler ME. Getting control of uncontrolled asthma. Am J Med 2014; 127:1049-1059. [PMID: 24844737 DOI: 10.1016/j.amjmed.2014.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 10/25/2022]
Abstract
Despite various treatment modalities, a large proportion of patients have asthma that remains uncontrolled. These patients remain at an increased risk of developing severe exacerbations, have a poor quality of life, and pose a high economic healthcare burden, with an estimated mean annual cost more than double that of patients with good symptom control. It is therefore important to accurately diagnose asthma and continually assess asthma control. Several validated tools are available to do this, including questionnaires, biomarker analysis, and bronchoscopy. Current guidelines advise physicians to establish a self-management program for the patient to assess and monitor asthma control. A further recommendation is the establishment of an educational action plan to increase treatment adherence and to improve asthma control. National and international guidelines provide long-term management strategies for these patients and recommend a stepwise approach for achieving and maintaining asthma control. Despite availability of a wide range of controller and reliever therapies, uncontrolled asthma remains a challenge and reflects the need for new therapeutic options. This review discusses current global guidelines for the assessment and management of asthma control and summarizes the broad spectrum of novel therapeutic agents currently under development for the treatment of asthma, including anticholinergics, chemoattractant receptor-homologous molecules expressed on T-helper 2 lymphocyte antagonists, and anti-interleukin (IL)-5, anti-IL-13, and anti-IL-4 agents.
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162
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Leaker BR, Singh D, Ali FY, Barnes PJ, O'Connor B. The effect of the novel phosphodiesterase-4 inhibitor MEM 1414 on the allergen induced responses in mild asthma. BMC Pulm Med 2014; 14:166. [PMID: 25351474 PMCID: PMC4228152 DOI: 10.1186/1471-2466-14-166] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 10/22/2014] [Indexed: 12/16/2022] Open
Abstract
Background Inhaled allergen challenge is a standard method to study airway responses to inflammatory provocation and evaluate the therapeutic potential of novel anti-inflammatory compounds in asthma. MEM 1414 is a novel oral PDE4 inhibitor with high affinity and selectivity creating the potential for an improved side effect profile vs non-selective PDE inhibitors. We evaluated the tolerability and effect of MEM 1414 on airway responses in mild asthmatics. Methods A randomised double blind placebo controlled cross over study in two centres, in which sixteen steroid naïve atopic asthmatics were challenged with inhaled allergen. Subjects were dosed with MEM 1414 (600 mg) or placebo, twice daily orally for 7 days. Allergen challenge was performed on day 6 (2 hours post-dose), and methacholine responsiveness was measured 24 hours post allergen (day 7). Biomarkers of drug effects using ex vivo LPS stimulation of whole blood production of interleukin (IL)-6 and leukotriene (LT)-B4 and fractional exhaled nitric oxide (FeNO) were measured on day 6 (0, 2 and 8 hours post-dose). Plasma pharmacokinetics were measured on days 1, 6 and 7. The primary endpoint was the effect on late asthmatic response to allergen. Results Treatment with MEM 1414 abrogated the late phase response with a mean difference in FEV1 (LAR 3–10 hours) of 104 ml (25%) vs placebo (p < 0.005), with no effect on the early response. Biomarker responses were also attenuated with MEM 1414 treatment with reductions in LPS-stimulated whole blood assays for TNFα at 8 hours (p < 0.03) and LTB4 at 24 hours (p = 0.0808) with no change in the IL-6 response. The MEM 1414 treatment phase was associated with higher incidence of nausea (6/16 MEM 1414 vs 2/16 placebo) and vomiting (3/16 vs 0/16 placebo). Conclusions Oral MEM 1414, a novel PDE4 inhibitor, significantly reduces the late response following inhaled allergen challenge. MEM 1414 also inhibited whole blood assays of cytokine production from inflammatory cells. MEM 1414 was associated with a typical adverse event profile of PDE4 inhibitors, namely nausea and vomiting although these were mild side effects. Trial registration number Current controlled trials ISRCTN48047493.
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Affiliation(s)
- Brian R Leaker
- Respiratory Clinical Trials Ltd, 20 Queen Anne Street, London W1G 8HU, UK.
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163
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Desai M, Oppenheimer J, Marshall GD. Exhaled nitric oxide in asthma care: the conundrum continues. Ann Allergy Asthma Immunol 2014; 113:584-6. [PMID: 25455521 DOI: 10.1016/j.anai.2014.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/16/2014] [Accepted: 09/22/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Mauli Desai
- ENT Faculty Practice, LLP, Ardsley, New York.
| | - John Oppenheimer
- Department of Medicine, Rutgers University, New Brunswick, New Jersey
| | - Gailen D Marshall
- Division of Clinical Immunology and Allergy, Laboratory of Behavioral Immunology Research, The University of Mississippi Medical Center, Jackson, Mississippi
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164
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Corcuera-Elosegui P, Sardón-Prado O, Aldasoro-Ruiz A, Korta-Murua J, Mintegui-Aramburu J, Emparanza-Knorr JI, Pérez-Yarza EG. Inflammatory patterns in asthmatic children based on alveolar nitric oxide determination. Arch Bronconeumol 2014; 51:279-84. [PMID: 25311845 DOI: 10.1016/j.arbres.2014.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 06/18/2014] [Accepted: 07/01/2014] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Nitric oxide (NO) levels can be measured at proximal (maximum airway NO flux [J'aw(NO)]) and distal (alveolar NO concentration [C(ANO)]) levels. Four inflammatory patterns have been described in asthmatic individuals, although their relevance has not been well established. The objective was to determine J'aw(NO) and C(ANO) in order to establish four inflammatory categories in asthmatics. MATERIAL AND METHODS Cross-sectional study of a sample consisting of healthy and asthmatic children. Exhaled NO was determined at multiple flows. J'aw(NO) and C(ANO) were obtained according to the two-compartment model. The asthma control questionnaire (ACQ) and spirometry were administered to asthmatic children. Patients were categorized as type I (normal J'aw(NO) and C(ANO)), type II (elevated J'aw(NO) and normal C(ANO)), type III (elevated J'aw(NO) and C(ANO)) and type IV (normal J'aw(NO) and elevated C(ANO)). Correlation between FE(NO,50), J'aw(NO) and C(ANO) was analyzed using Spearman's R Correlation Test. Analysis of variance and paired comparisons were performed using the Bonferroni correction. RESULTS One hundred sixty-two children were studied, of whom 49 (32.23%) were healthy controls and 103 (67.76%) asthmatics. In the control subjects, FE(NO,50) (ppb)(median and range) was 11.5 (1.6 to 27.3), J'aw(NO) (pl/s) was 516 (98.3 to 1470) and C(ANO) (ppb) was 2.2 (0.1 to 4.5). Forty-four (42.7%) of the asthmatic participants were categorized as type I, 41 (39.8%) as type II, 14 (13.5%) as type III and 4 (3.88%) as type IV. Good correlation was observed between J'aw(NO) and FE(NO,50) (r=0.97). There was no association between J'aw(NO) and C(ANO). FEV1/FVC decreased significantly in type III (mean 79.8±7.5). Morbidity was significantly higher in types III and IV. CONCLUSIONS Normal values obtained are similar to those previously reported. Asthmatics with high C(ANO) showed higher morbidity. No correlation was found between proximal and distal inflammation.
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Affiliation(s)
- Paula Corcuera-Elosegui
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - Olaia Sardón-Prado
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España; Departamento de Pediatría, Universidad del País Vasco (UPV/EHU), San Sebastián, Guipúzcoa, España.
| | - Ane Aldasoro-Ruiz
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - Javier Korta-Murua
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España; Departamento de Pediatría, Universidad del País Vasco (UPV/EHU), San Sebastián, Guipúzcoa, España
| | - Javier Mintegui-Aramburu
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - José I Emparanza-Knorr
- Unidad de Epidemiología (CIBER-ESP), Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - Eduardo G Pérez-Yarza
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España; Departamento de Pediatría, Universidad del País Vasco (UPV/EHU), San Sebastián, Guipúzcoa, España; Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), San Sebastián, Guipúzcoa, España
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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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166
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Hekking PPW, Bel EH. Developing and emerging clinical asthma phenotypes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:671-80; quiz 681. [PMID: 25439356 DOI: 10.1016/j.jaip.2014.09.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/19/2014] [Accepted: 09/21/2014] [Indexed: 01/14/2023]
Abstract
For more than a century, clinicians have attempted to subdivide asthma into different phenotypes based on triggers that cause asthma attacks, the course of the disease, or the prognosis. The first phenotypes that were described included allergic asthma, intrinsic or nonallergic asthma, infectious asthma, and aspirin-exacerbated asthma. These phenotypes are being reviewed elsewhere in this issue of the journal. The present article focuses on developing and emerging clinical asthma phenotypes. First, asthma phenotypes that are associated with environmental exposures (occupational agents, cigarette smoke, air pollution, cold dry air); second, asthma phenotypes that are associated with specific symptoms or clinical characteristics (cough, obesity, adult onset of disease); and third, asthma phenotypes that are based on biomarkers. This latter approach is the most promising because it attempts to identify asthma phenotypes with different underlying mechanisms so that therapies can be better targeted toward disease-specific features and disease outcomes can be improved.
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Affiliation(s)
- Pieter-Paul W Hekking
- The Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands.
| | - Elisabeth H Bel
- The Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands
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Abstract
OBJECTIVES Breath analysis and exhaled breath condensate (EBC) collection are simple and noninvasive processes whereby inflammatory mediators and other biomarkers can be assessed in diseases that affect the lung. It was hypothesised that markers of epithelial dysfunction and secretion, such as a low pH, 8-isoprostane, and release of epithelial factors such as trefoil factor 2 (TFF2) and mucin, would be elevated in the breath of those with inflammatory bowel disease (IBD). The aim was to compare the levels of these biomarkers in EBC and the fraction of expired nitric oxide (FENO) in children with Crohn disease (CD), in those with asthma, and in normal individuals in a pilot study. METHODS EBC was collected from patients in the 3 groups mentioned above in a cross-sectional design. pH, 8-isoprostane, TFF2, and mucin levels were measured in the EBC. Spirometry was performed in asthmatic patients and patients with IBD, whereas FENO and skin prick tests were performed in patients with IBD. RESULTS Breath samples including EBC were collected from 80 patients (30 CD, 30 asthma, 20 controls). Compared with controls, EBC pH was lower in children with IBD (P < 0.0001) or asthma (P = 0.0041). 8-Isoprostane levels differed between the 3 groups (P < 0.05). EBC TFF2 was mainly less than the limit of detection, whereas mucin levels did not differ significantly between the 3 groups. FENO was measurable in children with IBD, but did not correlate with disease activity or serum markers of inflammation. CONCLUSIONS A lower EBC pH may reflect inflammatory events either in the lung or systemically. 8-Isoprostane, FENO, and mucin were detected for the first time in the EBC of children with IBD. Further studies are required to assess the value of these assessments.
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168
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James AL, Knuiman MW, Divitini ML, Hui J, Hunter ML, Mulrennan SA, Musk AWB. Risk factors for respiratory symptoms in adults: the Busselton Health Study. Respirology 2014; 18:1256-60. [PMID: 23796074 DOI: 10.1111/resp.12147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 03/12/2013] [Accepted: 05/06/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE The prevalence of reported doctor-diagnosed 'asthma' increased between 1990 and 2005-2007 in Busselton, Western Australia, accompanied by increased reported cough and phlegm but not recent wheeze. Possible reasons for the increase in diagnosed asthma include environmental exposures and diagnostic transfer. The aim of this study was to relate subject characteristics and exposures to the presence of wheeze and/or current cough/phlegm in the 2005-2007 survey. METHODS A gender- and age-stratified random sample of 2862 adults from the Busselton shire completed questionnaires regarding doctor-diagnosed asthma, respiratory symptoms and environmental exposures; and measures of anthropometry, spirometry, exhaled nitric oxide (eNO), airway hyperresponsiveness (AHR) and atopy. Associations between respiratory symptoms and subject characteristics were assessed in 2656 subjects. RESULTS Wheeze was reported by 23% of subjects, cough/phlegm by 22% and both by 9%. The significant and independent correlates of wheeze were reflux symptoms, lung function, AHR, eNO, atopy, body mass index and smoking. The significant and independent correlates of cough/phlegm were reflux symptoms, lung function, smoking and dusty job. Subjects more likely to report only wheeze than only cough/phlegm were female, aged <40 years, atopic, had lower percentage predicted forced expiratory volume in one second (FEV1) or higher percentage predicted force vital capacity. CONCLUSIONS A variety of risk factors was associated with wheeze or cough/phlegm or both. Increased non-allergic exposures may account for increased prevalence of reported cough and phlegm and may contribute to increased reported asthma in adults.
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Affiliation(s)
- Alan L James
- Department of Pulmonary Physiology and Sleep Medicine, West Australian Sleep Disorders Research Institute, University of Western Australia, Perth, Western Australia, Australia; Busselton Population Medical Research Institute, University of Western Australia, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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169
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Abstract
Our understanding of the clinical implications of eosinophilic airway inflammation has increased significantly over the last 20 years, aided by the development of noninvasive means to assess it. This pattern of airway inflammation can occur in a diverse range of airway diseases. It is associated with a positive response to corticosteroids and a high risk of preventable exacerbations. Our new understanding of the role of eosinophilic airway inflammation has paved the way for the clinical development of a number of more specific inhibitors that may become new treatment options. Different definitions, ideas of disease, and adoption of biomarkers that are not well known are necessary to fully realize the potential of these treatments.
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170
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Honkoop PJ, Loijmans RJB, Termeer EH, Snoeck-Stroband JB, van den Hout WB, Bakker MJ, Assendelft WJJ, ter Riet G, Sterk PJ, Schermer TRJ, Sont JK. Symptom- and fraction of exhaled nitric oxide-driven strategies for asthma control: A cluster-randomized trial in primary care. J Allergy Clin Immunol 2014; 135:682-8.e11. [PMID: 25174865 DOI: 10.1016/j.jaci.2014.07.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 06/04/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aiming at partly controlled asthma (PCa) instead of controlled asthma (Ca) might decrease asthma medication use. Biomarkers, such as the fraction of exhaled nitric oxide (Feno), allow further tailoring of treatment. OBJECTIVE We sought to assess the cost-effectiveness and clinical effectiveness of pursuing PCa, Ca, or Feno-driven controlled asthma (FCa). METHODS In a nonblind, pragmatic, cluster-randomized trial in primary care, adults (18-50 years of age) with a doctor's diagnosis of asthma who were prescribed inhaled corticosteroids were allocated to one of 3 treatment strategies: (1) aiming at PCa (Asthma Control Questionnaire [ACQ] score <1.50); (2) aiming at Ca (ACQ score <0.75); and (3) aiming at FCa (ACQ score <0.75 and Feno value <25 ppb). During 12 months' follow-up, treatment was adjusted every 3 months by using an online decision support tool. Outcomes were incremental cost per quality-adjusted life year gained, asthma control (ACQ score), quality of life (Asthma Quality of Life Questionnaire score), asthma medication use, and severe exacerbation rate. RESULTS Six hundred eleven participants were allocated to the PCa (n = 219), Ca (n = 203), or FCa (n = 189) strategies. The FCa strategy improved asthma control compared with the PCa strategy (P < .02). There were no differences in quality of life (P ≥ .36). Asthma medication use was significantly lower for the PCa and FCa strategies compared with the Ca strategy (medication costs: PCa, $452; Ca, $551; and FCa, $456; P ≤ .04). The FCa strategy had the highest probability of cost-effectiveness at a willingness to pay of $50,000/quality-adjusted life year (86%; PCa, 2%; Ca, 12%). There were no differences in severe exacerbation rate. CONCLUSION A symptom- plus Feno-driven strategy reduces asthma medication use while sustaining asthma control and quality of life and is the preferred strategy for adult asthmatic patients in primary care.
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Affiliation(s)
- Persijn J Honkoop
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Rik J B Loijmans
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
| | - Evelien H Termeer
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jiska B Snoeck-Stroband
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Moira J Bakker
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem J J Assendelft
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands; Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
| | - Peter J Sterk
- Department of Pulmonology, Academic Medical Center, Amsterdam, The Netherlands
| | - Tjard R J Schermer
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jacob K Sont
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Shin MH, Park YJ, Kim KS, Cho DH, Uh IJ, Kim KH, Ha IJ, Chung WS, Jung HJ, Jung SK, Jang HJ. The anti-inflammatory effects of Alisma herb extract on allergic asthma mouse model. Mol Cell Toxicol 2014. [DOI: 10.1007/s13273-014-0021-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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172
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Abstract
PURPOSE OF REVIEW This review focuses on the most recent studies investigating fractional nitric oxide concentration in exhaled breath (FeNO) as a useful biomarker for identifying specific phenotypes in asthma and as a tool for asthma diagnosis, monitoring and clinical decision-making. RECENT FINDINGS On the basis of the current literature, it has been highlighted that FeNO is a clinically relevant marker in various clinical aspects of asthma: FeNO is a predictor for developing asthma in persistent rhinitis or in infants with respiratory symptoms; FeNO contributes to identification of asthma phenotypes in both children and adults, also in relation to severity; FeNO is useful in monitoring the effectiveness of inhaled corticosteroids (including compliance) and biologic treatments like omalizumab; FeNO, in conjunction with symptom registration and lung function measurements, contributes to asthma diagnosis and optimizes asthma management. SUMMARY FeNO provides further information in distinguishing different phenotypes in asthma, allowing a much more appropriate control of the disease, especially in patients with difficult/severe asthma. In the future, it would be interesting to shed light on the hidden biological mechanisms responsible for low or normal FeNO values in symptomatic asthmatic patients.
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173
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Calhoun KH. The role of fractional exhaled nitric oxide in asthma management. Otolaryngol Clin North Am 2014; 47:87-96. [PMID: 24286682 DOI: 10.1016/j.otc.2013.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Measuring fractional exhaled nitric oxide (FeNO) is a relatively new option for assessing allergic inflammation in the lungs. Clinical management of asthma is challenging, and measuring exhaled nitric oxide can provide another type of data to assist in meeting this challenge. FeNO is easy to perform, and the equipment is not forbiddingly expensive. FeNO provides a complement to traditional measures of asthma control and can help guide diagnostic and treatment choices. This article explains what it is, how the measurements are performed, what the norms are, and its use and limitations in the management of asthma.
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Affiliation(s)
- Karen H Calhoun
- Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA.
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Sardón O, Corcuera P, Aldasoro A, Korta J, Mintegui J, Emparanza JI, Pérez-Yarza EG. Alveolar nitric oxide and its role in pediatric asthma control assessment. BMC Pulm Med 2014; 14:126. [PMID: 25090994 PMCID: PMC4124482 DOI: 10.1186/1471-2466-14-126] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/29/2014] [Indexed: 11/17/2022] Open
Abstract
Background Nitric oxide can be measured at multiple flow rates to determine proximal (maximum airway nitric oxide flux; JawNO) and distal inflammation (alveolar nitric oxide concentration; CANO). The main aim was to study the association among symptoms, lung function, proximal (maximum airway nitric oxide flux) and distal (alveolar nitric oxide concentration) airway inflammation in asthmatic children treated and not treated with inhaled glucocorticoids. Methods A cross-sectional study with prospective data collection was carried out in a consecutive sample of girls and boys aged between 6 and 16 years with a medical diagnosis of asthma. Maximum airway nitric oxide flux and alveolar nitric oxide concentration were calculated according to the two-compartment model. In asthmatic patients, the asthma control questionnaire (CAN) was completed and forced spirometry was performed. In controls, differences between the sexes in alveolar nitric oxide concentration and maximum airway nitric oxide flux and their correlation with height were studied. The correlation among the fraction of exhaled NO at 50 ml/s (FENO50), CANO, JawNO, forced expiratory volume in 1 second (FEV1) and the CAN questionnaire was measured and the degree of agreement regarding asthma control assessment was studied using Cohen’s kappa. Results We studied 162 children; 49 healthy (group 1), 23 asthmatic participants without treatment (group 2) and 80 asthmatic patients treated with inhaled corticosteroids (group 3). CANO (ppb) was 2.2 (0.1-4.5), 3 (0.2-9.2) and 2.45 (0.1-24), respectively. JawNO (pl/s) was 516 (98.3-1470), 2356.67 (120–6110) and 1426 (156–11805), respectively. There was a strong association (r = 0.97) between FENO50 and JawNO and the degree of agreement was very good in group 2 and was good in group 3. There was no agreement or only slight agreement between the measures used to monitor asthma control (FEV1, CAN questionnaire, CANO and JawNO). Conclusions The results for CANO and JawNO in controls were similar to those found in other reports. There was no agreement or only slight agreement among the three measure instruments analyzed to assess asthma control. In our sample, no additional information was provided by CANO and JawNO.
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Affiliation(s)
- Olaia Sardón
- Division of Pediatric Respiratory Medicine, Hospital Universitario Donostia, Avda, Dr, Beguiristain número 118, San Sebastian, Guipúzcoa CP 20014, Spain.
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Impact of exhaled nitric oxide measurements on treatment decisions in an asthma specialty clinic. Ann Allergy Asthma Immunol 2014; 113:619-23. [PMID: 25060819 DOI: 10.1016/j.anai.2014.06.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 05/15/2014] [Accepted: 06/20/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Asthma management in an outpatient setting is best accomplished by clinical evaluation coupled with spirometry and symptom evaluation, but these assessments do not provide information about airway inflammation. Exhaled nitric oxide (fraction of exhaled nitric oxide [FeNO]) measures T-helper cell type 2-mediated airway inflammation and may be a useful adjunct in asthma management. OBJECTIVE To determine whether the use of FeNO in the specialist management of asthma results in more effective and cost-effective treatment decisions. METHODS Fifty subjects 7 to 60 years old with established asthma participated in this observational study. Subjects were evaluated by clinical examination, spirometry, and symptom assessment using the Asthma Control Test, and clinicians estimated airway inflammation and made treatment decisions based on these assessments. Then, FeNO was measured, and changes in therapy based on FeNO levels were documented. The estimated cost impact of using FeNO was calculated presuming ongoing FeNO use in patient management. RESULTS Without FeNO, the clinician's assessment of airway inflammation was incorrectly classified in 50% of subjects. FeNO results substantially altered treatment decisions in more than one third of subjects, notably medication augmentation in 10 (20%) and medication decreases in 8 (16%). Use of FeNO in addition to standard of care was estimated to save $629 per subject per year. CONCLUSION Measurement of FeNO augments routine clinical assessment of asthma by measuring airway inflammation. Knowledge of FeNO affects medication treatment decisions to augment or decrease pharmacotherapy, which has important long-term asthma management implications, most notably the potential to lower the costs and morbidity associated with asthma exacerbation. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01729247.
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176
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Malinovschi A, Van Muylem A, Michiels S, Michils A. FeNO as a predictor of asthma control improvement after starting inhaled steroid treatment. Nitric Oxide 2014; 40:110-6. [PMID: 25014062 DOI: 10.1016/j.niox.2014.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 06/14/2014] [Accepted: 06/27/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The fraction of NO in exhaled air (FeNO) is a marker of inflammation in asthma. The aim of the present study was to assess, in a real-world setting, whether only high (⩾50 ppb) FeNO levels predict improvement in asthma control when being treated with inhaled corticosteroids (ICS), as suggested by current guidelines on the clinical use of FeNO. METHODS FeNO and asthma control were assessed in a retrospective observational study in 153 non-smoking, steroid-naïve, adult subjects with asthma with a mean age of 40 years both before and after 6 weeks (median follow-up time) of treatment with 500 μg beclomethasone (median). RESULTS Having at the initial visit intermediate FeNO (⩾25 and <50 ppb) and high FeNO (⩾50 ppb), compared to normal FeNO (<25 ppb), were associated with a larger proportion of subjects achieving an improvement of Asthma Control Questionnaire (ACQ) score with ⩾1 (78% and 67% vs 43%, p<0.05) or both ⩾1 improvement and asthma control at follow-up (31% and 37% vs 4%, p<0.05). These associations were consistent in multiple logistic regression models after adjustments for confounders. CONCLUSIONS It is not only high but also intermediate FeNO levels that are associated with a significant improvement in asthma control after starting ICS treatment. This challenges current clinical guidelines stating that only high FeNO levels predict response to ICS treatment.
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Affiliation(s)
- Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden.
| | - Alain Van Muylem
- Chest Department, Erasme University Hospital and Université Libre de Bruxelles, Brussels, Belgium
| | - Sebastien Michiels
- Chest Department, Erasme University Hospital and Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Michils
- Chest Department, Erasme University Hospital and Université Libre de Bruxelles, Brussels, Belgium
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van der Valk RJ, Duijts L, Timpson NJ, Salam MT, Standl M, Curtin JA, Genuneit J, Kerhof M, Kreiner-Møller E, Cáceres A, Gref A, Liang LL, Taal HR, Bouzigon E, Demenais F, Nadif R, Ober C, Thompson EE, Estrada K, Hofman A, Uitterlinden AG, van Duijn C, Rivadeneira F, Li X, Eckel SP, Berhane K, Gauderman WJ, Granell R, Evans DM, St Pourcain B, McArdle W, Kemp JP, Smith GD, Tiesler CM, Flexeder C, Simpson A, Murray CS, Fuchs O, Postma DS, Bønnelykke K, Torrent M, Andersson M, Sleiman P, Hakonarson H, Cookson WO, Moffatt MF, Paternoster L, Melén E, Sunyer J, Bisgaard H, Koppelman GH, Ege M, Custovic A, Heinrich J, Gilliland FD, Henderson AJ, Jaddoe VW, de Jongste JC. Fraction of exhaled nitric oxide values in childhood are associated with 17q11.2-q12 and 17q12-q21 variants. J Allergy Clin Immunol 2014; 134:46-55. [PMID: 24315451 PMCID: PMC4334587 DOI: 10.1016/j.jaci.2013.08.053] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 06/21/2013] [Accepted: 08/28/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The fraction of exhaled nitric oxide (Feno) value is a biomarker of eosinophilic airway inflammation and is associated with childhood asthma. Identification of common genetic variants associated with childhood Feno values might help to define biological mechanisms related to specific asthma phenotypes. OBJECTIVE We sought to identify the genetic variants associated with childhood Feno values and their relation with asthma. METHODS Feno values were measured in children age 5 to 15 years. In 14 genome-wide association studies (N = 8,858), we examined the associations of approximately 2.5 million single nucleotide polymorphisms (SNPs) with Feno values. Subsequently, we assessed whether significant SNPs were expression quantitative trait loci in genome-wide expression data sets of lymphoblastoid cell lines (n = 1,830) and were related to asthma in a previously published genome-wide association data set (cases, n = 10,365; control subjects: n = 16,110). RESULTS We identified 3 SNPs associated with Feno values: rs3751972 in LYR motif containing 9 (LYRM9; P = 1.97 × 10(-10)) and rs944722 in inducible nitric oxide synthase 2 (NOS2; P = 1.28 × 10(-9)), both of which are located at 17q11.2-q12, and rs8069176 near gasdermin B (GSDMB; P = 1.88 × 10(-8)) at 17q12-q21. We found a cis expression quantitative trait locus for the transcript soluble galactoside-binding lectin 9 (LGALS9) that is in linkage disequilibrium with rs944722. rs8069176 was associated with GSDMB and ORM1-like 3 (ORMDL3) expression. rs8069176 at 17q12-q21, but not rs3751972 and rs944722 at 17q11.2-q12, were associated with physician-diagnosed asthma. CONCLUSION This study identified 3 variants associated with Feno values, explaining 0.95% of the variance. Identification of functional SNPs and haplotypes in these regions might provide novel insight into the regulation of Feno values. This study highlights that both shared and distinct genetic factors affect Feno values and childhood asthma.
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Affiliation(s)
- Ralf Jp van der Valk
- The Generation R Study Group, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Liesbeth Duijts
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- School of Social and Community Medicine, University of Bristol, Uk
| | - Nicolas J Timpson
- School of Social and Community Medicine, University of Bristol, Uk
- MRC Centre for Causal Analyses in Translational Epidemiology, University of Bristol, UK
| | - Muhammad T Salam
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Marie Standl
- Institute of Epidemiology I, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - John A Curtin
- University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Jon Genuneit
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Marjan Kerhof
- University Medical Center Groningen, University of Groningen, Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital
| | - Eskil Kreiner-Møller
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, The Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- The Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Alejandro Cáceres
- Center for Research in Environmental Epidemiology (CREAL), Barcelona, Catalonia, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain
- Spanish consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
| | - Anna Gref
- Institute of Environmental Medicine and Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Liming L Liang
- Department of Epidemiology, Harvard School of Public Health, Boston, USA
- Department of Biostatistics, Harvard School of Public Health, Boston, USA
| | - H Rob Taal
- The Generation R Study Group, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Emmanuelle Bouzigon
- Inserm, UMR 946, Genetic Variation and Human Diseases Unit, F-75010, Paris, France
- Univ Paris Diderot, Sorbonne Paris Cité, Institut Universitaire d'Hématologie, F- 75007, Paris, France
| | - Florence Demenais
- Inserm, UMR 946, Genetic Variation and Human Diseases Unit, F-75010, Paris, France
- Univ Paris Diderot, Sorbonne Paris Cité, Institut Universitaire d'Hématologie, F- 75007, Paris, France
| | - Rachel Nadif
- Inserm, Centre for research in Epidemiology and Population Health (CEPH), U1018, Respiratory and Environmental Epidemiology Team, F-94807, Villejuif, France
- Univ Paris-Sud, UMRS 1018, F-94807, Villejuif, France
| | - Carole Ober
- Department of Human Genetics, University of Chicago, Chicago, IL 60637
| | - Emma E Thompson
- Department of Human Genetics, University of Chicago, Chicago, IL 60637
| | - Karol Estrada
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - André G Uitterlinden
- The Generation R Study Group, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Cornélia van Duijn
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Xia Li
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Sandrah P Eckel
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Kiros Berhane
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - W James Gauderman
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Raquel Granell
- School of Social and Community Medicine, University of Bristol, Uk
| | - David M Evans
- School of Social and Community Medicine, University of Bristol, Uk
- MRC Centre for Causal Analyses in Translational Epidemiology, University of Bristol, UK
| | | | - Wendy McArdle
- School of Social and Community Medicine, University of Bristol, Uk
| | - John P Kemp
- School of Social and Community Medicine, University of Bristol, Uk
- MRC Centre for Causal Analyses in Translational Epidemiology, University of Bristol, UK
| | - George Davey Smith
- School of Social and Community Medicine, University of Bristol, Uk
- MRC Centre for Causal Analyses in Translational Epidemiology, University of Bristol, UK
| | - Carla Mt Tiesler
- Institute of Epidemiology I, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Claudia Flexeder
- Institute of Epidemiology I, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Angela Simpson
- University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Clare S Murray
- University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Oliver Fuchs
- Inselspital, Universitätsspital, Bern, Universitätklinik für Kinderheilkunde, Bern, Switzerland
- Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Department of Pulmonology, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaus Bønnelykke
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, The Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- The Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Maties Torrent
- Spanish consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- ib-salut, Area de Salut de Menorca, Balearic Islands, Spain
| | - Martin Andersson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Physiology, South Central Hospital, Stockholm, Sweden
| | - Patrick Sleiman
- Center for Applied Genomics, Abramson Research Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, Abramson Research Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - William O Cookson
- National Heart and Lung Institute, Imperial College London, London SW3 6LY
| | - Miriam F Moffatt
- National Heart and Lung Institute, Imperial College London, London SW3 6LY
| | - Lavinia Paternoster
- School of Social and Community Medicine, University of Bristol, Uk
- MRC Centre for Causal Analyses in Translational Epidemiology, University of Bristol, UK
| | - Erik Melén
- Institute of Environmental Medicine and Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
- Sach's Children's Hospital, Stockholm, Sweden
| | - Jordi Sunyer
- Center for Research in Environmental Epidemiology (CREAL), Barcelona, Catalonia, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain
- Spanish consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Pompeu Fabra University (UPF), Barcelona, Catalonia, Spain
| | - Hans Bisgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, The Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- The Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Gerard H Koppelman
- University Medical Center Groningen, University of Groningen, Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital
- University of Groningen, University Medical Center Groningen, Department of Pulmonology, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Markus Ege
- Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Adnan Custovic
- University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Joachim Heinrich
- Institute of Epidemiology I, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Frank D Gilliland
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, USA
| | | | - Vincent Wv Jaddoe
- The Generation R Study Group, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johan C de Jongste
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
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Angelis N, Porpodis K, Zarogoulidis P, Spyratos D, Kioumis I, Papaiwannou A, Pitsiou G, Tsakiridis K, Mpakas A, Arikas S, Tsiouda T, Katsikogiannis N, Kougioumtzi I, Machairiotis N, Argyriou M, Kessisis G, Zarogoulidis K. Airway inflammation in chronic obstructive pulmonary disease. J Thorac Dis 2014; 6 Suppl 1:S167-72. [PMID: 24672691 DOI: 10.3978/j.issn.2072-1439.2014.03.07] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 03/04/2014] [Indexed: 11/14/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is an inflammatory airway disease whose incidence and mortality increases every year. It is associated with an abnormal inflammatory response of the lung to toxic particles or gases (usually cigarette smoke). A central role in the pathophysiology has been shown to play a chronic inflammation of the airways that is expressed primarily by hypersecretion of mucus, stenosis of the smaller airways and the establishment of pulmonary emphysema. There is an increasing trend for assessing the inflammatory pattern of inflammatory airway diseases through mediators measured by noninvasive techniques. Markers in biological fluids and exhaled air have been the subject of intense evaluation over the past few years, with some of them reaching their introduction into clinical practice, while others remain as research tools. Of particular interest for the scientific community is the discovery of clinically exploitable biomarkers associated with specific phenotypes of the disease. Studying the effects of therapeutic interventions in these biomarkers may lead to targeted therapy based on phenotype and this is perhaps the future of therapeutics in COPD.
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Affiliation(s)
- Nikolaos Angelis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Konstantinos Porpodis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Paul Zarogoulidis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Dionysios Spyratos
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Ioannis Kioumis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Antonis Papaiwannou
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Georgia Pitsiou
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Kosmas Tsakiridis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Andreas Mpakas
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Stamatis Arikas
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Theodora Tsiouda
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Nikolaos Katsikogiannis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Ioanna Kougioumtzi
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Nikolaos Machairiotis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Michael Argyriou
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - George Kessisis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Konstantinos Zarogoulidis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 5 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 6 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
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Park JY, Lee T, Lee H, Lee YJ, Park JS, Cho YJ, Yoon HI, Lee JH, Lee CT. Significance of fractional exhaled nitric oxide in chronic eosinophilic pneumonia: a retrospective cohort study. BMC Pulm Med 2014; 14:81. [PMID: 24885379 PMCID: PMC4024211 DOI: 10.1186/1471-2466-14-81] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 05/06/2014] [Indexed: 11/29/2022] Open
Abstract
Background Chronic eosinophilic pneumonia (CEP) is characterized by chronic eosinophilic infiltration of the lung. It is dramatically responsive to corticosteroid treatment, but symptoms and radiopacities recur frequently after tapering or discontinuing the medication. Fractional exhaled nitric oxide (FeNO) is a well-known noninvasive marker of eosinophilic airway inflammation. The aim of this retrospective cohort study was to investigate the relationships of FeNO with peripheral eosinophilia and the clinical state of CEP and its validity for predicting exacerbation of CEP. Methods Standard clinical and laboratory parameters, peripheral eosinophil percentage and count, and FeNO level were measured in 18 patients with CEP at several assessment points over 1 year. Results FeNO level was positively correlated with peripheral eosinophil count (r = 0.341, P = 0.005) and percentage (r = 0.362, P = 0.003). The median (IQR) FeNO levels were 79 (41–88) and 35 (26–49) ppb in uncontrolled (13/74 measurements) and controlled (61/74 measurements) CEP, respectively (P = 0.010). The FeNO level of 66.0 ppb showed the largest area under the curve (0.835) for predicting exacerbation of CEP (sensitivity = 0.80, specificity = 0.84). Conclusion FeNO may be useful for monitoring eosinophilic parenchymal inflammation and determining the appropriate corticosteroid dose in CEP.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Respiratory Center, Seoul National University Bundang Hospital, 173-82 Gumi-Ro, Bundang-Gu, Seongnam 463-707, Republic of Korea.
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180
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Chou KT, Su KC, Huang SF, Hsiao YH, Tseng CM, Su VYF, Hung SC, Perng DW. Exhaled nitric oxide predicts eosinophilic airway inflammation in COPD. Lung 2014; 192:499-504. [PMID: 24816967 DOI: 10.1007/s00408-014-9591-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 04/21/2014] [Indexed: 01/24/2023]
Abstract
PURPOSE Chronic obstructive pulmonary disease (COPD) with eosinophilic airway inflammation may represent a unique phenotype, possibly with shared features of COPD and asthma. The role of exhaled nitric oxide (eNO) in identifying COPD patients with sputum eosinophilia was examined in this study. METHODS Ninety COPD patients without past medical history of asthma or allergic diseases were prospectively enrolled, and their eNO, lung function, and cellular profile of induced sputum were measured. Eosinophil cationic protein and IgE in sputum and venous blood also were determined. Subjects with and without sputum eosinophilia (>3 %) were compared. The role of eNO in the prediction of sputum eosinophilia was assessed in a logistic regression model. RESULTS Patients with sputum eosinophilia had significantly higher levels of eNO (29 vs. 18 ppb, p = 0.01) than those without. The difference in serum total IgE (168 vs. 84.9 IU/ml, p = 0.057) and percentages of positive allergen test results (48.3 vs. 29.5 %, p = 0.082) showed a trend toward significance. The sputum eosinophil level was significantly correlated to the eNO level (r = 0.485, p < 0.001). The eNO level at the cutoff of 23.5 ppb had the maximum sum of sensitivity (62.1 %) and specificity (70.5 %). The unadjusted and adjusted odds ratios of a higher eNO level (>23.5 ppb) in the prediction of sputum eosinophilia were 3.909 (confidence interval (CI) 1.542-9.91, p = 0.004) and 4.329 (CI 1.306-14.356, p = 0.017), respectively. CONCLUSIONS eNO is a good marker to identify COPD patients with eosinophilic airway inflammation.
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Affiliation(s)
- Kun-Ta Chou
- Department of Chest Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan
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Al-Alawi M, Hassan T, Chotirmall SH. Advances in the diagnosis and management of asthma in older adults. Am J Med 2014; 127:370-8. [PMID: 24380710 DOI: 10.1016/j.amjmed.2013.12.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 11/25/2013] [Accepted: 12/02/2013] [Indexed: 11/25/2022]
Abstract
Global estimates on aging predict an increased burden of asthma in the older population. Consequently, its recognition, diagnosis, and management in clinical practice require optimization. This review aims to provide an update for clinicians, highlighting advances in the understanding of the aging process and immunosenescence together with their applicability to asthma from a diagnostic and therapeutic perspective. Aging impacts airway responses and immune function, and influences efficacy of emerging phenotype-specific therapies when applied to the elderly patient. Differentiating eosinophilic and neutrophilic disease accounts for atopic illness and distinguishes long-standing from late-onset asthma. Therapeutic challenges in drug delivery, treatment adherence, and side-effect profiles persist in the older patient, while novel recording devices developed to aid detection of an adequate inhalation evaluate treatment effectiveness and compliance more accurately than previously attainable. Anticytokine therapies improve control of brittle asthma, while bronchial thermoplasty is an option in refractory cases. Multidimensional intervention strategies prove best in the management of asthma in the older adult, which remains a condition that is not rare but rarely diagnosed in this patient population.
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Affiliation(s)
- Mazen Al-Alawi
- Department of Medicine, Our Lady of Lourdes Hospital, Navan, Republic of Ireland
| | - Tidi Hassan
- Department of Respiratory Medicine, Mater Misericordiae Hospital, Eccles Street, Dublin 7, Republic of Ireland
| | - Sanjay H Chotirmall
- Department of Medicine, St James's Hospital, James's Street, Dublin 8, Republic of Ireland.
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182
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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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183
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Jonaid BS, Pronk A, Doekes G, Heederik D. Exhaled nitric oxide in spray painters exposed to isocyanates: effect modification by atopy and smoking. Occup Environ Med 2014; 71:415-22. [PMID: 24683011 DOI: 10.1136/oemed-2013-101672] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Isocyanate asthma is one of the most frequently identified forms of occupational asthma in industrialised countries. The underlying mechanisms have not been clarified. There is only limited information about the relationship between exhaled nitric oxide (eNO) and occupational exposure to isocyanates and asthma. OBJECTIVES To investigate the association between isocyanate exposure and eNO levels in isocyanate-exposed workers and to elucidate whether eNO acts as a marker of airway inflammation controlling for smoking and atopy in an industry-wide survey. METHODS Information on estimated personal isocyanate exposure, measured eNO levels, health effects and sensitisation were analysed in 229 workers from a cross-sectional study. Univariate and multiple regression analyses were used to explore the exposure-response relationships between isocyanate exposure and eNO, stratified by smoking and atopy. RESULTS A marginally significant exposure-response relationship was found between isocyanate exposure and eNO in atopic, non-smokers (p=0.054). eNO was significantly associated with atopy and smoking, bronchial hyper-responsiveness (BHR), work-related conjunctivitis and rhinitis after adjustment for age, gender, atopy and smoking (p<0.05). A borderline significant association was found between eNO and asthma-like symptoms after adjustment for age, gender, atopy and current smoking (p=0.055). In a small group of isocyanate-exposed workers with positive serum-specific immunoglobulin E (IgE) antibodies to hexamethylene diisocyanate (HDI), elevated eNO levels were clearly exposure related. eNO was associated with the positive specific IgG antibodies to HDI in non-atopic, non-smokers (p=0.03). CONCLUSIONS Increased eNO levels may indicate increased airway inflammation in atopic, non-smokers exposed to isocyanates especially at higher levels of isocyanate exposure.
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Affiliation(s)
- Badri Sadat Jonaid
- Division of Environmental Epidemiology, Institute for Risk Assessment Sciences (IRAS), Utrecht University, The Netherlands
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184
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Zairina E, Stewart K, Abramson MJ, George J. The effectiveness of non-pharmacological healthcare interventions for asthma management during pregnancy: a systematic review. BMC Pulm Med 2014; 14:46. [PMID: 24642132 PMCID: PMC3994784 DOI: 10.1186/1471-2466-14-46] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While reviews have been published on asthma management in pregnant women, none has examined the effectiveness of non-pharmacological healthcare interventions for optimizing asthma management in pregnant women. This systematic review aims to identify non-pharmacological healthcare interventions for optimizing asthma management during pregnancy and to examine their effects on maternal asthma control and neonatal outcomes. METHODS The Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, EMBASE, PsycINFO, CINAHL Plus and International Pharmaceutical Abstracts (IPA) were searched. Two reviewers independently assessed the identified studies against the eligibility criteria and extracted relevant information. The effects of the intervention were assessed qualitatively. RESULTS Nine studies were identified, of which six were rejected according to the exclusion criteria. The three studies included in the final review described an education program, progressive muscle relaxation (PMR) and Fraction of exhaled Nitric Oxide (FeNO) guided management of asthma in pregnant women. The PMR and FeNO-guided interventions showed significant improvements in maternal asthma control (lung function and quality of life) and neonatal outcomes (birth weight). CONCLUSIONS Further evidence from well-designed studies evaluating non-pharmacological healthcare interventions for optimizing asthma management in pregnant women is required.
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Affiliation(s)
- Elida Zairina
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Kay Stewart
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Michael J Abramson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
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185
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Gross TJ, Kremens K, Powers LS, Brink B, Knutson T, Domann FE, Philibert RA, Milhem MM, Monick MM. Epigenetic silencing of the human NOS2 gene: rethinking the role of nitric oxide in human macrophage inflammatory responses. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2014; 192:2326-38. [PMID: 24477906 PMCID: PMC3943971 DOI: 10.4049/jimmunol.1301758] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Macrophages, including alveolar macrophages, are primary phagocytic cells of the innate immune system. Many studies of macrophages and inflammation have been done in mouse models, in which inducible NO synthase (NOS2) and NO are important components of the inflammatory response. Human macrophages, in contrast to mouse macrophages, express little detectable NOS2 and generate little NO in response to potent inflammatory stimuli. The human NOS2 gene is highly methylated around the NOS2 transcription start site. In contrast, mouse macrophages contain unmethylated cytosine-phosphate-guanine (CpG) dinucleotides proximal to the NOS2 transcription start site. Further analysis of chromatin accessibility and histone modifications demonstrated a closed conformation at the human NOS2 locus and an open conformation at the murine NOS2 locus. In examining the potential for CpG demethylation at the NOS2 locus, we found that the human NOS2 gene was resistant to the effects of demethylation agents both in vitro and in vivo. Our data demonstrate that epigenetic modifications in human macrophages are associated with CpG methylation, chromatin compaction, and histone modifications that effectively silence the NOS2 gene. Taken together, our findings suggest there are significant and underappreciated differences in how murine and human macrophages respond to inflammatory stimuli.
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Affiliation(s)
- Thomas J. Gross
- Department of Medicine, Carver College of Medicine, The
University of Iowa, Iowa City, Iowa, 52242
| | - Karol Kremens
- Department of Medicine, Carver College of Medicine, The
University of Iowa, Iowa City, Iowa, 52242
| | - Linda S. Powers
- Department of Medicine, Carver College of Medicine, The
University of Iowa, Iowa City, Iowa, 52242
| | - Brandi Brink
- Department of Medicine, Carver College of Medicine, The
University of Iowa, Iowa City, Iowa, 52242
| | - Tina Knutson
- Department of Medicine, Carver College of Medicine, The
University of Iowa, Iowa City, Iowa, 52242
| | - Frederick E. Domann
- Department of Radiation Oncology, Carver College of
Medicine, The University of Iowa, Iowa City, Iowa, 52242
| | - Robert A. Philibert
- Department of Psychiatry, Carver College of Medicine, The
University of Iowa, Iowa City, Iowa, 52242
| | - Mohammed M. Milhem
- Department of Medicine, Carver College of Medicine, The
University of Iowa, Iowa City, Iowa, 52242
| | - Martha M. Monick
- Department of Medicine, Carver College of Medicine, The
University of Iowa, Iowa City, Iowa, 52242
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186
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Bjermer L, Alving K, Diamant Z, Magnussen H, Pavord I, Piacentini G, Price D, Roche N, Sastre J, Thomas M, Usmani O. Current evidence and future research needs for FeNO measurement in respiratory diseases. Respir Med 2014; 108:830-41. [PMID: 24636813 DOI: 10.1016/j.rmed.2014.02.005] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 01/12/2014] [Accepted: 02/08/2014] [Indexed: 12/18/2022]
Abstract
Although not yet widely implemented, fraction of exhaled nitric oxide (FeNO) has emerged in recent years as a potentially useful biomarker for the assessment of airway inflammation both in undiagnosed patients with non-specific respiratory symptoms and in those with established airway disease. Research to date essentially suggests that FeNO measurement facilitates the identification of patients exhibiting T-helper cell type 2 (Th2)-mediated airway inflammation, and effectively those in whom anti-inflammatory therapy, particularly inhaled corticosteroids (ICS), is beneficial. In some studies, FeNO-guided management of patients with established airway disease is associated with lower exacerbation rates, improvements in adherence to anti-inflammatory therapy, and the ability to predict risk of future exacerbations or decline in lung function. Despite these data, concerns regarding the applicability and utility of FeNO in clinical practice still remain. This article reviews the current evidence, both supportive and critical of FeNO measurement, in the diagnosis and management of asthma and other inflammatory airway diseases. It additionally provides suggestions regarding the practical application of FeNO measurement: how it could be integrated into routine clinical practice, how its utility could be assessed and its true value to both clinicians and patients could be established. Although some unanswered questions remain, current evidence suggests that FeNO is potentially a valuable tool for improving the personalised management of inflammatory airway diseases.
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Affiliation(s)
- Leif Bjermer
- Department of Respiratory Medicine and Allergology, Skane University Hospital, 22185 Lund, Sweden.
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Zuzana Diamant
- Department of Respiratory Medicine and Allergology, Skane University Hospital, 22185 Lund, Sweden; Department of General Practice & QPS-NL, Groningen, The Netherlands
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Germany
| | - Ian Pavord
- Department of Respiratory Medicine, Thoracic Surgery and Allergy, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - Giorgio Piacentini
- Faculty of Medicine, University of Verona, Italy; Department of Paediatrics, Policlinico GB Rossi, Verona, Italy
| | | | - Nicolas Roche
- University Paris Descartes, Respiratory and Intensive Care Medicine Department, Cochin Hospital Group, Paris, France
| | - Joaquin Sastre
- Fundacion Jimenez Diaz, Allergy Service and CIBERES, Institute Carlos III, Madrid, Spain
| | | | - Omar Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
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187
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Haccuria A, Michils A, Michiels S, Van Muylem A. Exhaled nitric oxide: a biomarker integrating both lung function and airway inflammation changes. J Allergy Clin Immunol 2014; 134:554-9. [PMID: 24522091 DOI: 10.1016/j.jaci.2013.12.1070] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 11/28/2013] [Accepted: 12/10/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The increased fraction of exhaled nitric oxide (Feno) values observed in asthmatic patients are thought to reflect increased airway inflammation. However, Feno values can be affected by airway caliber reduction, representing a bias when using Feno values to assess asthma control. OBJECTIVE We sought to determine the effect of changes in both airway caliber and inflammation on Feno values using the allergen challenge model. METHODS FEV1 and Feno values were measured during early airway responses (EARs) and late airway responses after challenge with house dust mite allergens in 15 patients with mild allergic asthma. Helium and sulfur hexafluoride (SF6) phase III expired concentration slopes (SHe and SSF6, respectively) from single-breath washout tests were measured to identify sites of airway constriction. RESULTS In EARs, FEV1 and Feno value decreases reached 36.8% and 22%, respectively (P < .001). ΔSHe was greater than ΔSSF6 (+189.4% vs +82.2%, P = .001). In late airway responses FEV1 and Feno value decreases reached 31.7% and 28.7%, respectively (P < .001), with the same ΔSHe and ΔSSF6 pattern (+155.8% vs +76%, P = .001). Eight hours after the EAR, FEV1 was still decreased (P < .001), whereas Feno values had returned to baseline. At 24 hours, FEV1 had returned to baseline, with Feno values increased by 38.7% (P = .04). CONCLUSION In patients with mild allergic asthma, airway caliber changes modulate changes in Feno values resulting from airway inflammation. Therefore Feno should no longer be considered solely an inflammation biomarker but rather a biomarker that integrates both airway inflammation and lung function changes. Furthermore, early and late phases resulting from allergen exposure were shown to involve similar lung regions.
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Affiliation(s)
- Amaryllis Haccuria
- Chest Department, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium; Chest Department, Centre Hospitalier Régional de Namur, Namur, Belgium
| | - Alain Michils
- Chest Department, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Sébastien Michiels
- Chest Department, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Van Muylem
- Chest Department, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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188
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Nuijsink M, De Jongste JC, Pijnenburg MW. Will symptom-based therapy be effective for treating asthma in children? Curr Allergy Asthma Rep 2014; 13:421-6. [PMID: 23775350 DOI: 10.1007/s11882-013-0364-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Traditionally, symptoms are important patient-oriented outcomes in asthma treatment, and assessment of symptoms is an essential component of assessing asthma control. However, variable airways obstruction, airways hyperresponsiveness and chronic inflammation are key components of the asthma syndrome, and correlations among these hallmarks and symptoms are weak or even absent. Therefore, it might be questioned if symptom-based therapy is effective for treating asthma in (all) children. To date, there is no firm indication that monitoring asthma based on repetitive lung function measurement or markers of airway inflammation is superior to monitoring based on symptoms only. In the majority of patients, symptom-based asthma management may well be sufficient, and in preschool children, symptoms are presently the only feasible outcome. Nevertheless, there is some evidence that selected groups might benefit from an approach that takes into account individual phenotypic characteristics. In patients with poor perception, those with a discordant phenotype and those with persistent severe asthma, considering lung function, airways hyperresponsiveness and inflammatory markers in treatment decisions might improve outcomes.
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Affiliation(s)
- Marianne Nuijsink
- Department of Paediatrics, Juliana Children's Hospital, The Hague, The Netherlands,
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189
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Divekar R, Ameredes BT, Calhoun WJ. Symptom-based controller therapy: a new paradigm for asthma management. Curr Allergy Asthma Rep 2014; 13:427-33. [PMID: 23904098 DOI: 10.1007/s11882-013-0375-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Appropriate management of persistent asthma, according to US and international guidelines, requires daily use of controller medications, most generally, inhaled corticosteroids (ICS). This approach, although effective and well established, imposes burdens of treatment and side effects onto asthma patients. A growing body of evidence suggests that patients with persistent asthma need not be managed with daily ICS, but rather can use them on an intermittent basis, occasioned by the occurrence of symptoms sufficient to warrant treatment with a rescue inhaler. Large, randomized, controlled studies, over a range of asthma severity, and in a range of ages from pediatrics to adults, suggest that, in well-selected patients, a symptom-based approach to administering controller therapy may produce equivalent outcomes, while reducing exposure to ICS. The concept of providing anti-inflammatory treatment to the patient, at the time inflammation is developing, is termed 'temporal personalization'. The evidence to date suggests that symptom-based controller therapy is broadly useful in selected asthma patients, and is a management approach that could be incorporated into US and international guidelines for asthma.
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Affiliation(s)
- Rohit Divekar
- Division of Allergy and Clinical Immunology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA
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190
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Abstract
The inherent limitations of spirometry and clinical history have prompted clinicians and scientists to search for surrogate markers of airway diseases. Although few biomarkers have been widely accepted into the clinical armamentarium, the authors explore three sources of biomarkers that have shown promise as indicators of disease severity and treatment response. In asthma, exhaled nitric oxide measurements can predict steroid responsiveness and sputum eosinophil counts have been used to titrate anti-inflammatory therapies. In chronic obstructive pulmonary disease, inflammatory plasma biomarkers, such as fibrinogen, club cell secretory protein-16 and surfactant protein D, can denote greater severity and predict the risk of exacerbations. While the multitude of disease phenotypes in respiratory medicine make biomarker development especially challenging, these three may soon play key roles in the diagnosis and management of airway diseases.
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191
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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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192
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Abstract
There are three major problems with asthma care in the USA and misuse of asthma drug therapy contributes to each. Asthma patients suffer from symptoms regularly partly because healthcare providers do not understand the Expert Panel Report III (EPR3) recommendations on assessing asthma symptoms to determine drug treatment and, consequently, undertreat the disease. Asthma patients experience exacerbations often in part because the EPR3 provides limited guidance on using exacerbation risk to guide asthma treatment, again leading to undertreatment. The EPR3 recommends inhaled corticosteroids as the preferred therapy for mild persistent asthma but American healthcare providers disregard this recommendation based on different perceptions about the risks and benefits of inhaled corticosteroids and choose drug treatments with higher healthcare costs.
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Affiliation(s)
- Gene L Colice
- The George Washington University School of Medicine, Director, Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, 110 Irving St., NW, Washington, DC 20010, USA.
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193
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Blonder JP, Mutka SC, Sun X, Qiu J, Green LH, Mehra NK, Boyanapalli R, Suniga M, Look K, Delany C, Richards JP, Looker D, Scoggin C, Rosenthal GJ. Pharmacologic inhibition of S-nitrosoglutathione reductase protects against experimental asthma in BALB/c mice through attenuation of both bronchoconstriction and inflammation. BMC Pulm Med 2014; 14:3. [PMID: 24405692 PMCID: PMC3893392 DOI: 10.1186/1471-2466-14-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/03/2014] [Indexed: 12/16/2022] Open
Abstract
Background S-nitrosoglutathione (GSNO) serves as a reservoir for nitric oxide (NO) and thus is a key homeostatic regulator of airway smooth muscle tone and inflammation. Decreased levels of GSNO in the lungs of asthmatics have been attributed to increased GSNO catabolism via GSNO reductase (GSNOR) leading to loss of GSNO- and NO- mediated bronchodilatory and anti-inflammatory actions. GSNOR inhibition with the novel small molecule, N6022, was explored as a therapeutic approach in an experimental model of asthma. Methods Female BALB/c mice were sensitized and subsequently challenged with ovalbumin (OVA). Efficacy was determined by measuring both airway hyper-responsiveness (AHR) upon methacholine (MCh) challenge using whole body plethysmography and pulmonary eosinophilia by quantifying the numbers of these cells in the bronchoalveolar lavage fluid (BALF). Several other potential biomarkers of GSNOR inhibition were measured including levels of nitrite, cyclic guanosine monophosphate (cGMP), and inflammatory cytokines, as well as DNA binding activity of nuclear factor kappa B (NFκB). The dose response, onset of action, and duration of action of a single intravenous dose of N6022 given from 30 min to 48 h prior to MCh challenge were determined and compared to effects in mice not sensitized to OVA. The direct effect of N6022 on airway smooth muscle tone also was assessed in isolated rat tracheal rings. Results N6022 attenuated AHR (ED50 of 0.015 ± 0.002 mg/kg; Mean ± SEM) and eosinophilia. Effects were observed from 30 min to 48 h after treatment and were comparable to those achieved with three inhaled doses of ipratropium plus albuterol used as the positive control. N6022 increased BALF nitrite and plasma cGMP, while restoring BALF and plasma inflammatory markers toward baseline values. N6022 treatment also attenuated the OVA-induced increase in NFκB activation. In rat tracheal rings, N6022 decreased contractile responses to MCh. Conclusions The significant bronchodilatory and anti-inflammatory actions of N6022 in the airways are consistent with restoration of GSNO levels through GSNOR inhibition. GSNOR inhibition may offer a therapeutic approach for the treatment of asthma and other inflammatory lung diseases. N6022 is currently being evaluated in clinical trials for the treatment of inflammatory lung disease.
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Affiliation(s)
- Joan P Blonder
- N30 Pharmaceuticals, Inc, 3122 Sterling Circle, Suite 200, Boulder, CO 80301, USA.
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194
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Effect of nanoparticles exposure on fractional exhaled nitric oxide (FENO) in workers exposed to nanomaterials. Int J Mol Sci 2014; 15:878-94. [PMID: 24413755 PMCID: PMC3907844 DOI: 10.3390/ijms15010878] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 12/26/2013] [Accepted: 01/03/2014] [Indexed: 12/21/2022] Open
Abstract
Fractional exhaled nitric oxide (FENO) measurement is a useful diagnostic test of airway inflammation. However, there have been few studies of FENO in workers exposed to nanomaterials. The purpose of this study was to examine the effect of nanoparticle (NP) exposure on FENO and to assess whether the FENO is increased in workers exposed to nanomaterials (NM). In this study, both exposed workers and non-exposed controls were recruited from NM handling plants in Taiwan. A total of 437 subjects (exposed group = 241, non-exposed group = 196) completed the FENO and spirometric measurements from 2009–2011. The authors used a control-banding (CB) matrix to categorize the risk level of each participant. In a multivariate linear regression analysis, this study found a significant association between risk level 2 of NP exposure and FENO. Furthermore, asthma, allergic rhinitis, peak expiratory flow rate (PEFR), and NF-κB were also significantly associated with FENO. When the multivariate logistic regression model was adjusted for confounders, nano-TiO2 in all of the NM exposed categories had a significantly increased risk in FENO > 35 ppb. This study found associations between the risk level of NP exposure and FENO (particularly noteworthy for Nano-TiO2). Monitoring FENO in the lung could open up a window into the role nitric oxide (NO) may play in pathogenesis.
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195
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Fractional exhaled nitric oxide in clinical trials: an overview. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 788:237-45. [PMID: 23835984 DOI: 10.1007/978-94-007-6627-3_34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Designing clinical trials in asthma it is crucial to find the perfect primary endpoint for showing bioequivalence, especially when the investigational medicinal product is not a bronchodilator, but a substance, which suppresses the inflammatory process, e.g. inhalative corticosteroids (ICS). In the past, lung function parameters were used as the primary endpoint, which entails a long study duration and hundreds of patients. The measurement of fractional exhaled nitric oxide (FeNO) is established as a non-invasive marker for eosinophilic inflammation, and several guidelines focus on that diagnosis. FeNO is a surrogate measure of eosinophilic inflammation and at the same time, eosinophilic airway inflammation is usually steroid responsive. Thus, FeNO should be a part of the clinical management of asthma in ambulatory settings in conjunction with other conventional methods of asthma assessment. Furthermore, FeNO should be used to determine the presence or absence of eosinophilic airway inflammation, to determine the likelihood of steroid responsiveness, to measure response to steroid therapy, and level of inflammation control. In addition, FeNO is a useful tool to monitor patient ICS treatment adherence and allergen exposure. FeNO may be used to predict steroid responsiveness and as a measure to determine the optimal treatment of airway inflammation. FeNO has all characteristics of a good marker for bioequivalence measurements in the market approval process of generic ICS products. With a reliable study design in terms of patient population, concomitant medication, equipment and other factors, which can influence the measurement, efficient clinical trials can be performed, with a relatively short treatment time of 2-4 weeks and 50-100 patients.
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196
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Lee BJ. Treatment of mild asthma: Is it necessary to keep regular inhaled corticosteroids? ALLERGY ASTHMA & RESPIRATORY DISEASE 2014. [DOI: 10.4168/aard.2014.2.3.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Byung-Jae Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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197
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Abstract
Severe asthma has been increasingly recognized as a heterogenous disease with varied clinical characteristics and pathophysiological processes. Patients with severe asthma suffer significant impairment in their daily life and impose a substantial burden on health care resources. The recent work of consortia groups has led to an improved definition of severe asthma as well as better characterization of the patients with severe disease. Different approaches, including unbiased cluster analyses, have been utilized to identify severe asthma phenotypes (subgroups) defined by their clinical characteristics and immune processes. Recognition of severe asthma phenotypes has assisted the development of targeted therapies by identifying patients more likely to respond to the specific agent. In this article, we discuss the evolution of our understanding of severe asthma and review the currently available therapies and promising drugs in development. In addition, we examine the role of bronchoscopy in severe asthma and the emerging evidence regarding bronchial thermoplasty.
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198
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Abstract
During inspiration and expiration, gases traverse the conducting airways as they are transported between the environment and the alveolar region of the lungs. The term "conducting" airways is used broadly as the airway tree is thought largely to provide a conduit for the respiratory gases, oxygen and carbon dioxide. However, despite a significantly smaller surface area, and thicker barrier separating the gas phase from the blood when compared to the alveolar region, the airway tree can participate in gas exchange under special conditions such as high water solubility, high chemical reactivity, or production of the gas within the airway wall tissue. While these conditions do not apply to the respiratory gases, other gases demonstrate substantial exchange of the airways and are of particular importance to the inflammatory response of the lungs, the medical-legal field, occupational health, metabolic disorders, or protection of the delicate alveolar membrane. Given the significant structural differences between the airways and the alveolar region, the physical determinants that control airway gas exchange are unique and require different models (both experimental and mathematical) to explore. Our improved physiological understanding of airway gas exchange combined with improved analytical methods to detect trace compounds in the exhaled breath provides future opportunities to develop new exhaled biomarkers that are characteristic of pulmonary and systemic conditions.
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Affiliation(s)
- Steven C George
- Department of Biomedical Engineering, University of California, Irvine, California, USA.
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199
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Abstract
New asthma guidelines of National Asthma Education and Prevention Program (NAEPP) were released recently with a special emphasis on new information in asthma management. The new asthma guidelines emphasize several key terms including severity, control, impairment, risk, and responsiveness that are relevant for advancing the care of asthma. New directions in asthma research that could advance asthma management include early diagnosis and intervention, use of combination therapy to achieve asthma control, application of biomarkers and genetics to individualize asthma therapy, and the identification of immunomodulator therapy to alter the course of the disease. This review will discuss the application of biomarkers for asthma management. One biomarker that can serve as a prototype for the application of biomarkers to asthma care is exhaled nitric oxide (eNO). Initially used as a research tool and now being applied in clinical practice, this biomarker has been available for approximately 10 years. As such, valuable lessons have been learned regarding the advantages and limitations of this biomarker for asthma care.
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Affiliation(s)
- Stanley J Szefler
- Divisions of Pediatric Clinical Pharmacology and Allergy and Immunology, Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colorado, USA
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200
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Price D, Ryan D, Burden A, Von Ziegenweidt J, Gould S, Freeman D, Gruffydd-Jones K, Copland A, Godley C, Chisholm A, Thomas M. Using fractional exhaled nitric oxide (FeNO) to diagnose steroid-responsive disease and guide asthma management in routine care. Clin Transl Allergy 2013; 3:37. [PMID: 24195942 PMCID: PMC3826517 DOI: 10.1186/2045-7022-3-37] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 10/18/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a surrogate marker of eosinophilic airway inflammation and good predictor of corticosteroid response. AIM To evaluate how FeNO is being used to guide primary care asthma management in the United Kingdom (UK) with a view to devising practical algorithms for the use of FeNO in the diagnosis of steroid-responsive disease and to guide on-going asthma management. METHODS Eligible patients (n = 678) were those in the Optimum Patient Care Research Database (OPCRD) aged 4-80 years who, at an index date, had their first FeNO assessment via NIOX MINO® or Flex®. Eligible practices were those using FeNO measurement in at least ten patients during the study period. Patients were characterized over a one-year baseline period immediately before the index date. Outcomes were evaluated in the year immediately following index date for two patient cohorts: (i) those in whom FeNO measurement was being used to identify steroid-responsive disease and (ii) those in whom FeNO monitoring was being used to guide on-going asthma management. Outcomes for cohort (i) were incidence of new ICS initiation at, or within the one-month following, their first FeNO measurement, and ICS dose during the outcome year. Outcomes for cohort (ii) were adherence, change in adherence (from baseline) and ICS dose. OUTCOMES In cohort (i) (n = 304) the higher the FeNO category, the higher the percentage of patients that initiated ICS at, or in the one month immediately following, their first FeNO measurement: 82%, 46% and 26% of patients with high, intermediate and low FeNO, respectively. In cohort (ii) (n = 374) high FeNO levels were associated with poorer baseline adherence (p = 0.005) but greater improvement in adherence in the outcome year (p = 0.017). Across both cohorts, patients with high FeNO levels were associated with significantly higher ICS dosing (p < 0.001). CONCLUSIONS In the UK, FeNO is being used in primary practice to guide ICS initiation and dosing decisions and to identify poor ICS adherence. Simple algorithms to guide clinicians in the practical use of FeNO could improved diagnostic accuracy and better tailored asthma regimens.
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Affiliation(s)
- David Price
- Research in Real Life, Cambridge, UK
- Respiratory Effectiveness Group, Cambridge, UK
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Dermot Ryan
- Woodbrook Medical Centre, Loughborough and Honorary Fellow at the University of Edinburgh, Edinburgh, UK
| | | | | | | | - Daryl Freeman
- Mundesley Medical Practice and Norfolk Community Health & Care, Norfolk, UK
| | - Kevin Gruffydd-Jones
- Box Surgery, Wiltshire; Respiratory Lead, Royal College of General Practitioners, London, and Honorary Lecturer, University of Bath, Bath, UK
| | | | | | | | - Mike Thomas
- Primary Care Research, University of Southampton, Southampton, UK
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