201
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Schoettler N, Strek ME. Recent Advances in Severe Asthma: From Phenotypes to Personalized Medicine. Chest 2019; 157:516-528. [PMID: 31678077 DOI: 10.1016/j.chest.2019.10.009] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/15/2019] [Accepted: 10/18/2019] [Indexed: 12/31/2022] Open
Abstract
This review focuses on recent clinical and translational discoveries in severe and uncontrolled asthma that now enable phenotyping and personalized therapies in these patients. Although asthma is common in both children and adults and typically responds to standard therapies, a subset of individuals with asthma experience severe and/or persistent symptoms despite appropriate therapies. Airflow obstruction leading to frequent symptoms requiring higher levels of controller therapy is the cardinal feature of severe asthma, but the underlying molecular mechanisms, or endotypes, are diverse and variable between individuals. Two major risk factors that contribute to severe asthma are genetics and environmental exposures that modulate immune responses, and although these often interact in complex manners that are not fully understood, certain endotypes converge in severe asthma. A number of studies have evaluated various features of patients with severe asthma and classified patients into phenotypes with clinical relevance. This phenotyping is now incorporated into clinical practice and can be used to guide advanced biological therapies that target specific molecules and inflammatory pathways that contribute to asthma pathogenesis.
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Affiliation(s)
- Nathan Schoettler
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
| | - Mary E Strek
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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202
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Brasier AR, Boldogh I. Targeting inducible epigenetic reprogramming pathways in chronic airway remodeling. Drugs Context 2019; 8:dic-2019-8-3. [PMID: 31692901 PMCID: PMC6821469 DOI: 10.7573/dic.2019-8-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 02/08/2023] Open
Abstract
Allergic asthma is a chronic inflammatory airway disease whose clinical course is punctuated by acute exacerbations from aeroallergen exposure or respiratory virus infections. Aeroallergens and respiratory viruses stimulate toll-like receptor (TLR) signaling, producing oxidative injury and inflammation. Repetitive exacerbations produce complex mucosal adaptations, cell-state changes, and structural remodeling. These structural changes produce substantial morbidity, decrease lung capacity, and impair quality of life. We will review recent systems-level studies that provide fundamental new insights into how repetitive activation of innate signaling pathways produce epigenetic ‘training’ to induce adaptive epithelial responses. Oxidative stress produced downstream of TLR signaling induces transient oxidation of guanine bases in the regulatory regions of inflammatory genes. The epigenetic mark 8-oxoG is bound by a pleiotropic DNA repair enzyme, 8-oxoguanine DNA glycosylase (OGG1), which induces conformational changes in adjacent DNA to recruit the NFκB·bromodomain-containing protein 4 (BRD4) complex. The NFκB·BRD4 complex not only plays a central role in inflammation, but also triggers mesenchymal transition and extracellular matrix remodeling. Small molecule inhibitors of OGG1-8-oxoG binding and BRD4–acetylated histone interaction have been developed. We present studies demonstrating efficacy of these in reducing airway inflammation in preclinical models. Targeting inducible epigenetic reprogramming pathway shows promise for therapeutics in reversing airway remodeling in a variety of chronic airway diseases.
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Affiliation(s)
- Allan R Brasier
- Institute for Clinical and Translational Research, University of Wisconsin-Madison School of Medicine and Public Health, 4246 Health Sciences Learning Center, 750 Highland Ave, Madison, WI 53705, USA
| | - Istvan Boldogh
- Department of Microbiology and Immunology, University of Texas Medical Branch at Galveston, 301 University Blvd, Galveston, TX 77555, USA
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203
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Marozkina N, Zein J, DeBoer MD, Logan L, Veri L, Ross K, Gaston B. Dehydroepiandrosterone Supplementation May Benefit Women with Asthma Who Have Low Androgen Levels: A Pilot Study. Pulm Ther 2019; 5:213-220. [PMID: 32026412 PMCID: PMC6967310 DOI: 10.1007/s41030-019-00101-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Indexed: 01/09/2023] Open
Abstract
Introduction Among individuals with severe asthma, FEV1 is low in individuals with low dehydroepiandrosterone (DHEA) sulfate (DHEAS) levels. In the Severe Asthma Research Program (SARP), no women with DHEAS > 200 μg/dL had an FEV1 < 60% predicted. DHEA has benefited patients with COPD and pulmonary hypertension in small trials. Therefore, we hypothesized that DHEA supplementation may improve FEV1 in asthmatic women with low DHEAS. Methods Premenopausal, nonsmoking, otherwise healthy women, 18-50 years old, with mild or moderate asthma and baseline FEV1 > 60% predicted received 100 mg DHEA orally every 12 h for 2 weeks. Spirometry and DHEAS were measured at the initial visit and 2 weeks later, after completion of DHEA treatment. Based on our previous work, the primary outcome variable for this pilot study was post-albuterol spirometry in the low-DHEAS group. Subjects also continued their other routine asthma management. Results Serum DHEAS increased with DHEA treatment in women with starting DHEAS < 200 µg/dL: this increase was from 71 ± 23 to 725 ± 295 µg/dL (n = 10; p = 0.0001). The increase in the high-DHEAS group was smaller. Post-albuterol FEV1 increased by 51 mL, from 3.026 ± 0.5 to 3.077 ± 0.49 L (n = 10; p = 0.034 by paired t test, significant after Bonferroni), in women with low DHEAS. In the high-DHEAS group (baseline DHEAS ≥ 200 µg/dl), post-albuterol FEV1 did not change significantly (n = 3, p = NS). Three subjects were excluded: one had comorbid COPD, one could not perform spirometry, and one did not take the DHEA. There were no adverse effects of DHEA treatment in this trial. Conclusions Endocrine treatments (corticosteroids) are a mainstay of anti-inflammatory management for moderate and severe asthma. Their use has improved asthma outcomes. Androgens also reduce airway inflammation and promote airway smooth muscle relaxation, but are rarely used clinically for asthma treatment. Our results suggest that the over-the-counter steroid DHEA may improve lung function in asthma outcomes among women with DHEAS < 200 ug/dL.
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Affiliation(s)
| | - Joe Zein
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Laurie Logan
- Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Laura Veri
- Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Kristie Ross
- Case Western Reserve University, Cleveland, OH, USA
- Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Benjamin Gaston
- Case Western Reserve University, Cleveland, OH, USA.
- Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
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204
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Ross KR, Gupta R, DeBoer MD, Zein J, Phillips BR, Mauger DT, Li C, Myers RE, Phipatanakul W, Fitzpatrick AM, Ly NP, Bacharier LB, Jackson DJ, Celedón JC, Larkin A, Israel E, Levy B, Fahy JV, Castro M, Bleecker ER, Meyers D, Moore WC, Wenzel SE, Jarjour NN, Erzurum SC, Teague WG, Gaston B. Severe asthma during childhood and adolescence: A longitudinal study. J Allergy Clin Immunol 2019; 145:140-146.e9. [PMID: 31622688 DOI: 10.1016/j.jaci.2019.09.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Morbidity and mortality associated with childhood asthma are driven disproportionately by children with severe asthma. However, it is not known from longitudinal studies whether children outgrow severe asthma. OBJECTIVE We sought to study prospectively whether well-characterized children with severe asthma outgrow their asthma during adolescence. METHODS Children with asthma were assessed at baseline with detailed questionnaires, allergy tests, and lung function tests and were reassessed annually for 3 years. The population was enriched for children with severe asthma, as assessed by the American Thoracic Society/European Respiratory Society guidelines, and subject classification was reassessed annually. RESULTS At baseline, 111 (59%) children had severe asthma. Year to year, there was a decrease in the proportion meeting the criteria for severe asthma. After 3 years, only 30% of subjects met the criteria for severe asthma (P < .001 compared with enrollment). Subjects experienced improvements in most indices of severity, including symptom scores, exacerbations, and controller medication requirements, but not lung function. Surprisingly, boys and girls were equally likely to has resolved asthma (33% vs 29%). The odds ratio in favor of resolution of severe asthma was 2.75 (95% CI, 1.02-7.43) for those with a peripheral eosinophil count of greater than 436 cells/μL. CONCLUSIONS In longitudinal analysis of this well-characterized cohort, half of the children with severe asthma no longer had severe asthma after 3 years; there was a stepwise decrease in the proportion meeting severe asthma criteria. Surprisingly, asthma severity decreased equally in male and female subjects. Peripheral eosinophilia predicted resolution. These data will be important for planning clinical trials in this population.
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Affiliation(s)
- Kristie R Ross
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Ritika Gupta
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland
| | - Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Joe Zein
- Department of Pathobiology, Lerner Research Institute, and the Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brenda R Phillips
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Chun Li
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Ross E Myers
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Wanda Phipatanakul
- Department of Pediatrics, Harvard University School of Medicine, Boston, Mass
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Ngoc P Ly
- Department of Pediatrics, San Francisco School of Medicine, University of California, San Francisco, Calif
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Juan C Celedón
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pa
| | - Allyson Larkin
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pa
| | - Elliot Israel
- Department of Pediatrics, Harvard University School of Medicine, Boston, Mass
| | - Bruce Levy
- Department of Pediatrics, Harvard University School of Medicine, Boston, Mass
| | - John V Fahy
- Department of Pediatrics, San Francisco School of Medicine, University of California, San Francisco, Calif
| | - Mario Castro
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Eugene R Bleecker
- Department of Medicine, University of Arizona Health Sciences, Tucson, Ariz
| | - Deborah Meyers
- Department of Medicine, University of Arizona Health Sciences, Tucson, Ariz
| | - Wendy C Moore
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute at the University of Pittsburgh Medical Center-University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Nizar N Jarjour
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Serpil C Erzurum
- Department of Pathobiology, Lerner Research Institute, and the Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - W Gerald Teague
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Benjamin Gaston
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.
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205
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Grunwell JR, Nguyen KM, Bruce AC, Fitzpatrick AM. Bronchodilator Dose Responsiveness in Children and Adolescents: Clinical Features and Association with Future Asthma Exacerbations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:953-964. [PMID: 31614217 DOI: 10.1016/j.jaip.2019.09.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/20/2019] [Accepted: 09/23/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Bronchodilator reversibility measures are often associated with poor asthma outcomes in children. Whether bronchodilator dose responsiveness is similarly useful in children is unclear. OBJECTIVE We hypothesized that children and adolescents requiring higher doses of bronchodilator to achieve maximal bronchodilation would have unique risk factors and increased risk of future exacerbation. METHODS Children (6-11 years, N = 299) and adolescents (12-21 years, N = 331) with confirmed asthma underwent clinical phenotyping procedures and a test of maximal bronchodilation with escalating doses of albuterol sulfate up to 720 mcg. Outcome measures were assessed at 12 months and included exacerbations treated with systemic corticosteroids, emergency department (ED) visits, and hospitalizations for asthma. RESULTS A total of 6.7% of children and 9.3% of adolescents had poor bronchodilator dose responsiveness, defined as attainment of maximal forced expiratory volume in 1 second with 720 mcg albuterol. Risk factors included type 2 inflammation, prior exacerbations, and greater asthma severity; historical pneumonia and tobacco exposure were also risk factors in children. Children and adolescents with poor bronchodilator dose responsiveness did not have increased current symptoms or impaired quality of life, but had approximately 2-fold increased odds of exacerbation or ED visit and approximately 3-fold increased odds of hospitalization by 12 months, independent of airflow obstruction. CONCLUSIONS Bronchodilator dose responsiveness may be useful for phenotyping and may be of utility in practice and future studies focused on asthma outcomes or quantification of treatment responses. In children and adolescents, this phenotype of poor bronchodilator responsiveness may be associated with periods of relatively stable disease yet marked airway constriction in response to triggers, including tobacco smoke, respiratory infections/pneumonia, and aeroallergens.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Alice C Bruce
- Department of Pediatrics, Emory University, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
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206
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Fitzpatrick AM, Szefler SJ, Mauger DT, Phillips BR, Denlinger LC, Moore WC, Sorkness RL, Wenzel SE, Gergen PJ, Bleecker ER, Castro M, Erzurum SC, Fahy JV, Gaston BM, Israel E, Levy BD, Meyers DA, Teague WG, Bacharier LB, Ly NP, Phipatanakul W, Ross KR, Zein J, Jarjour NN. Development and initial validation of the Asthma Severity Scoring System (ASSESS). J Allergy Clin Immunol 2019; 145:127-139. [PMID: 31604088 DOI: 10.1016/j.jaci.2019.09.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 09/09/2019] [Accepted: 09/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tools for quantification of asthma severity are limited. OBJECTIVE We sought to develop a continuous measure of asthma severity, the Asthma Severity Scoring System (ASSESS), for adolescents and adults, incorporating domains of asthma control, lung function, medications, and exacerbations. METHODS Baseline and 36-month longitudinal data from participants in phase 3 of the Severe Asthma Research Program (NCT01606826) were used. Scale properties, responsiveness, and a minimally important difference were determined. External replication was performed in participants enrolled in the Severe Asthma Research Program phase 1/2. The utility of ASSESS for detecting treatment response was explored in participants undergoing corticosteroid responsiveness testing with intramuscular triamcinolone and participants receiving biologics. RESULTS ASSESS scores ranged from 0 to 20 (8.78 ± 3.9; greater scores reflect worse severity) and differed among 5 phenotypic groups. Measurement properties were acceptable. ASSESS was responsive to changes in quality of life with a minimally important difference of 2, with good specificity for outcomes of asthma improvement and worsening but poor sensitivity. Replication analyses yielded similar results, with a 2-point decrease (improvement) associated with improvements in quality of life. Participants with a 2-point or greater decrease (improvement) in ASSESS scores also had greater improvement in lung function and asthma control after triamcinolone, but these differences were limited to phenotypic clusters 3, 4, and 5. Participants treated with biologics also had a 2-point or greater decrease (improvement) in ASSESS scores overall. CONCLUSIONS The ASSESS tool is an objective measure that might be useful in epidemiologic and clinical research studies for quantification of treatment response in individual patients and phenotypic groups. However, validation studies are warranted.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Stanley J Szefler
- Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Brenda R Phillips
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | | | - Wendy C Moore
- Department of Internal Medicine, Wake Forest University, Winston-Salem, NC
| | | | - Sally E Wenzel
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Peter J Gergen
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | | | - Mario Castro
- Department of Internal Medicine, Washington University, St Louis, Mo
| | | | - John V Fahy
- Department of Medicine, San Francisco, Calif
| | - Benjamin M Gaston
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Bruce D Levy
- Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - W Gerald Teague
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | | | - Ngoc P Ly
- Department of Pediatrics, University of California San Francisco, Cleveland, Ohio
| | | | - Kristie R Ross
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Joe Zein
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin, Madison, Wis
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207
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Adeli M, El-Shareif T, Hendaus MA. Asthma exacerbation related to viral infections: An up to date summary. J Family Med Prim Care 2019; 8:2753-2759. [PMID: 31681638 PMCID: PMC6820381 DOI: 10.4103/jfmpc.jfmpc_86_19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 02/01/2019] [Accepted: 08/27/2019] [Indexed: 12/21/2022] Open
Abstract
Asthma exacerbation can be a major life threatening event. Viruses have been pinned as the cause behind the vast majority of these exacerbations. The purpose of this short review is to explore the mechanisms behind these exacerbations, focusing mostly on viral infections as triggers. We will also be discussing the phenotypes prone to asthma exacerbation, the pathophysiology of viral induced asthma and ventilation patterns of asthmatic lungs. This manuscript will assist primary care physicians in delineating the proper pathophysiology of the disease as well as the management.
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Affiliation(s)
- Mehdi Adeli
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar.,Department of Pediatrics, Hamad General Corporation, Doha, Qatar.,Department of Clinical Pediatrics, Weill- Cornell Medicine, Doha, Qatar
| | | | - Mohamed A Hendaus
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar.,Department of Pediatrics, Hamad General Corporation, Doha, Qatar.,Department of Clinical Pediatrics, Weill- Cornell Medicine, Doha, Qatar
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208
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Bourdin A, Bjermer L, Brightling C, Brusselle GG, Chanez P, Chung KF, Custovic A, Diamant Z, Diver S, Djukanovic R, Hamerlijnck D, Horváth I, Johnston SL, Kanniess F, Papadopoulos N, Papi A, Russell RJ, Ryan D, Samitas K, Tonia T, Zervas E, Gaga M. ERS/EAACI statement on severe exacerbations in asthma in adults: facts, priorities and key research questions. Eur Respir J 2019; 54:13993003.00900-2019. [PMID: 31467120 DOI: 10.1183/13993003.00900-2019] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/17/2019] [Indexed: 01/05/2023]
Abstract
Despite the use of effective medications to control asthma, severe exacerbations in asthma are still a major health risk and require urgent action on the part of the patient and physician to prevent serious outcomes such as hospitalisation or death. Moreover, severe exacerbations are associated with substantial healthcare costs and psychological burden, including anxiety and fear for patients and their families. The European Academy of Allergy and Clinical Immunology (EAACI) and the European Respiratory Society (ERS) set up a task force to search for a clear definition of severe exacerbations, and to also define research questions and priorities. The statement includes comments from patients who were members of the task force.
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Affiliation(s)
- Arnaud Bourdin
- Université de Montpellier, CHU Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Leif Bjermer
- Dept of Respiratory Medicine and Allergy, Lung and Allergy research Unit, Lund, Sweden
| | - Christopher Brightling
- Dept of Infection, Immunity and Inflammation, Institute for Lung Health, NIHR BRC Respiratory Medicine, University of Leicester, Leicester, UK
| | - Guy G Brusselle
- Dept of Respiratory Diseases, Ghent University Hospital, Ghent, Belgium
| | | | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College, London, UK
| | - Adnan Custovic
- Dept of Paediatrics, Imperial College London, London, UK
| | - Zuzana Diamant
- Dept of Respiratory Medicine and Allergology, Skane University Hospital, Lund, Sweden.,Respiratory and Allergy Research, QPS Netherlands, The Netherlands
| | - Sarah Diver
- Dept of Respiratory Sciences, College of Life Sciences, Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Ratko Djukanovic
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Ildikó Horváth
- National Koranyi Institute for Pulmonology, and Dept of Public Health, Semmelweis University, Budapest, Hungary
| | | | | | - Nikos Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Allergy Dept, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Richard J Russell
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Dept of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Dermot Ryan
- Allergy and Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.,Woodbrook Medical Centre, Loughborough, UK
| | | | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Mina Gaga
- 7th Respiratory Medicine Dept, Athens Chest Hospital, Athens, Greece
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209
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Allinne J, Scott G, Lim WK, Birchard D, Erjefält JS, Sandén C, Ben LH, Agrawal A, Kaur N, Kim JH, Kamat V, Fury W, Huang T, Stahl N, Yancopoulos GD, Murphy AJ, Sleeman MA, Orengo JM. IL-33 blockade affects mediators of persistence and exacerbation in a model of chronic airway inflammation. J Allergy Clin Immunol 2019; 144:1624-1637.e10. [PMID: 31562870 DOI: 10.1016/j.jaci.2019.08.039] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 08/15/2019] [Accepted: 08/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Severe inflammatory airway diseases are associated with inflammation that does not resolve, leading to structural changes and an overall environment primed for exacerbations. OBJECTIVE We sought to identify and inhibit pathways that perpetuate this heightened inflammatory state because this could lead to therapies that allow for a more quiescent lung that is less predisposed to symptoms and exacerbations. METHODS Using prolonged exposure to house dust mite in mice, we developed a mouse model of persistent and exacerbating airway disease characterized by a mixed inflammatory phenotype. RESULTS We show that lung IL-33 drives inflammation and remodeling beyond the type 2 response classically associated with IL-33 signaling. IL-33 blockade with an IL-33 neutralizing antibody normalized established inflammation and improved remodeling of both the lung epithelium and lung parenchyma. Specifically, IL-33 blockade normalized persisting and exacerbating inflammatory end points, including eosinophilic, neutrophilic, and ST2+CD4+ T-cell infiltration. Importantly, we identified a key role for IL-33 in driving lung remodeling because anti-IL-33 also re-established the presence of ciliated cells over mucus-producing cells and decreased myofibroblast numbers, even in the context of continuous allergen exposure, resulting in improved lung function. CONCLUSION Overall, this study shows that increased IL-33 levels drive a self-perpetuating amplification loop that maintains the lung in a state of lasting inflammation and remodeled tissue primed for exacerbations. Thus IL-33 blockade might ameliorate symptoms and prevent exacerbations by quelling persistent inflammation and airway remodeling.
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Affiliation(s)
| | | | | | | | - Jonas S Erjefält
- Unit of Airway Inflammation, Lund University, Lund, Sweden; Medetect AB, Lund, Sweden
| | | | | | | | | | | | | | - Wen Fury
- Regeneron Pharmaceuticals, Tarrytown, NY
| | | | - Neil Stahl
- Regeneron Pharmaceuticals, Tarrytown, NY
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210
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Lambrecht BN, Hammad H, Fahy JV. The Cytokines of Asthma. Immunity 2019; 50:975-991. [PMID: 30995510 DOI: 10.1016/j.immuni.2019.03.018] [Citation(s) in RCA: 574] [Impact Index Per Article: 114.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 01/13/2023]
Abstract
Asthma is a chronic inflammatory airway disease associated with type 2 cytokines interleukin-4 (IL-4), IL-5, and IL-13, which promote airway eosinophilia, mucus overproduction, bronchial hyperresponsiveness (BHR), and immunogloubulin E (IgE) synthesis. However, only half of asthma patients exhibit signs of an exacerbated Type 2 response. "Type 2-low" asthma has different immune features: airway neutrophilia, obesity-related systemic inflammation, or in some cases, few signs of immune activation. Here, we review the cytokine networks driving asthma, placing these in cellular context and incorporating insights from cytokine-targeting therapies in the clinic. We discuss established and emerging paradigms in the context of the growing appreciation of disease heterogeneity and argue that the development of new and improved therapeutics will require understanding the diverse mechanisms underlying the spectrum of asthma pathologies.
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Affiliation(s)
- Bart N Lambrecht
- Laboratory of Immunoregulation, VIB Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Hamida Hammad
- Laboratory of Immunoregulation, VIB Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Cardiovascular Research Institute, University of California, San Francisco, San Francisco, USA
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211
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Ash SY, Sanchez-Ferrero GV, Schiebler ML, Rahaghi FN, Rai A, Come CE, Ross JC, Colon AG, Cardet JC, Bleecker ER, Castro M, Fahy JV, Fain SB, Gaston BM, Hoffman EA, Jarjour NN, Lempel JK, Mauger DT, Tattersall MC, Wenzel SE, Levy BD, Washko GR, Israel E, San Jose Estepar R. Estimated Ventricular Size, Asthma Severity, and Exacerbations: The Severe Asthma Research Program III Cohort. Chest 2019; 157:258-267. [PMID: 31521672 DOI: 10.1016/j.chest.2019.08.2185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/25/2019] [Accepted: 08/11/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Relative enlargement of the pulmonary artery (PA) on chest CT imaging is associated with respiratory exacerbations in patients with COPD or cystic fibrosis. We sought to determine whether similar findings were present in patients with asthma and whether these findings were explained by differences in ventricular size. METHODS We measured the PA and aorta diameters in 233 individuals from the Severe Asthma Research Program III cohort. We also estimated right, left, and total epicardial cardiac ventricular volume indices (eERVVI, eELVVI, and eETVVI, respectively). Associations between the cardiac and PA measures (PA-to-aorta [PA/A] ratio, eERVVI-to-eELVVI [eRV/eLV] ratio, eERVVI, eELVVI, eETVVI) and clinical measures of asthma severity were assessed by Pearson correlation, and associations with asthma severity and exacerbation rate were evaluated by multivariable linear and zero-inflated negative binomial regression. RESULTS Asthma severity was associated with smaller ventricular volumes. For example, those with severe asthma had 36.1 mL/m2 smaller eETVVI than healthy control subjects (P = .003) and 14.1 mL/m2 smaller eETVVI than those with mild/moderate disease (P = .011). Smaller ventricular volumes were also associated with a higher rate of asthma exacerbations, both retrospectively and prospectively. For example, those with an eETVVI less than the median had a 57% higher rate of exacerbations during follow-up than those with eETVVI greater than the median (P = .020). Neither PA/A nor eRV/eLV was associated with asthma severity or exacerbations. CONCLUSIONS In patients with asthma, smaller cardiac ventricular size may be associated with more severe disease and a higher rate of asthma exacerbations. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01761630; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Samuel Y Ash
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA.
| | | | - Mark L Schiebler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Ashish Rai
- Department of Medicine, North Shore Medical Center, Salem, MA
| | - Carolyn E Come
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - James C Ross
- Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Alysha G Colon
- College of Medicine, University of Florida, Gainesville, FL
| | - Juan Carlos Cardet
- Division of Allergy and Immunology, Department of Medicine, University of South Florida, Tampa, FL
| | - Eugene R Bleecker
- Division of Genetics, Genomics and Precision Medicine, University of Arizona, Tucson, AZ
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, CA
| | - Sean B Fain
- Departments of Medical Physics, Radiology, and Biomedical Engineering, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Benjamin M Gaston
- Division of Pulmonology, Allergy, and Immunology, and Pediatric Pulmonology, Rainbow Babies and Children's Hospital and Cleveland Medical Center, Cleveland, OH
| | - Eric A Hoffman
- Departments of Radiology, Biomedical Engineering, and Medicine, University of Iowa, Iowa City, IA
| | - Nizar N Jarjour
- Division of Pulmonary and Critical Care Medicine (Dr Jarjour), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason K Lempel
- Department of Radiology, Cleveland Clinic, Cleveland, OH
| | - David T Mauger
- Division of Biostatistics and Bioinformatics, Penn State Eberly College of Science, University Park, PA
| | - Matthew C Tattersall
- Division of Cardiovascular Medicine (Dr Tattersall), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sally E Wenzel
- Division of Pulmonary, Allergy and Critical Care, University of Pittsburgh, Pittsburgh, PA
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - George R Washko
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
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Sintobin I, Siroux V, Holtappels G, Pison C, Nadif R, Bousquet J, Bachert C. Sensitisation to staphylococcal enterotoxins and asthma severity: a longitudinal study in the EGEA cohort. Eur Respir J 2019; 54:13993003.00198-2019. [PMID: 31285304 DOI: 10.1183/13993003.00198-2019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/01/2019] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Evidence is accumulating that Staphylococcus aureus plays an important role as disease modifier in upper and lower airway diseases. Sensitisation to S. aureus enterotoxins (SEs) was associated with an increased risk of severe asthma in previous cross-sectional studies, but evidence from longitudinal studies is lacking. We aimed to assess associations between SE-sensitisation and the subsequent risk for asthma severity and exacerbations. METHODS This is a nested case-control study from the 20-year Epidemiological Study of the Genetics and Environment of Asthma (EGEA) cohort, including 225 adults (75 without asthma, 76 with mild asthma and 74 with severe asthma) in EGEA2 (2003-2007). For 173 of these individuals, SE-sensitisation was measured on samples collected 11 years earlier (EGEA1). Cross-sectional associations were conducted for EGEA1 and EGEA2. Longitudinal analyses estimated the association between SE-sensitisation in EGEA1 and the risk of severe asthma and asthma exacerbations assessed in the follow-up. Models were adjusted for sex, age, smoking, parental asthma/allergy and skin-prick test to house dust mite. RESULTS SE-sensitisation varied between 39% in controls to 58% and 76% in mild and severe asthma, respectively, in EGEA1. An adjusted cross-sectional association showed that SE-sensitisation was associated with an increased risk of severe, but not for mild asthma. SE-sensitisation in EGEA1 was associated with severe asthma (adjusted OR 2.69, 95% CI 1.18-6.15) and asthma exacerbations (adjusted OR 4.59, 95% CI 1.40-15.07) assessed 10-20 years later. CONCLUSION For the first time, this study shows that being sensitised to SEs is associated with an increased subsequent risk of severe asthma and asthma exacerbations.
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Affiliation(s)
- Ina Sintobin
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium.,Both authors contributed equally
| | - Valerie Siroux
- Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Inserm, CNRS, University Grenoble Alpes, Institute for Advanced Biosciences (IAB), U1209 Joint Research Center, Grenoble, France.,Both authors contributed equally
| | | | - Christophe Pison
- Université Grenoble Alpes, Grenoble, France.,Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU de Grenoble, Inserm 1055, Grenoble, France
| | - Rachel Nadif
- Inserm, U1168, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, Villejuif, France.,Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, Montigny le Bretonneux, France
| | - Jean Bousquet
- Inserm, U1168, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, Villejuif, France.,Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, Montigny le Bretonneux, France.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universitätzu Berlin, and Berlin Institute of Health, Comprehensive Allergy Center, Dept of Dermatology and Allergy, Berlin, Germany.,MACVIA-France, Fondation Partenariale FMC VIA-LR, Montpellier, France
| | - Claus Bachert
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium .,Division of ENT Diseases, CLINTEC, Karolinska Institute, University of Stockholm, Stockholm, Sweden
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213
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Poorbahrami K, Mummy DG, Fain SB, Oakes JM. Patient-specific modeling of aerosol delivery in healthy and asthmatic adults. J Appl Physiol (1985) 2019; 127:1720-1732. [PMID: 31513445 DOI: 10.1152/japplphysiol.00221.2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The magnitude and regional heterogeneity of airway obstructions in severe asthmatics is likely linked to insufficient drug delivery, as evidenced by the inability to mitigate exacerbations with inhaled aerosol medications. To understand the correlation between morphometric features, airflow distribution, and inhaled dosimetry, we perform dynamic computational simulations in two healthy and four asthmatic subjects. Models incorporate computed tomography-based and patient-specific central airway geometries and hyperpolarized 3He MRI-measured segmental ventilation defect percentages (SVDPs), implemented as resistance boundary conditions. Particles [diameters (dp) = 1, 3, and 5 μm] are simulated throughout inhalation, and we record their initial conditions, both spatially and temporally, with their fate in the lung. Predictions highlight that total central airway deposition is the same between the healthy subjects (26.6%, dp = 3 μm) but variable among the asthmatic subjects (ranging from 5.9% to 59.3%, dp = 3 μm). We found that by preferentially releasing the particles during times of fast or slow inhalation rates we enhance either central airway deposition percentages or peripheral particle delivery, respectively. These predictions highlight the potential to identify with simulations patients who may not receive adequate therapeutic dosages with inhaled aerosol medication and therefore identify patients who may benefit from alternative treatment strategies. Furthermore, by improving regional dose levels, we may be able to preferentially deliver drugs to the airways in need, reducing associated adverse side effects.NEW & NOTEWORTHY Although it is evident that exacerbation mitigation is unsuccessful in some asthmatics, it remains unclear whether or not these patients receive adequate dosages of inhaled therapeutics. By coupling MRI and computed tomography data with patient-specific computational models, our predictions highlight the large intersubject variability, specifically in severe asthma.
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Affiliation(s)
- Kamran Poorbahrami
- Department of Mechanical and Industrial Engineering, Northeastern University, Boston, Massachusetts
| | - David G Mummy
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Sean B Fain
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jessica M Oakes
- Department of Bioengineering, Northeastern University, Boston, Massachusetts
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214
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Grossman NL, Ortega VE, King TS, Bleecker ER, Ampleford EA, Bacharier LB, Cabana MD, Cardet JC, Carr TF, Castro M, Denlinger LC, Denson JL, Fandino N, Fitzpatrick AM, Hawkins GA, Holguin F, Krishnan JA, Lazarus SC, Nyenhuis SM, Phipatanakul W, Ramratnam SK, Wenzel S, Peters SP, Meyers DA, Wechsler ME, Israel E. Exacerbation-prone asthma in the context of race and ancestry in Asthma Clinical Research Network trials. J Allergy Clin Immunol 2019; 144:1524-1533. [PMID: 31520679 DOI: 10.1016/j.jaci.2019.08.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/27/2019] [Accepted: 08/16/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Minority groups of African descent experience disproportionately greater asthma morbidity compared with other racial groups, suggesting that genetic variation from a common ancestry could influence exacerbation risk. OBJECTIVE We evaluated clinical trial measures in the context of self-reported race and genetic ancestry to identify risk factors for asthma exacerbations. METHODS One thousand eight hundred forty multiethnic subjects from 12 Asthma Clinical Research Network and AsthmaNet trials were analyzed for incident asthma exacerbations with Poisson regression models that included clinical measures, self-reported race (black, non-Hispanic white, and other), and estimates of global genetic African ancestry in a subgroup (n = 760). RESULTS Twenty-four percent of 1840 subjects self-identified as black. Black and white subjects had common risk factors for exacerbations, including a history of 2 or more exacerbations in the previous year and FEV1 percent predicted values, whereas chronic sinusitis, allergic rhinitis, and gastroesophageal reflux disease were only associated with increased exacerbation risk in black subjects. In the combined multiethnic cohort, neither race (P = .30) nor percentage of genetic African ancestry as a continuous variable associated with exacerbation risk (adjusted rate ratio [RR], 1.26 [95% CI, 0.94-1.70; P = .13]; RR per 1-SD change [32% ancestry], 0.97 [95% CI, 0.78-1.19; P = .74]). However, in 161 black subjects with genetic data, those with African ancestry greater than the median (≥82%) had a significantly greater risk of exacerbation (RR, 3.06 [95% CI, 1.09-8.6; P = .03]). CONCLUSION Black subjects have unique risk factors for asthma exacerbations, of which global African genetic ancestry had the strongest effect.
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Affiliation(s)
- Nicole L Grossman
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Lahey Hospital and Medical Center, Burlington, Mass
| | - Victor E Ortega
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Tonya S King
- Department of Public Health Sciences, Pennsylvania State University School of Medicine, Hershey, Pa
| | - Eugene R Bleecker
- Department of Medicine, Division of Genetics, Genomics, and Precision Medicine, University of Arizona College of Medicine, Tucson, Ariz
| | | | - Leonard B Bacharier
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Michael D Cabana
- Department of Pediatrics, University of California San Francisco, San Francisco, Calif
| | - Juan C Cardet
- Deparment of Internal Medicine, Divison of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Tara F Carr
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona, Tucson, AZ
| | - Mario Castro
- Department of Internal Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Kansas, Kansas City, Kan
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wis
| | - Joshua L Denson
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, Colo
| | - Nicolas Fandino
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | | | - Gregory A Hawkins
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC
| | - Fernando Holguin
- Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, Colo
| | - Jerry A Krishnan
- Department of Medicine, University of Illinois Hospital & Health Sciences System, Chicago, Ill
| | - Stephen C Lazarus
- Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Sharmilee M Nyenhuis
- Department of Medicine, University of Illinois Hospital & Health Sciences System, Chicago, Ill
| | - Wanda Phipatanakul
- Division of Pediatric Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sima K Ramratnam
- Department of Pediatrics, University of Wisconsin School of Medicine, Madison, Wis
| | - Sally Wenzel
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pa
| | - Stephen P Peters
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Deborah A Meyers
- Department of Medicine, Division of Genetics, Genomics, and Precision Medicine, University of Arizona College of Medicine, Tucson, Ariz
| | - Michael E Wechsler
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, Colo
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
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215
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Janson C, Malinovschi A, Amaral AFS, Accordini S, Bousquet J, Buist AS, Canonica GW, Dahlén B, Garcia-Aymerich J, Gnatiuc L, Kowalski ML, Patel J, Tan W, Torén K, Zuberbier T, Burney P, Jarvis D. Bronchodilator reversibility in asthma and COPD: findings from three large population studies. Eur Respir J 2019; 54:13993003.00561-2019. [PMID: 31221806 DOI: 10.1183/13993003.00561-2019] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 05/28/2019] [Indexed: 12/27/2022]
Abstract
Bronchodilator response (BDR) testing is used as a diagnostic method in obstructive airway diseases. The aim of this investigation was to compare different methods for measuring BDR in participants with asthma and chronic obstructive pulmonary disease (COPD) and to study to the extent to which BDR was related to symptom burden and phenotypic characteristics.Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were measured before and 15 min after 200 μg of salbutamol in 35 628 subjects aged ≥16 years from three large international population studies. The subjects were categorised in three groups: current asthma (n=2833), COPD (n=1146) and no airway disease (n=31 649). Three definitions for flow-related reversibility (increase in FEV1) and three for volume-related reversibility (increase in FVC) were used.The prevalence of bronchodilator reversibility expressed as increase FEV1 ≥12% and 200 mL was 17.3% and 18.4% in participants with asthma and COPD, respectively, while the corresponding prevalence was 5.1% in those with no airway disease. In asthma, bronchodilator reversibility was associated with wheeze (OR 1.36, 95% CI 1.04-1.79), atopy (OR 1.36, 95% CI 1.04-1.79) and higher exhaled nitric oxide fraction, while in COPD neither flow- nor volume-related bronchodilator reversibility was associated with symptom burden, exacerbations or health status after adjusting for pre-bronchodilator FEV1Bronchodilator reversibility was at least as common in participants with COPD as those with asthma. This indicates that measures of reversibility are of limited value for distinguishing asthma from COPD in population studies. However, in asthma, bronchodilator reversibility may be a phenotypic marker.
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Affiliation(s)
- Christer Janson
- Dept of Medical Sciences, Respiratory Allergy and Sleep Research, Uppsala University, Uppsala, Sweden .,Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrei Malinovschi
- Dept of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Andre F S Amaral
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College London, London, UK
| | - Simone Accordini
- Unit of Epidemiology and Medical Statistics, Dept of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jean Bousquet
- Fondation FMC VIA-LR, Montpellier, France.,Euforea, Brussels, Belgium.,Allergy Centre Charité, Dept of Dermatology and Allergy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - A Sonia Buist
- Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | | | - Barbro Dahlén
- Dept of Medicine, Unit for Heart and Lung disease, Karolinska Institutet, Stockholm, Sweden
| | - Judith Garcia-Aymerich
- ISGlobal, Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Louisa Gnatiuc
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Dept of Population Health, University of Oxford, Oxford, UK
| | - Marek L Kowalski
- Dept of Immunology and Allergy, Medical University of Lodz, Lodz, Poland
| | - Jaymini Patel
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College London, London, UK
| | - Wan Tan
- Centre for Heart Lung Innovation (Tan, Sin), University of British Columbia, St. Paul's Hospital Vancouver, Vancouver, BC, Canada
| | - Kjell Torén
- Dept of Occupational and Environmental Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Torsten Zuberbier
- Allergy Centre Charité, Dept of Dermatology and Allergy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Burney
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College London, London, UK
| | - Deborah Jarvis
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College London, London, UK
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216
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Licari A, Fuchs D, Marseglia G, Ciprandi G. Tryptophan metabolic pathway and neopterin in asthmatic children in clinical practice. Ital J Pediatr 2019; 45:114. [PMID: 31455379 PMCID: PMC6712831 DOI: 10.1186/s13052-019-0699-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/06/2019] [Indexed: 12/16/2022] Open
Abstract
Tryptophan metabolic pathway is involved in pathogenic mechanisms of asthma. This study aimed to evaluate tryptophan metabolites and neopterin in a group of asthmatic children. Tryptophan metabolites and neopterin were measured in asthmatic children (121, 71 males, 50 females, mean age 11.6 + 3.2 years) and well-matched healthy controls (63, 32 males, 31 females, mean age 10.7 + 2.6 years). Tryptophan, kynurenine, and neopterin levels were significantly higher in asthmatic children than in healthy controls (p < 0.01; p < 0.01; p = 0.0015 respectively). Tryptophan metabolites and neopterin are increased in asthmatic children; these mediators underline the complex mechanisms involved in the immune response in asthma.
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Affiliation(s)
- Amelia Licari
- Pediatrics Clinic, Department of Pediatrics, Ospedale San Matteo, University of Pavia, Pavia, Italy
| | - Dietmar Fuchs
- Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Gianluigi Marseglia
- Pediatrics Clinic, Department of Pediatrics, Ospedale San Matteo, University of Pavia, Pavia, Italy
| | - Giorgio Ciprandi
- Allergy Clinic, Casa di Cura Villa Montallegro, Via Montezovetto 27, 16132, Genoa, Italy.
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217
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Acute Severe Asthma in Adolescent and Adult Patients: Current Perspectives on Assessment and Management. J Clin Med 2019; 8:jcm8091283. [PMID: 31443563 PMCID: PMC6780340 DOI: 10.3390/jcm8091283] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Asthma is a chronic airway inflammatory disease that is associated with variable expiratory flow, variable respiratory symptoms, and exacerbations which sometimes require hospitalization or may be fatal. It is not only patients with severe and poorly controlled asthma that are at risk for an acute severe exacerbation, but this has also been observed in patients with otherwise mild or moderate asthma. This review discusses current aspects on the pathogenesis and pathophysiology of acute severe asthma exacerbations and provides the current perspectives on the management of acute severe asthma attacks in the emergency department and the intensive care unit.
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218
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Abstract
PURPOSE OF REVIEW To explore the latest insight of the literature on the asthma/bronchiectasis phenotype providing an updated overview about epidemiological, clinical and biological evidence linking these two conditions. RECENT FINDINGS An increasing body of literature has shown that the association of asthma and bronchiectasis is a frequent phenomenon leading to a more severe disease with frequent exacerbations. The mechanisms by which the two diseases are linked are still not well established but they share several clinical and immunological features and many comorbidities. SUMMARY The early identification of bronchiectasis through high-definition computer tomography in patients with severe asthma is crucial in order to provide an adequate treatment for both diseases and therefore to better control symptoms, exacerbations and infections.
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219
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Custovic A, Belgrave D, Lin L, Bakhsoliani E, Telcian AG, Solari R, Murray CS, Walton RP, Curtin J, Edwards MR, Simpson A, Rattray M, Johnston SL. Cytokine Responses to Rhinovirus and Development of Asthma, Allergic Sensitization, and Respiratory Infections during Childhood. Am J Respir Crit Care Med 2019; 197:1265-1274. [PMID: 29466680 DOI: 10.1164/rccm.201708-1762oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
RATIONALE Immunophenotypes of antiviral responses, and their relationship with asthma, allergy, and lower respiratory tract infections, are poorly understood. OBJECTIVES We characterized multiple cytokine responses of peripheral blood mononuclear cells to rhinovirus stimulation, and their relationship with clinical outcomes. METHODS In a population-based birth cohort, we measured 28 cytokines after stimulation with rhinovirus-16 in 307 children aged 11 years. We used machine learning to identify patterns of cytokine responses, and related these patterns to clinical outcomes, using longitudinal models. We also ascertained phytohemagglutinin-induced T-helper cell type 2 (Th2)-cytokine responses (PHA-Th2). MEASUREMENTS AND MAIN RESULTS We identified six clusters of children based on their rhinovirus-16 responses, which were differentiated by the expression of four cytokine/chemokine groups: interferon-related (IFN), proinflammatory (Inflam), Th2-chemokine (Th2-chem), and regulatory (Reg). Clusters differed in their clinical characteristics. Children with an IFNmodInflamhighestTh2-chemhighestReghighest rhinovirus-16-induced pattern had a PHA-Th2low response, and a very low asthma risk (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.01-0.81; P = 0.03). Two clusters had a high risk of asthma and allergic sensitization, but with different trajectories from infancy to adolescence. The IFNlowestInflamhighTh2-chemlowRegmod cluster exhibited a PHA-Th2lowest response and was associated with early-onset asthma and sensitization, and the highest risk of asthma exacerbations (OR, 1.37; 95% CI, 1.07-1.76; P = 0.014) and lower respiratory tract infection hospitalizations (OR, 2.40; 95% CI, 1.26-4.58; P = 0.008) throughout childhood. In contrast, the IFNhighestInflammodTh2-chemmodReghigh cluster with a rhinovirus-16-cytokine pattern was characterized by a PHA-Th2highest response, and a low prevalence of asthma/sensitization in infancy that increased sharply to become the highest among all clusters by adolescence (but with a low risk of asthma exacerbations). CONCLUSIONS Early-onset troublesome asthma with early-life sensitization, later-onset milder allergic asthma, and disease protection are each associated with different patterns of rhinovirus-induced immune responses.
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Affiliation(s)
- Adnan Custovic
- 1 Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom.,2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Danielle Belgrave
- 1 Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
| | - Lijing Lin
- 3 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Eteri Bakhsoliani
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Aurica G Telcian
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Roberto Solari
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Clare S Murray
- 5 Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Ross P Walton
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - John Curtin
- 5 Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Michael R Edwards
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Angela Simpson
- 5 Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Magnus Rattray
- 3 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Sebastian L Johnston
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
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220
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Affiliation(s)
- Lawrence E K Gray
- 1 School of Medicine, Deakin University, Geelong, Victoria, Australia; and
| | - Peter D Sly
- 2 Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
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Qin L, Gibson PG, Simpson JL, Baines KJ, McDonald VM, Wood LG, Powell H, Fricker M. Dysregulation of sputum columnar epithelial cells and products in distinct asthma phenotypes. Clin Exp Allergy 2019; 49:1418-1428. [PMID: 31264263 DOI: 10.1111/cea.13452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/21/2019] [Accepted: 06/26/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Dysfunction of the bronchial epithelium plays an important role in asthma; however, its measurement is challenging. Columnar epithelial cells are often quantified, yet rarely analysed, in induced sputum studies. OBJECTIVE We aimed to test whether sputum columnar epithelial cell proportion and count are altered in asthma, and whether they are associated with clinical and inflammatory variables. We aimed to test whether sputum-based measures could provide a relatively non-invasive means through which to monitor airway epithelial activation status. METHODS We examined the relationship of sputum columnar epithelial cells with clinical and inflammatory variables of asthma in a large retrospective cross-sectional cohort (901 participants with asthma and 138 healthy controls). In further studies, we used flow cytometry, microarray, qPCR and ELISA to characterize sputum columnar epithelial cells and their products. RESULTS Multivariate analysis and generation of 90th centile cut-offs (≥11% or ≥18.1 × 104 /mL) to identify columnar epithelial cell "high" asthma revealed a significant relationship between elevated sputum columnar cells and male gender, severe asthma and non-neutrophilic airway inflammation. Flow cytometry showed viable columnar epithelial cells were present in all sputum samples tested. An epithelial gene signature (SCGB3A1, LDLRAD1, FOXJ1, DNALI1, CFAP157, CFAP53) was detected in columnar epithelial cell-high sputum. CLCA1 mRNA and periostin protein, previously identified biomarkers of IL-13-mediated epithelial activation, were elevated in columnar epithelial cell-high sputum samples, but only when accompanied by eosinophilia. CONCLUSIONS & CLINICAL RELEVANCE Sputum columnar epithelial cells are related to important clinical and inflammatory variables in asthma. Measurement of epithelial biomarkers in sputum samples could allow non-invasive assessment of altered bronchial epithelium status in asthma.
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Affiliation(s)
- Ling Qin
- Priority Research Centre for Healthy Lungs, The University of Newcastle, New Lambton Heights, NSW, Australia.,Department of Respiratory Medicine (Department of Pulmonary and Critical Care Medicine), Xiangya Hospital, Central South University, Changsha, China
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, The University of Newcastle, New Lambton Heights, NSW, Australia.,National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Jodie L Simpson
- Priority Research Centre for Healthy Lungs, The University of Newcastle, New Lambton Heights, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Katherine J Baines
- Priority Research Centre for Healthy Lungs, The University of Newcastle, New Lambton Heights, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, The University of Newcastle, New Lambton Heights, NSW, Australia.,National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, The University of Newcastle, New Lambton Heights, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Heather Powell
- Priority Research Centre for Healthy Lungs, The University of Newcastle, New Lambton Heights, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Michael Fricker
- Priority Research Centre for Healthy Lungs, The University of Newcastle, New Lambton Heights, NSW, Australia.,National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia
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Maspero JF, Katelaris CH, Busse WW, Castro M, Corren J, Chipps BE, Peters AT, Pavord ID, Ford LB, Sher L, Rabe KF, Rice MS, Rowe P, Lu Y, Harel S, Jagerschmidt A, Khan AH, Kamat S, Pirozzi G, Amin N, Ruddy M, Graham NMH, Mannent LP, Teper A. Dupilumab Efficacy in Uncontrolled, Moderate-to-Severe Asthma with Self-Reported Chronic Rhinosinusitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:527-539.e9. [PMID: 31351189 DOI: 10.1016/j.jaip.2019.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/10/2019] [Accepted: 07/12/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for IL-4 and IL-13 signaling, key drivers of type 2 inflammation. In the phase 3 study (NCT02414854), add-on dupilumab 200 mg/300 mg every 2 weeks, versus placebo, significantly reduced severe asthma exacerbations and improved pre-bronchodilator forced expiratory volume in 1 second (FEV1) and quality-of-life measures in patients with uncontrolled, moderate-to-severe asthma, with greater efficacy observed in those with a high baseline type 2 phenotype. OBJECTIVE To assess the efficacy and safety of dupilumab in patients with uncontrolled, moderate-to-severe asthma with or without self-reported comorbid chronic rhinosinusitis (CRS or non-CRS). METHODS Comorbid CRS was self-reported by patients using an e-diary. Annualized severe exacerbation rates, changes from baseline in pre- and post-bronchodilator FEV1, patient-reported outcomes, type 2 biomarkers, and safety were assessed. RESULTS CRS was self-reported by 382 of 1902 (20.1%) patients. Dupilumab 200 mg/300 mg reduced annualized severe exacerbation rates by 63%/61%, respectively, in patients with CRS, and by 42%/40% in patients without CRS (all P < .001 vs placebo). Dupilumab also improved lung function and patient-reported asthma control and quality of life, and suppressed type 2 biomarkers versus placebo in both subgroups. Clinical responses were rapid, with near-maximal responses observed at the earliest measured time points and sustained at week 52. Improvements observed in the CRS subgroup were similar to or numerically greater than those in the non-CRS subgroup. CONCLUSION Dupilumab showed efficacy and was generally well tolerated in patients with uncontrolled, moderate-to-severe asthma with or without CRS.
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Affiliation(s)
| | - Constance H Katelaris
- Campbelltown Hospital, Campbelltown, NSW, Australia; Western Sydney University, Sydney, NSW, Australia
| | - William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Mario Castro
- Washington University School of Medicine, Saint Louis, Mo
| | | | - Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Anju T Peters
- Division of Allergy-Immunology and the Sinus and Allergy Center, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | | | | | - Lawrence Sher
- Peninsula Research Associates, Rolling Hills Estates, Calif
| | - Klaus F Rabe
- LungenClinic Grosshansdorf, Member of the German Center for Lung Research (DZL), Grosshansdorf, Germany; Christian-Albrechts-University of Kiel, Member of the German Center for Lung Research (DZL), Kiel, Germany
| | | | | | - Yufang Lu
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY
| | - Sivan Harel
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY
| | | | | | | | | | - Nikhil Amin
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY
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Yuan H, Liu X, Li L, Wang G, Liu C, Zeng Y, Mao R, Du C, Chen Z. Clinical and pulmonary function changes in cough variant asthma with small airway disease. Allergy Asthma Clin Immunol 2019; 15:41. [PMID: 31303871 PMCID: PMC6604225 DOI: 10.1186/s13223-019-0354-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/20/2019] [Indexed: 02/05/2023] Open
Abstract
Background It is known that small airway disease is present across all asthma severities; however, its prevalence and clinical characteristics in cough variant asthma (CVA) have not been fully illuminated. Methods A total of 77 CVA patients with preserved proximal airway function (FEV1/FVC > 70%) were enrolled in this study. The correlation between forced expiratory flow at 50% (FEF50%) and FEF25–75% in the CVA population was first evaluated. FEF50% was determined to be an easy and feasible parameter for identifying small airway disease. CVA with small airway disease is defined as FEF50% < 70%, whereas CVA with normal small airways is identified as FEF50% > 70%. Demographic features, clinical characteristics, lung function and induced sputum test results were determined at the initial visit and at the final visit 1 year later. Results FEF50% is a good marker for small airway disease. The cutoff value of 70% is more sensitive than the previously published 60% for identifying more patients with small airway problems early. Nearly half of the CVA population (45.4%) in our cohort had small airway disease. In both group, symptoms improved greatly after anti-asthmatic treatment. Interestingly, the changes in symptom scores [Asthma Control Test (ACT) and ACQ] were even greater in the CVA with small airway disease group than in the control group because of the higher medication usage in this subpopulation in real life. However anti-asthmatic therapy can not reverse small airway dysfunction. At last visit, FEF50% of CVA with small airway diseases was 57.2% ± 10.5%, still much lower than the control group (FEF50% = 92.6% ± 16.5%). Conclusions In our cohort, nearly half of the CVA population had small airway disease. Their demographic features, clinical characteristics, airway eosinophils and drug responsiveness were quite similar between two groups, which means these indices can not be used as markers to identify small airway obstruction. We found FEF50% is an easy and feasible marker for early identification. Regular anti-asthmatic medication helped to improve clinical scores in patients with small airway disease, but the obstruction could not be reversed over 1-year period.
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Affiliation(s)
- Honglei Yuan
- 1Respiratory Division of Zhongshan Hospital, Shanghai Institute of Respiratory Disease, Fudan University, No. 180 Fenglin Road, Shanghai, China
| | - Xiaojing Liu
- 1Respiratory Division of Zhongshan Hospital, Shanghai Institute of Respiratory Disease, Fudan University, No. 180 Fenglin Road, Shanghai, China.,2Respiratory Division of the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Li Li
- 1Respiratory Division of Zhongshan Hospital, Shanghai Institute of Respiratory Disease, Fudan University, No. 180 Fenglin Road, Shanghai, China
| | - Gang Wang
- 3Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Chunfang Liu
- 4Department of Laboratory Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuzhen Zeng
- 1Respiratory Division of Zhongshan Hospital, Shanghai Institute of Respiratory Disease, Fudan University, No. 180 Fenglin Road, Shanghai, China
| | - Ruolin Mao
- 1Respiratory Division of Zhongshan Hospital, Shanghai Institute of Respiratory Disease, Fudan University, No. 180 Fenglin Road, Shanghai, China
| | - Chunling Du
- 5Respiratory Division of Qingpu Hospital Affiliated to Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihong Chen
- 1Respiratory Division of Zhongshan Hospital, Shanghai Institute of Respiratory Disease, Fudan University, No. 180 Fenglin Road, Shanghai, China
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Wu TD, Brigham EP, Keet CA, Brown TT, Hansel NN, McCormack MC. Association Between Prediabetes/Diabetes and Asthma Exacerbations in a Claims-Based Obese Asthma Cohort. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:1868-1873.e5. [PMID: 30857941 PMCID: PMC6612446 DOI: 10.1016/j.jaip.2019.02.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/29/2019] [Accepted: 02/14/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Metabolic dysfunction may contribute to worsened asthma in obesity. The relationship between prediabetes and diabetes, metabolic conditions more common in obesity, and asthma outcomes is not well characterized. OBJECTIVE We sought to determine the association between prediabetes/diabetes and asthma exacerbations in an obese asthma cohort. METHODS A retrospective cohort of US obese adults with asthma, aged 18-64, was created from a claims-based health services database spanning 2010 to 2015. Individuals with a hemoglobin A1c (HbA1c) measurement were identified, categorized as within normal (<5.6%), prediabetes (5.7% to 6.4%), and diabetes (≥6.5%) ranges. Exacerbations, defined as asthma-related hospitalization, emergency department visit, or corticosteroid prescription ±14 days of an asthma-related outpatient visit, were ascertained. Associations were fit with zero-inflated negative binomial models, adjusted for age, sex, region, smoking, medication use, and comorbidities. RESULTS A total of 5722 individuals were identified. Higher HgbA1c was associated with higher asthma exacerbation rates. In the fully adjusted model, compared with individuals with normal HbA1c, those in the prediabetes range had a 27% higher rate (95% confidence interval [CI], 5% to 52%), and those in the diabetes range had a 33% higher rate (95% CI, 2% to 73%). CONCLUSIONS Prediabetes and diabetes were associated with higher rates of asthma exacerbation among obese adults with asthma. Results support evidence that insulin resistance and metabolic syndrome, metabolic features common in prediabetes/diabetes, can influence asthma morbidity.
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Affiliation(s)
- Tianshi David Wu
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Emily P Brigham
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Corinne A Keet
- Division of Pediatric Allergy and Immunology, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Todd T Brown
- Division of Endocrinology, Diabetes, and Metabolism, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Meredith C McCormack
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md.
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The role of doxycycline in the management of chronic rhinosinusitis with nasal polyps. Am J Otolaryngol 2019; 40:467-472. [PMID: 31126631 DOI: 10.1016/j.amjoto.2019.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/21/2019] [Accepted: 03/04/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Many theories on the pathophysiology of chronic rhinosinusitis with nasal polyposis (CRSwNP) exist. The most effective management of CRSwNP has not been elucidated. Doxycycline, which has anti-inflammatory and anti-bacterial properties, has shown durable effects; however, its efficacy in combination with standard therapy has not been examined. We hypothesized that its addition to the standard anti-inflammatory regimen would improve patient outcomes. METHODS We performed a double-blind, placebo-controlled trial at a tertiary level institution. Patients with moderate or severe CRSwNP were randomized into two groups, each receiving a 20-day course of oral corticosteroids and doxycycline or placebo. The 22-item Sinonasal Outcome Test (SNOT-22), nasal polyp scores, and visual analog scale (VAS) scores were recorded at the initial, 3-, 8- and 12-week visits. RESULTS 49 patients were enrolled, 24 in the experimental and 25 in the placebo group with 3 moderate disease patients in each group. There were 12 dropouts in the treatment group and 14 in the placebo group. The most common reasons for dropout were severe CRS and asthma exacerbations. There was no significant difference in SNOT-22 scores, nasal polyp scores, and VAS scores between the two arms. CONCLUSIONS Non-surgical management of patients with CRSwNP remains challenging. Our conclusions are limited given the high dropout rate and thus, limited sample size with inadequate power. This study is important, however, because a high dropout rate of mostly severe disease patients may illustrate that this patient population may not be optimally managed with medical therapy alone.
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226
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Dimitrova D, Youroukova V, Ivanova-Todorova E, Tumangelova-Yuzeir K, Velikova T. Serum levels of IL-5, IL-6, IL-8, IL-13 and IL-17A in pre-defined groups of adult patients with moderate and severe bronchial asthma. Respir Med 2019; 154:144-154. [PMID: 31260861 DOI: 10.1016/j.rmed.2019.06.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/05/2019] [Accepted: 06/25/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Bronchial asthma (BA) is a complex disease characterised by persistent inflammation. Exhaled nitric oxide (FeNO) and blood eosinophil count (b-Eos) are biomarkers for type 2 endotype of BA. OBJECTIVE To analyse a panel of serum interleukins and total IgE in predefined by FeNO and b-Eos groups of moderate and severe BA patients. METHODS Serum levels of IL-5, IL-6, IL-8, IL-13 and IL-17A (ELISA) were measured in 30 healthy controls (HC) and 80 adult BA patients. BA patients were split into 4 groups. Group 1:Low FeNO/Low b-Eos (n = 23; 28.8%); Group 2:Low FeNO/High b-Eos (n = 17; 21.3%); Group 3:High FeNO/Low b-Eos (n = 15; 18.8%); Group 4:High FeNO/High b-Eos (n = 25; 31.3%). RESULTS All interleukins and total IgE were significantly higher in patients with BA as compared with HC. IL-5 levels were highest in Group 2 (p < 0.05). IL-6, IL-13 and IL-17A levels were elevated in Groups 2, 3 and 4 as compared with HC (p < 0.05). Higher IL-8 levels were associated with a pattern of current smokers. Highest IL-17A levels were found in type 2 high groups with frequent exacerbations, mostly uncontrolled and severe BA. We have found a distinct pattern for each group based on demographic, clinical, functional, immunological and inflammatory characteristics. CONCLUSION FeNO and b-Eos are useful in the identification of severe type 2 BA subgroups with frequent exacerbations. IL-5, IL-6, IL-13 and IL-17A are involved in the persistent type 2 immune response in moderate and severe BA. We have identified a pattern of refractory, severe type 2/IL-17A high BA in the real clinical practice.
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Affiliation(s)
- Denitsa Dimitrova
- Medical Faculty of Medical University - Sofia, Department of Pulmonary Diseases, MHATPD St. Sofia, Bulgaria.
| | - Vania Youroukova
- Medical Faculty of Medical University - Sofia, Department of Pulmonary Diseases, MHATPD St. Sofia, Bulgaria.
| | - Ekaterina Ivanova-Todorova
- Medical Faculty of Medical University - Sofia, Department of Clinical Laboratory and Clinical Immunology, Laboratory of Clinical Immunology, University Hospital St. Ivan Rilski, Bulgaria.
| | - Kalina Tumangelova-Yuzeir
- Medical Faculty of Medical University - Sofia, Laboratory of Clinical Immunology, University Hospital St. Ivan Rilski, Bulgaria.
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Roach DJ, Ruangnapa K, Fleck RJ, Rattan MS, Zhang Y, Hossain MM, Guilbert TW, Woods JC. Structural lung abnormalities on computed tomography correlate with asthma inflammation in bronchoscopic alveolar lavage fluid. J Asthma 2019; 57:968-979. [PMID: 31187669 DOI: 10.1080/02770903.2019.1622714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Image scoring systems have been developed to assess the severity of specific lung abnormalities in patients diagnosed with various pulmonary diseases except for asthma. A comprehensive asthma imaging scoring system may identify specific abnormalities potentially linking these to inflammatory phenotypes.Methods: Computed tomography (CT) images of 88 children with asthma (50 M/38 F, mean age 7.8 ± 5.4 years) acquired within 12 months of bronchoscopic alveolar lavage fluid (BALF) sampling that assessed airway inflammation cell types were reviewed along with CT images of 49 controls (27 M/22 F, mean age 3.4 ± 2.2 years). Images were scored using a comprehensive scoring system to quantify bronchiectasis (BR), bronchial wall thickening (BWT), ground glass opacity, mucus plugging (MP), consolidations, linear densities (LD), and air trapping (AT). Each category was scored 0-2 in each of six lobar regions (with lingula separated from left upper lobe).Results: Absolute average overall scores of the controls and children with asthma were 0.72 ± 1.59 and 5.39 ± 5.83, respectively (P < 0.0001). Children with asthma scored significantly higher for BR (N = 20, 0.33 ± 0.80, P = 0.0002), BWT (N = 28, 0.72 ± 1.40, P < 0.0001), MP (N = 28, 0.37 ± 1.12, P = 0.0052), consolidation (N = 31, 0.67 ± 1.22, P < 0.0001), LD (N = 58, 1.12 ± 1.44, P < 0.0001), and AT (N = 52, 1.78 ± 2.31, P < 0.0001). There was a significant difference between the BR score of children with positive inflammatory response in BALF (N = 53) and those who were negative for airway inflammation cells (0.14 ± 0.36, P = 0.040).Conclusions: Significant lung structural abnormalities were readily identified on CT of children with asthma, with image differentiation of those with an inflammatory response on BALF. Chest imaging demonstrates potential as a noninvasive clinical tool for additional characterization of asthma phenotypes.
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Affiliation(s)
- David J Roach
- Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kanokpan Ruangnapa
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand
| | - Robert J Fleck
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Mantosh S Rattan
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Yin Zhang
- Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Md Monir Hossain
- Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Theresa W Guilbert
- Department of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Jason C Woods
- Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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Abstract
PURPOSE OF REVIEW This article reviews the progress in the search for the genetic determinants of severe asthma. RECENT FINDINGS Twin studies estimate that approximately 25% of the phenotypic variability in asthma severity is determined by genetic factors, with the remainder determined by nongenetic factors including environmental and psychosocial factors, behavioral traits, and comorbidities. Most genetic association studies of asthma severity performed to date are underpowered and not designed to clearly distinguish asthma severity variants from asthma susceptibility variants. However, the most recent genome-wide asthma severity association study, conducted in more than 57 000 individuals, demonstrated significant associations for 25 loci, including three not previously associated with asthma: GATA3, MUC5AC, and KIAA1109. Of these, the MUC5AC association was restricted to cohorts that included moderate-to-severe (but not mild) asthma. Additional insights from rare monogenic disorders that can present as severe asthma include recognition that loss-of-function variants in the filaggrin gene known to cause ichthyosis vulgaris are consistently associated with more severe asthma outcomes. Other notable loci of interest include RAD50-IL13 on chromosome 5q and the ORMDL3-GSDMB locus on chromosome 17q21. SUMMARY Severe asthma is a polygenic trait. Future research should explore the role of rare genetic variation and gene-by-environment interaction.
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229
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Fitzpatrick AM, Gillespie SE, Mauger DT, Phillips BR, Bleecker ER, Israel E, Meyers DA, Moore WC, Sorkness RL, Wenzel SE, Bacharier LB, Castro M, Denlinger LC, Erzurum SC, Fahy JV, Gaston BM, Jarjour NN, Larkin A, Levy BD, Ly NP, Ortega VE, Peters SP, Phipatanakul W, Ramratnam S, Teague WG. Racial disparities in asthma-related health care use in the National Heart, Lung, and Blood Institute's Severe Asthma Research Program. J Allergy Clin Immunol 2019; 143:2052-2061. [PMID: 30635198 PMCID: PMC6556425 DOI: 10.1016/j.jaci.2018.11.022] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 11/07/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite advances in asthma care, disparities persist. Black patients are disproportionally affected by asthma and also have poorer outcomes compared with white patients. OBJECTIVE We sought to determine associations between black and white patients and asthma-related health care use, accounting for complex relationships. METHODS This study was completed as part of the National Heart, Lung, and Blood Institute's Severe Asthma Research Program, a prospective observational cohort. Between November 2012 and February 2015, it enrolled 579 participants 6 years and older with 1 year of observation time and complete data. Inverse probability of treatment weighting was used to balance racial groups with respect to community and family socioeconomic variables and environmental exposure variables. The primary outcome was emergency department (ED) use for asthma. Secondary outcomes included inhaled corticosteroid use, outpatient physician's office visits for asthma, and asthma-related hospitalization. RESULTS Black patients had greater odds of ED use over 1 year (odds ratio, 2.19; 95% CI, 1.43-3.35) but also differed in the majority (>50%) of baseline variables measured. After statistical balancing of the racial groups, the difference between black and white patients with respect to ED use no longer reached the level of significance. Instead, in secondary analyses black patients were less likely to see an outpatient physician for asthma management (adjusted odds ratio, 0.57; 95% CI, 0.38-0.85). CONCLUSIONS The disparity in ED use was eliminated after consideration of multiple variables. Social and environmental policies and interventions tailored to black populations with a high burden of asthma are critical to reduction (or elimination) of these disparities.
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Affiliation(s)
| | | | - David T Mauger
- Pennsylvania State University, Department of Public Health Sciences, Hershey, Pa
| | - Brenda R Phillips
- Pennsylvania State University, Department of Public Health Sciences, Hershey, Pa
| | | | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Department of Medicine, Boston, Mass
| | | | - Wendy C Moore
- Wake Forest University, Department of Medicine, Winston-Salem, NC
| | | | - Sally E Wenzel
- University of Pittsburgh, Department of Medicine, Pittsburgh, Pa
| | | | - Mario Castro
- Washington University, Departments of Medicine and Pediatrics, St Louis, Mo
| | | | | | - John V Fahy
- University of California, San Francisco, Departments of Medicine and Pediatrics, Calif
| | - Benjamin M Gaston
- Case Western Reserve University, Department of Pediatrics, Cleveland, Ohio
| | | | - Allyson Larkin
- University of Pittsburgh, Department of Medicine, Pittsburgh, Pa
| | - Bruce D Levy
- Brigham and Women's Hospital, Harvard Medical School, Department of Medicine, Boston, Mass
| | - Ngoc P Ly
- University of California, San Francisco, Departments of Medicine and Pediatrics, Calif
| | - Victor E Ortega
- Wake Forest University, Department of Medicine, Winston-Salem, NC
| | - Stephen P Peters
- Wake Forest University, Department of Medicine, Winston-Salem, NC
| | - Wanda Phipatanakul
- Boston Children's Hospital, Harvard Medical School, Department of Pediatrics, Boston, Mass
| | - Sima Ramratnam
- University of Wisconsin, Department of Medicine, Madison
| | - W Gerald Teague
- University of Virginia, Department of Pediatrics, Charlottesville, Va
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Bardin PG, Rangaswamy J, Yo SW. Managing comorbid conditions in severe asthma. Med J Aust 2019; 209:S11-S17. [PMID: 30453867 DOI: 10.5694/mja18.00196] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 11/20/2018] [Indexed: 12/26/2022]
Abstract
Asthma care has increasingly focused on personalised management for severe asthma, and recognition of the role and importance of comorbid conditions has increased. Severe asthma can be crippling; associated comorbid conditions often play a key role in the significant disease morbidity and frequently contribute to a severe and difficult-to-treat asthma phenotype. Comorbid conditions can be broadly grouped as being either airway-related or airway-unrelated. Airway-related comorbid conditions with the greatest impact are allergic rhinitis, chronic rhinosinusitis, vocal cord dysfunction, lung fungal sensitisation and underlying structural lung disease. The most important airway-unrelated comorbid conditions are obesity, obstructive sleep apnoea, gastro-oesophageal reflux disease and anxiety and depression. A diagnostic and management algorithm for comorbid conditions in severe asthma is outlined. It concentrates initially on the group with common comorbid conditions that can be managed in primary care. If asthma remains troublesome, emphasis can shift to identifying uncommon and more complex factors. The algorithm allows for personalised diagnostic and management pathways to be implemented. Personalised diagnosis and management of comorbid conditions are essential to achieving effective and improved outcomes for patients with severe asthma.
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Affiliation(s)
- Philip G Bardin
- Monash Lung and Sleep, Monash Hospital and University, Melbourne, VIC
| | | | - Shaun W Yo
- Monash Lung and Sleep, Monash Hospital and University, Melbourne, VIC
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231
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Abstract
Severe asthma accounts for only a small proportion of the children with asthma but a disproportionately high amount of resource utilization and morbidity. It is a heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting confirmatory history and objective evidence of asthma and excluding possible masquerading diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled with appropriate management, from asthma that requires the highest level of therapy to maintain control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat asthma includes an assessment of medication delivery, the home environment, and, if possible, the school and other frequented locations, the psychosocial situation, and comorbid conditions. Once identified, aggressive management of issues related to poor adherence and drug delivery, remediation of environmental triggers, and treatment of comorbid conditions is necessary to characterize the degree of control that can be achieved with standard therapies. For the small proportion of patients whose disease remains poorly controlled with these interventions, the clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility for biologic therapies. Management of severe asthma refractory to traditional therapies involves considering the various biologic and other newly approved treatments as well as emerging therapies based on the individual patient characteristics.
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232
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Shah SP, Grunwell J, Shih J, Stephenson S, Fitzpatrick AM. Exploring the Utility of Noninvasive Type 2 Inflammatory Markers for Prediction of Severe Asthma Exacerbations in Children and Adolescents. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2624-2633.e2. [PMID: 31100552 DOI: 10.1016/j.jaip.2019.04.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Noninvasive markers of type 2 inflammation are needed to identify children and adolescents who might benefit from personalized biologic therapy. OBJECTIVE We hypothesized that blood eosinophil counts would predict 1 or more acute visits for asthma and that prediction could be improved with the addition of a second, noninvasive type 2 inflammatory biomarker. METHODS Children and adolescents 5 to 21 years (N = 589) with an asthma exacerbation necessitating systemic corticosteroid treatment in the previous year completed a characterization visit and telephone calls at 6 and 12 months. The primary outcome was an acute visit for asthma with receipt of systemic corticosteroids. Acute visits were verified by medical record review. Exploratory outcomes included time to first acute visit and hospitalization. RESULTS Acute visits occurred in 106 (35.5%) children and 72 (24.8%) adolescents. Elevated blood eosinophils were associated with increased odds and shorter time to first acute visit, but optimal cut-points differed by age (≥150 vs ≥300 cells/μL for children vs adolescents, respectively). The addition of a second marker of type 2 inflammation did not improve prediction in children, but increased the odds and hazard of an acute visit up to 16.2% and 11.9%, respectively, in adolescents. Similar trends were noted for hospitalizations. CONCLUSIONS Blood eosinophils and other noninvasive markers of type 2 inflammation may be useful in the clinical assessment of children and adolescents with asthma. However, features of type 2 inflammation vary by age. Whether children and adolescents also respond differently to management of type 2 inflammation is unclear and warrants further evaluation.
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Affiliation(s)
- Samar P Shah
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jocelyn Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer Shih
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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Dupilumab improves asthma outcomes irrespective of frequency of previous asthma exacerbation history. Ann Allergy Asthma Immunol 2019; 123:222-224.e1. [PMID: 31075309 DOI: 10.1016/j.anai.2019.04.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 11/21/2022]
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234
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Maniscalco M, Calabrese C, D'Amato M, Guida P, Molino A, Aliani M, De Tullio R, Foschino Barbaro M, Ricciardolo FLM, Carpagnano GE. Association between exhaled nitric oxide and nasal polyposis in severe asthma. Respir Med 2019; 152:20-24. [PMID: 31128605 DOI: 10.1016/j.rmed.2019.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/09/2019] [Accepted: 04/21/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although several contributions exist on the role of fractional exhaled NO (FeNO) in diagnosis and management of asthma, no studies have analysed the association between FeNO in patients with severe asthma and nasal polyposis. AIM We investigated the potential association between FeNO and the presence of nasal polyps in patients affected by severe asthma. METHODS Study population included 93 severe asthmatic adult patients consecutively enrolled from four Italian specialist clinic centres from 2015 to 2018. In these patients lung function, asthma control, FeNO, blood eosinophils and CT scan of paranasal sinuses were evaluated. RESULTS Nasal polyposis was observed in 28 patients (30%). Among univariate predictors (lower BMI, higher FeNO, eosinophil and neutrophil count), recursive partitioning analysis identified as best predictors of nasal polyposis high values of eosinophil count (≥6.5% or >420 cells/mm3) and FeNO (≥39 ppb). The 40 patients with low eosinophil count and FeNO had a significant lower occurrence of nasal polyposis than those with higher values (8% vs 58%; p < 0.001). The stratification algorithm had a good performance in discriminate patients with and without nasal polyposis (area under the receiver operating characteristic curve of 0.768). CONCLUSIONS Our results show that FeNO might improve to detect nasal polyposis in patients with severe asthma and a low level of blood eosinophils counts, identifying individuals with high susceptibility to this condition.
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Affiliation(s)
- Mauro Maniscalco
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA, IRCCS, Telese Terme, Benevento, Italy.
| | - Cecilia Calabrese
- Department of Respiratory Medicine, University Federico II, Naples, Italy
| | - Maria D'Amato
- Department of Respiratory Medicine, University Federico II, Naples, Italy
| | - Pietro Guida
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA, IRCCS, Telese Terme, Benevento, Italy
| | - Antonio Molino
- Department of Respiratory Medicine, University Federico II, Naples, Italy
| | - Maria Aliani
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA, IRCCS, Cassano Delle Murge, Bari, Italy
| | - Renato De Tullio
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA, IRCCS, Cassano Delle Murge, Bari, Italy
| | - Mariapia Foschino Barbaro
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, Italy
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235
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Lee E, Hong SJ. Phenotypes of allergic diseases in children and their application in clinical situations. KOREAN JOURNAL OF PEDIATRICS 2019; 62:325-333. [PMID: 31096745 PMCID: PMC6753312 DOI: 10.3345/kjp.2018.07395] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/18/2019] [Indexed: 12/25/2022]
Abstract
Allergic diseases, including allergic rhinitis, asthma, and atopic dermatitis, are common heterogeneous diseases that encompass diverse phenotypes and different pathogeneses. Phenotype studies of allergic diseases can facilitate the identification of risk factors and their underlying pathophysiology, resulting in the application of more effective treatment, selection of better treatment responses, and prediction of prognosis for each phenotype. In the early phase of phenotype studies in allergic diseases, artificial classifications were usually performed based on clinical features, such as triggering factors or the presence of atopy, which can result in the biased classification of phenotypes and limit the characterization of heterogeneous allergic diseases. Subsequent phenotype studies have suggested more diverse phenotypes for each allergic disease using relatively unbiased statistical methods, such as cluster analysis or latent class analysis. The classifications of phenotypes in allergic diseases may overlap or be unstable over time due to their complex interactions with genetic and encountered environmental factors during the illness, which may affect the disease course and pathophysiology. In this review, diverse phenotype classifications of allergic diseases, including atopic dermatitis, asthma, and wheezing in children, allergic rhinitis, and atopy, are described. The review also discusses the applications of the results obtained from phenotype studies performed in other countries to Korean children. Consideration of changes in the characteristics of each phenotype over time in an individual’s lifespan is needed in future studies.
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Affiliation(s)
- Eun Lee
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Soo-Jong Hong
- Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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236
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Licari A, Brambilla I, Sacchi L, Marseglia G, Ciprandi G. Periostin, type 2 biomarker, is not associated with asthma control grade in asthmatic allergic children. Respir Med 2019; 151:118-120. [PMID: 31047107 DOI: 10.1016/j.rmed.2019.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/07/2019] [Accepted: 04/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Allergic asthma is characterized by type 2 inflammation. Periostin has been proposed as type 2 biomarker. OBJECTIVE To test the hypothesis that serum periostin could be associated with the asthma control grade in a group of children with allergic asthma and recruited in clinical practice. PATIENTS AND METHODS 121 consecutive children (71 males, 50 females, mean age 11.6 ± 3.2 years) with allergic asthma were visited for the first time at a third-level paediatric clinic. Serum periostin was evaluated with gender, BMI and z score BMI, lung function, FeNO, ACT questionnaire, VAS of breathing perception, peripheral eosinophils, total serum IgE, oral corticosteroid (CS) use in the past year, control asthma grade and asthma severity (according to GINA document). RESULTS Serum periostin was not associated with the asthma control grade and did not correlate with blood eosinophils and FeNO. In addition, peripheral eosinophils, serum IgE, and FeNO were not associated with the asthma control grade. On the contrary, gender, FEV1, FEV1/FVC ratio, FEF25-75, ACT, VAS of breathing perception, oral corticosteroid use, and asthma severity grade were associated with the asthma control grade. CONCLUSIONS Serum periostin seems to be scarcely useful to assess the asthma control in children with allergic asthma in clinical practice. There is the need to identify reliable inflammation biomarkers able to correlate with the asthma control grade.
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Affiliation(s)
- Amelia Licari
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Ilaria Brambilla
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Lucia Sacchi
- Laboratory for Biomedical Informatics "Mario Stefanelli", Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Gianluigi Marseglia
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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237
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Carr TF, Zeki AA, Kraft M. Eosinophilic and Noneosinophilic Asthma. Am J Respir Crit Care Med 2019; 197:22-37. [PMID: 28910134 DOI: 10.1164/rccm.201611-2232pp] [Citation(s) in RCA: 216] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Tara F Carr
- 1 Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona; and
| | - Amir A Zeki
- 2 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, California
| | - Monica Kraft
- 1 Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona; and
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Pérez de Llano L, Martínez-Moragón E, Plaza Moral V, Trisan Alonso A, Sánchez CA, Callejas FJ, Vera E, Soto Campos JG, Martinez Rivera C, Alcázar Navarrete B, Urrutia Landa I, Garcia Rivero JL, Padilla Galo A, Alvarez Gutierrez F, Landete P, Ramos González J, Aracil CF, Carretero Gracia JÁ, Lluch I, Puente L, Andujar-Espinosa R, Cosío BG. Unmet therapeutic goals and potential treatable traits in a population of patients with severe uncontrolled asthma in Spain. ENEAS study. Respir Med 2019; 151:49-54. [PMID: 31047117 DOI: 10.1016/j.rmed.2019.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/05/2019] [Accepted: 03/15/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Luis Pérez de Llano
- Pneumology Service, Hospital Universitario Lucus Augusti, EOXI Lugo, Cervo e Monforte, Spain Grupo BIOCHUS, Instituto de Investigación Sanitaria Santiago de Compostela (IDIS), Spain
| | | | - Vicente Plaza Moral
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Department of Medicine, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Luis Puente
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Borja Garcia Cosío
- Hospital Universitario Son Espases-IdISBa-CIBERES, Palma de Mallorca, Islas Baleares, Spain
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239
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Tashiro H, Shore SA. Obesity and severe asthma. Allergol Int 2019; 68:135-142. [PMID: 30509734 PMCID: PMC6540088 DOI: 10.1016/j.alit.2018.10.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/26/2018] [Accepted: 10/30/2018] [Indexed: 12/11/2022] Open
Abstract
Obesity is an important global health issue for both children and adults. Obesity increases the prevalence and incidence of asthma and also increases the risk for severe asthma. Here we describe the features of severe asthma phenotypes for which obesity is a defining characteristic, including steroid resistance, airway inflammation, and co-morbidities. We also review current concepts regarding the mechanistic basis for the impact of obesity in severe asthma, including possible roles for vitamin D deficiency, systemic inflammation, and the microbiome. Finally, we describe data indicating a role for diet, weight loss, and exercise in the treatment of severe asthma with obesity. Better understanding of the mechanistic basis for the role of obesity in severe asthma could lead to new therapeutic options for this population.
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Affiliation(s)
- Hiroki Tashiro
- Department of Environmental Health, Harvard University T.H. Chan School of Public Health, Boston, MA, USA
| | - Stephanie A Shore
- Department of Environmental Health, Harvard University T.H. Chan School of Public Health, Boston, MA, USA.
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240
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Tikhonova IV, Grinevich AA, Kosyakova NI, Safronova VG. Delayed kinetics of phagocytosis related respiratory burst in blood is a distinctive feature of moderate exacerbation of bronchial asthma. Free Radic Biol Med 2019; 134:327-334. [PMID: 30685404 DOI: 10.1016/j.freeradbiomed.2019.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 01/10/2019] [Accepted: 01/20/2019] [Indexed: 01/15/2023]
Abstract
Atopic bronchial asthma based on allergy history and chronic inflammation is hazardous to patients due to the risk of exacerbation. The sign of severe exacerbation is considered an abundant number and high activity of granulocytes in respiratory system and blood. Relationships between the ability of cells in blood to produce reactive radicals and their metabolites and the severity of asthma remain largely unclear. Kinetics of respiratory burst evoked by microbe particles in blood samples of patients was studied to reveal the most significant predictors distinguishing states of moderate exacerbation and out of exacerbation. Asthmatic patients with exacerbation (n = 18) or out of exacerbation (n = 62) and healthy individuals (n = 43) were characterized on respiratory function, cell count in blood and kinetics of generation of reactive radicals and their metabolites during phagocytosis. Mean values of respiratory parameters forced expiratory volume in 1 s and peak expiratory flow rate in patients with exacerbation were significantly differed compared with same of patients out of exacerbation and healthy individuals. Mean values of cell count in blood did not significantly differed in patients with exacerbation and out of exacerbation. Receiver operating characteristic analysis showed that both cell count and respiratory indexes did not discriminate patients with exacerbation from out of exacerbation. A delayed response to opsonized zymosan was revealed in patients with exacerbation compared to other examinees: lengthened lag-time and Tmax, reduced production of reactive species. Tmax was the most statistically significant predictor to discriminate bronchial asthma exacerbation from bronchial asthma out of exacerbation (area under curve >90%, p < 10-5) and controls (area under curve >80%, p < 10-5). Thus kinetic parameters of the phagocyte response to opsonized zymosan in the whole blood are the best predictors of bronchial asthma exacerbation in comparison with respiratory parameters and blood cell count. This test can be used for immunological monitoring of bronchial asthma status to prevent exacerbation.
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Affiliation(s)
- Irina V Tikhonova
- Laboratory of Cellular Neurobiology, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, 142290, Russia
| | - Andrey A Grinevich
- Laboratory of Cellular Neurobiology, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, 142290, Russia; Laboratory of Cellular Engineering, Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, Pushchino, 142290, Russia
| | - Ninel I Kosyakova
- Department of Allergology and Immunology, Hospital of Pushchino Scientific Centre, Russian Academy of Sciences, Pushchino, 142290, Russia
| | - Valentina G Safronova
- Laboratory of Cellular Neurobiology, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, 142290, Russia; Department of Allergology and Immunology, Hospital of Pushchino Scientific Centre, Russian Academy of Sciences, Pushchino, 142290, Russia.
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241
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Haktanir Abul M, Phipatanakul W. Severe asthma in children: Evaluation and management. Allergol Int 2019; 68:150-157. [PMID: 30648539 DOI: 10.1016/j.alit.2018.11.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 12/17/2022] Open
Abstract
Severe asthma in children is associated with significant morbidity. Children with severe asthma are at increased risk for adverse outcomes including medication-related side effects, life-threatening exacerbations, and impaired quality of life. It is important to differentiate between severe therapy resistant asthma and difficult-to-treat asthma due to comorbidities. The most common problems that need to be excluded before a diagnosis of severe asthma can be made are poor medication adherence, poor medication technique or incorrect diagnosis of asthma. Difficult to treat asthma is a much more common reason for persistent symptoms and exacerbations and can be managed if comorbidities are clearly addressed. Children with persistent symptoms and exacerbations despite correct inhaler technique and good medical adherence to standard Step 4 asthma therapies according to the guidelines1,2, should be referred to an asthma specialist with expertise in severe asthma.
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Affiliation(s)
- Mehtap Haktanir Abul
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Wanda Phipatanakul
- Harvard Medical School, Boston, MA, USA; Division of Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA.
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242
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Louis R, Pilette C, Michel O, Michils A, Brusselle G, Poskin A, Van Schoor J, Denhaerynck K, Vancayzeele S, Abraham I, Gurdain S. Variability in total serum IgE over 1 year in severe asthmatics. Allergy Asthma Clin Immunol 2019; 15:20. [PMID: 30976287 PMCID: PMC6441212 DOI: 10.1186/s13223-019-0331-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 03/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background Immunoglobulin E (IgE) is the treatment target of omalizumab, a monoclonal antibody indicated in the treatment of severe allergic asthma. Long-term variability of serum total IgE (sIgEtot) in asthmatics remains poorly documented. Methods In this prospective study, sIgEtot levels were measured over 1 year at 7 time points in 41 severe asthmatics treated with high-dose of inhaled corticosteroids and long-acting β2 agonists. 33 patients were atopic based on at least one positive RAST to common aeroallergens. Patients were divided into three groups according to their baseline sIgEtot level: low (< 76 IU/mL; n = 10), intermediate (76-700 IU/mL; n = 20) or high (> 700 IU/mL; n = 11). Patients also completed the six-item Juniper Asthma Control Questionnaire (ACQ6). The sIgEtot variability and factors predictive for this variability were studied, as well as ACQ6 outcomes. Results The variation in sIgEtot level was mostly the consequence of between patient-variability, which represented 96%, 71% and 96% of the total variability in the low, intermediate and high sIgEtot subgroups, respectively. The residual within-patient variability was therefore limited. In 10/41 patients, sIgEtot levels increased or decreased, for at least one visit, beyond the predefined range of the subgroups to which they were assigned (< 76 IU/mL; 76-700 IU/mL; > 700 IU/mL). There was a significant but weak correlation between sIgEtot and ACQ6 score over all time points (r = 0.15, p = 0.02), but sIgEtot failed to associate with severe exacerbation. sIgEtot decreased by 3% with any additional year of age for the whole group (p = 0.01) and increased by 5% per one unit of allergen exposure score in atopic patients (p = 0.002). Conclusion In severe asthmatics, limited within-patient variability of sIgEtot levels was observed over 1 year as opposed to marked between-subject variability. sIgEtot decreases with age. Variation in sIgEtot weakly associates with asthma control but not with exacerbation.
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Affiliation(s)
- Renaud Louis
- 1Service de Pneumologie-Allergologie, CHU Sart Tilman B35, 4000 Liege, Belgium
| | - Charles Pilette
- 2Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Olivier Michel
- 3CHU Brugmann, Place A.Van Gehuchten 4, 1020 Brussels, Belgium
| | - Alain Michils
- 4CUB Hôpital Erasme, Route de Lennik 808, 1070 Brussels, Belgium
| | - Guy Brusselle
- 5UZ Gent, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | | | | | - Kris Denhaerynck
- Matrix45, LLC, 6159 West Sunset Road, Tucson, AZ 85743 USA.,8University of Basel, Basel, Switzerland
| | | | - Ivo Abraham
- Matrix45, LLC, 6159 West Sunset Road, Tucson, AZ 85743 USA
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Sciurba JC, Gieseck RL, Jiwrajka N, White SD, Karmele EP, Redes J, Vannella KM, Henderson NC, Wynn TA, Hart KM. Fibroblast-specific integrin-alpha V differentially regulates type 17 and type 2 driven inflammation and fibrosis. J Pathol 2019; 248:16-29. [PMID: 30536905 DOI: 10.1002/path.5215] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 11/08/2018] [Accepted: 12/03/2018] [Indexed: 01/04/2023]
Abstract
Fibroproliferative diseases affect a significant proportion of the world's population. Despite this, core mechanisms driving organ fibrosis of diverse etiologies remain ill defined. Recent studies suggest that integrin-alpha V serves as a master driver of fibrosis in multiple organs. Although diverse mechanisms contribute to the progression of fibrosis, TGF-β and IL-13 have emerged as central mediators of fibrosis during type 1/type 17, and type 2 polarized inflammatory responses, respectively. To investigate if integrin-alpha V interactions or signaling is critical to the development of type 2 fibrosis, we analyzed fibroblast-specific integrin-alpha V knockout mice in three type 2-driven inflammatory disease models. While we confirmed a role for integrin-alpha V in type 17-associated fibrosis, integrin-alpha V was not critical to the development of type 2-driven fibrosis. Additionally, our studies support a novel mechanism through which fibroblasts, via integrin-alpha V expression, are capable of regulating immune polarization. We show that when integrin-alpha V is deleted on fibroblasts, initiation of type 17 inflammation is inhibited leading to a deregulation of type 2 inflammation. This mechanism is most evident in a model of severe asthma, which is characterized by a mixed type 2/type 17 inflammatory response. Together, these findings suggest dual targeting of integrin-alpha V and type 2 pathways may be needed to ameliorate fibrosis and prevent rebound of opposing pro-fibrotic and inflammatory mechanisms. Copyright © 2018 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Joshua C Sciurba
- Immunopathogenesis Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Richard L Gieseck
- Immunopathogenesis Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Nikhil Jiwrajka
- Immunopathogenesis Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sandra D White
- Immunopathogenesis Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Erik P Karmele
- Immunopathogenesis Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jamie Redes
- MRC Centre for Inflammation Research, Centre for Multiple Sclerosis Research, BHF Centre for Cardiovascular Science, and Centre for Immunity Infection and Evolution, University of Edinburgh, Edinburgh, UK
| | - Kevin M Vannella
- Immunopathogenesis Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Neil C Henderson
- Molecular Signal Transduction Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Thomas A Wynn
- Immunopathogenesis Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Kevin M Hart
- Immunopathogenesis Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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A sputum 6-gene signature predicts future exacerbations of poorly controlled asthma. J Allergy Clin Immunol 2019; 144:51-60.e11. [PMID: 30682452 DOI: 10.1016/j.jaci.2018.12.1020] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 12/17/2018] [Accepted: 12/26/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Improved diagnostic tools for predicting future exacerbation frequency in asthmatic patients are required. A sputum gene expression signature of 6 biomarkers (6-gene signature [6GS], including Charcot-Leyden crystal galectin [CLC]; carboxypeptidase 3 [CPA3]; deoxyribonuclease 1-like 3 [DNASE1L3]; alkaline phosphatase, liver/bone/kidney [ALPL]; CXCR2; and IL1B) predicts inflammatory and treatment response phenotypes in patients with stable asthma. Recently, we demonstrated that azithromycin (AZM) add-on treatment in patients with uncontrolled moderate-to-severe asthma significantly reduced asthma exacerbations (AMAZES clinical trial). OBJECTIVES We sought to test whether the 6GS predicts future exacerbation and inflammatory phenotypes in a subpopulation of AMAZES and to test the effect of AZM therapy on 6GS expression and prognostic capacity. METHODS One hundred forty-two patients (73 placebo-treated and 69 AZM-treated patients) had sputum stored for quantitative PCR of 6GS markers at baseline and after 48 weeks of treatment. Logistic regression and receiver operating characteristic and area under the curve (AUC) determination were performed on baseline measures, and in an exploratory analysis the predictive value of the 6GS was compared with conventional biomarkers for exacerbation and inflammatory phenotypes. RESULTS The 6GS significantly predicted all future exacerbation phenotypes tested. Calculated AUCs for the 6GS were significantly greater than AUCs for peripheral blood eosinophil counts, sputum neutrophil counts, and combined sputum eosinophil and neutrophil counts. 6GS AUCs were also numerically but not significantly greater than those for fractional exhaled nitric oxide values and sputum eosinophil counts. AZM treatment altered neither 6GS expression nor the predictive capacity of the 6GS for future exacerbation phenotypes. The 6GS was a significant predictor of airway inflammatory phenotype in this population. CONCLUSION We demonstrate that a sputum gene signature can predict future exacerbation phenotypes of asthma, with the greatest biomarker performance in identifying those who would experience frequent severe exacerbations. AZM therapy did not modify 6GS expression or biomarker performance, suggesting the therapeutic action of AZM is independent of 6GS-related inflammatory pathways.
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Nishima S, Kozawa M, Milligan KL, Papadopoulos NG. Omalizumab and unmet needs in severe asthma and allergic comorbidities in Japanese children. Asia Pac Allergy 2019; 9:e7. [PMID: 30740355 PMCID: PMC6365659 DOI: 10.5415/apallergy.2019.9.e7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 01/17/2019] [Indexed: 01/20/2023] Open
Abstract
Childhood asthma is one condition within a family of allergic diseases, which includes allergic rhinitis, atopic dermatitis, and food allergy, among others. Omalizumab is an anti-IgE antibody therapy that was approved in Japan for children with asthma and added to the Japanese pediatric asthma guidelines in 2017. This review highlights the Japanese clinical perspectives in pediatric allergic asthma, and consideration for allergic comorbidities, and reflects on omalizumab clinical trials in progress to present comprehensive future opportunities.
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Affiliation(s)
- Sankei Nishima
- National Hospital Organization, Fukuoka National Hospital, Fukuoka, Japan
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Mahay G, Le Brun M, Taillé C. [Asthma exacerbations in adults: Preventing and treat]. Presse Med 2019; 48:303-309. [PMID: 30665786 DOI: 10.1016/j.lpm.2018.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/04/2018] [Indexed: 11/19/2022] Open
Abstract
Exacerbations of asthma are still responsible for 900 deaths per year in France, most of which are considered preventable. They have a major impact on the quality of life of patients and are responsible for a large part of the socio-economic cost of asthma in France. Exacerbations of asthma can be partly prevented by inhaled corticosteroid treatment as controller therapy, at a dose adapted to the level of control of symptoms and the management of aggravating factors. Every patient should benefit from a written action plan that allows them to start oral corticosteroid therapy as soon as possible during an exacerbation. The treatment combines short-acting bronchodilators with systemic corticosteroids. Systemic antibiotic therapy has no place in the treatment of exacerbations. The patient must be seen early in the course of an exacerbation of asthma to review all of his follow-up.
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Affiliation(s)
- Guillaume Mahay
- CHU de Rouen, hôpital Charles-Nicole, service de pneumologie, oncologie thoracique, soins intensifs respiratoires, 76031 Rouen, France
| | - Mathilde Le Brun
- CHU de Rouen, hôpital Charles-Nicole, service de pneumologie, oncologie thoracique, soins intensifs respiratoires, 76031 Rouen, France
| | - Camille Taillé
- Assistance publique-Hôpitaux de Paris, hôpital Bichat, centre de référence des maladies pulmonaires rares, service de pneumologie, département hospitalo-universitaire FIRE, 75877 Paris cedex 18, France; Université Paris Diderot, Inserm UMR 1152, 75018 Paris, France; LabEx Inflamex, 75018 Paris, France.
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247
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Greenblatt RE, Zhao EJ, Henrickson SE, Apter AJ, Hubbard RA, Himes BE. Factors associated with exacerbations among adults with asthma according to electronic health record data. Asthma Res Pract 2019; 5:1. [PMID: 30680222 PMCID: PMC6339400 DOI: 10.1186/s40733-019-0048-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/10/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Asthma is a chronic inflammatory lung disease that affects 18.7 million U.S. adults. Electronic health records (EHRs) are a unique source of information that can be leveraged to understand factors associated with asthma in real-life populations. In this study, we identify demographic factors and comorbidities associated with asthma exacerbations among adults according to EHR-derived data and compare these findings to those of epidemiological studies. METHODS We obtained University of Pennsylvania Hospital System EHR-derived data for asthma encounters occurring between 2011 and 2014. Regression analyses were performed to model asthma exacerbation frequency as explained by age, sex, race/ethnicity, health insurance type, smoking status, body mass index (BMI) and various comorbidities. We analyzed data from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2012 to compare findings with those from the EHR-derived data. RESULTS Based on data from 9068 adult patients with asthma, 33.37% had at least one exacerbation over the four-year study period. In a proportional odds logistic regression predicting number of exacerbations during the study period (levels: 0, 1-2, 3-4, 5+ exacerbations), after controlling for age, race/ethnicity, sex, health insurance type, and smoking status, the highest odds ratios (ORs) of significantly associated factors were: chronic bronchitis (2.70), sinusitis (1.50), emphysema (1.39), fluid and electrolyte disorders (1.35), class 3 obesity (1.32), and diabetes (1.28). An analysis of NHANES data showed associations for class 3 obesity, anemia and chronic bronchitis with exacerbation frequency in an adjusted model controlling for age, race/ethnicity, sex, financial class and smoking status. CONCLUSIONS EHR-derived data is helpful to understand exacerbations in real-life asthma patients, facilitating design of detailed studies and interventions tailored for specific populations.
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Affiliation(s)
- Rebecca E. Greenblatt
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Edward J. Zhao
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Sarah E. Henrickson
- Division of Allergy-Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104 USA
- Institute for Immunology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Andrea J. Apter
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Blanca E. Himes
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
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248
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Zeiger RS, Schatz M, Yang SJ, Chen W. Fractional Exhaled Nitric Oxide-Assisted Management of Uncontrolled Persistent Asthma: A Real-World Prospective Observational Study. Perm J 2019; 23:18-109. [PMID: 31050641 PMCID: PMC6499115 DOI: 10.7812/tpp/18-109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
CONTEXT The utility of fractional exhaled nitric oxide (FeNO) measurement in real-world asthma management requires investigation. OBJECTIVE To determine whether FeNO-assisted care added to standard asthma management improves asthma control in a managed care organization. DESIGN Prospective observational study in patients aged 12 years and older with uncontrolled persistent asthma identified during a scheduled visit to an Allergy Department that routinely used FeNO (FeNO-assisted care, n = 426) vs visits to 4 Allergy Departments that did not, but followed routine guideline-based care (standard care, n = 925). The FeNO-assisted care was based on FeNO level, asthma control status, and step-care level. MAIN OUTCOME MEASURES Composite primary outcome was 1 or more asthma exacerbations or 7 or more dispensed canisters containing short-acting β2-agonists in the follow-up year. Inverse probability of treatment weighting propensity scoring balanced covariates, and multivariable regression analyses compared outcomes between groups. RESULTS Compared with standard care, FeNO-assisted care was not associated with reducing the primary composite outcome (adjusted risk ratio = 0.94, 95% confidence interval = 0.69-1.29, p = 0.71), nor with a reduction in asthma exacerbations or dispensing of 7 or more short-acting β2-agonist canisters as separate outcomes. In an atopic subgroup with aeroallergen sensitization, the composite outcome was similar between groups, but the rate of asthma exacerbations was lower with FeNO-assisted treatment (adjusted rate ratio = 0.67, 95% confidence interval = 0.49-0.91, p = 0.01). CONCLUSION These findings suggest future studies of FeNO-assisted care should be directed at the atopic phenotype.
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Affiliation(s)
- Robert Stephen Zeiger
- Department of Allergy, Clairemont Mesa Medical Center, San Diego, CA
- Kaiser Permanente Southern California Research and Evaluation, Pasadena
| | - Michael Schatz
- Department of Allergy, Clairemont Mesa Medical Center, San Diego, CA
| | - Su-Jau Yang
- Kaiser Permanente Southern California Research and Evaluation, Pasadena
| | - Wansu Chen
- Kaiser Permanente Southern California Research and Evaluation, Pasadena
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Abstract
The recent Lancet commission has highlighted that "asthma" should be used to describe a clinical syndrome of wheeze, breathlessness, chest tightness, and sometimes cough. The next step is to deconstruct the airway into components of fixed and variable airflow obstruction, inflammation, infection and altered cough reflex, setting the airway disease in the context of extra-pulmonary co-morbidities and social and environmental factors. The emphasis is always on delineating treatable traits, including variable airflow obstruction caused by airway smooth muscle constriction (treated with short- and long-acting β-2 agonists), eosinophilic airway inflammation (treated with inhaled corticosteroids) and chronic bacterial infection (treated with antibiotics with benefit if it is driving the disease). It is also important not to over-treat the untreatable, such as fixed airflow obstruction. These can all be determined using simple, non-invasive tests such as spirometry before and after acute administration of a bronchodilator (reversible airflow obstruction); peripheral blood eosinophil count, induced sputum, exhaled nitric oxide (airway eosinophilia); and sputum or cough swab culture (bacterial infection). Additionally, the pathophysiology of risk domains must be considered: these are risk of an asthma attack, risk of poor airway growth, and in pre-school children, risk of progression to eosinophilic school age asthma. Phenotyping the airway will allow more precise diagnosis and targeted treatment, but it is important to move to endotypes, especially in the era of increasing numbers of biologicals. Advances in -omics technology allow delineation of pathways, which will be particularly important in TH2 low eosinophilic asthma, and also pauci-inflammatory disease. It is very important to appreciate the difficulties of cluster analysis; a patient may have eosinophilic airway disease because of a steroid resistant endotype, because of non-adherence to basic treatment, and a surge in environmental allergen burden. Sophisticated -omics approaches will be reviewed in this manuscript, but currently they are not being used in clinical practice. However, even while they are being evaluated, management of the asthmas can and should be improved by considering the pathophysiologies of the different airway diseases lumped under that umbrella term, using simple, non-invasive tests which are readily available, and treating accordingly.
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Affiliation(s)
- Andrew Bush
- Departments of Paediatrics and Paediatric Respiratory Medicine, Royal Brompton Harefield NHS Foundation Trust and Imperial College, London, United Kingdom
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Ross KR, Teague WG, Gaston BM. Life Cycle of Childhood Asthma: Prenatal, Infancy and Preschool, Childhood, and Adolescence. Clin Chest Med 2018; 40:125-147. [PMID: 30691707 DOI: 10.1016/j.ccm.2018.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Asthma is a heterogeneous developmental disorder influenced by complex interactions between genetic susceptibility and exposures. Wheezing in infancy and early childhood is highly prevalent, with a substantial minority of children progressing to established asthma by school age, most of whom are atopic. Adolescence is a time of remission of symptoms with persistent lung function deficits. The transition to asthma in adulthood is not well understood.
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Affiliation(s)
- Kristie R Ross
- Division of Pediatric Pulmonology, Allergy, Immunology and Sleep Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - W Gerald Teague
- Pediatric Asthma Center of Excellence, Department of Pediatrics, University of Virginia School of Medicine, 409 Lane Road, Building MR4, Room 2112, PO Box 801349, Charlottesville, VA 22908, USA
| | - Benjamin M Gaston
- Division of Pediatric Pulmonology, Allergy, Immunology and Sleep Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Children's Lung Foundation, 2109 Adelbert Road, BRB 827, Cleveland, OH 44106, USA
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