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Allergic Asthma in the Era of Personalized Medicine. J Pers Med 2022; 12:jpm12071162. [PMID: 35887659 PMCID: PMC9321181 DOI: 10.3390/jpm12071162] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 01/17/2023] Open
Abstract
Allergic asthma is the most common asthma phenotype and is characterized by IgE sensitization to airborne allergens and subsequent typical asthmatic symptoms after exposure. A form of type 2 (T2) airway inflammation underlies allergic asthma. It usually arises in childhood and is accompanied by multimorbidity presenting with the occurrence of other atopic diseases, such as atopic dermatitis and allergic rhinitis. Diagnosis of the allergic endotype is based on in vivo (skin prick tests) and/or in vitro (allergen-specific IgE levels, component-resolved diagnosis (CRD)) documentation of allergic sensitization. Biomarkers identifying patients with allergic asthma include total immunoglobulin E (IgE) levels, fractional exhaled nitric oxide (FeNO) and serum eosinophil counts. The treatment of allergic asthma is a complex procedure and requires a patient-tailored approach. Besides environmental control involving allergen avoidance measurements and cornerstone pharmacological interventions based on inhaled drugs, allergen-specific immunotherapy (AIT) and biologics are now at the forefront when it comes to personalized management of asthma. The current review aims to shed light on the distinct phenotype of allergic asthma, ranging over its current definition, clinical characteristics, pathophysiology and biomarkers, as well as its treatment options in the era of precision medicine.
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Abstract
PURPOSE OF REVIEW The interplay of asthma and coronavirus disease 2019 (COVID-19) in children is yet unknown. The purpose of this review is to determine the interplay of asthma and asthma therapeutics and COVID-19. RECENT FINDINGS There is no evidence to date that asthma is a risk factor for more severe COVID-19 outcomes, especially in children. There is actually some basis to suggest that children with atopic asthma may be at reduced risk of asthma exacerbations during COVID-19. The impact of asthma therapeutics on COVID-19 outcomes is unclear, but guidance is relatively uniform in recommending that those with asthma remain on current asthma medications. A focus on social determinants of health may be increasingly important during the pandemic and beyond. SUMMARY Asthma in children appears to be more friend, than foe, during COVID-19.
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Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
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Kim JH, Jin J, Park SY, Park SY, Kim HJ, Kim MH, Kwon HS, Song WJ, Kim SH, Park HW, Chang YS, Cho YS, Cho YJ, Cho SH, Moon HB, Kim TB. Discontinuation of inhaled corticosteroids in patients with controlled asthma: The DISCO (Discontinuation of Inhaled Steroid in Controlled asthmatics Over 6 months) study. Ann Allergy Asthma Immunol 2021; 127:123-130.e1. [PMID: 33819615 DOI: 10.1016/j.anai.2021.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/09/2021] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although inhaled corticosteroids (ICSs) are the recommended first-line therapy for asthma, determining whether to continue or discontinue ICS treatment in patients with mild asthma remains challenging for clinicians. Several studies have revealed that patients with mild-persistent asthma maintained a well-controlled state after ICS withdrawal. However, the long-term outcomes of ICS withdrawal have not yet been determined. OBJECTIVE To determine the possible clinical outcomes of the discontinuation of ICS in patients with well-controlled mild asthma. METHODS We investigated the clinical outcomes of discontinuing ICSs in patients with well-controlled mild asthma and compared the time to loss of control (LOC) between patients who stopped ICS treatment (ICS withdrawal group, IWG) and those who continued treatment for 3 years (continuous ICS group, CIG). RESULTS A significant difference in the time to LOC was observed between the IWG and CIG (hazard ratio, 2.56; 95% confidence interval, 1.52-4.33; P < .001). Increasing fractional exhaled nitric oxide levels (P = 0.008) and sputum eosinophil counts (%) (P = 0.015) revealed a weak but significant association with LOC risk in the CIG. The sputum eosinophil counts (P = 0.039) and serum total immunoglobulin E levels (P = 0.014) were significantly higher in the LOC group than in the non-LOC group of the CIG. CONCLUSION Our results suggest that the maintenance of ICS treatment may help keep patients' asthma under control. Furthermore, patients with LOC had significantly higher sputum eosinophil counts in the CIG than those in the non-LOC group. Therefore, continuous ICS use by patients with mild, well-controlled asthma could be associated with good clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: KCT0002234.
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Affiliation(s)
- Jung-Hyun Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Internal Medicine, Korean Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Juhae Jin
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - So-Young Park
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Internal Medicine, Division of Pulmonary, Allergy and Critical care medicine, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Hyo-Jung Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Min-Hye Kim
- Department of Internal Medicine, Ewha Women University School of Medicine, Seoul, Republic of Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Heung-Woo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Joo Cho
- Department of Internal Medicine, Ewha Women University School of Medicine, Seoul, Republic of Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Bom Moon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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van Boven FE, de Jong NW, Braunstahl GJ, Arends LR, Gerth van Wijk R. Effectiveness of the Air Purification Strategies for the Treatment of Allergic Asthma: A Meta-Analysis. Int Arch Allergy Immunol 2020; 181:395-402. [PMID: 32187604 DOI: 10.1159/000506284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/27/2020] [Indexed: 12/26/2022] Open
Abstract
We updated the meta-analysis published by McDonald et al. [Chest 2002;122;1535-1542] by reviewing the effectiveness of air purification for the treatment of home-related allergic asthma (dust mite, dog, cat, and cockroach). We analysed the trials included by McDonald et al. as well as studies published since 2000. Data on asthma symptoms scores (ASS), medication use, forced expiratory volume in 1 s as a percentage of the predicted value (FEV1 %pred), histamine provocative concentration causing a 20% reduction in FEV1 (PC20), Asthma Quality of Life Questionnaire (AQLQ) scores, and fractional exhaled nitric oxide (FeNO) levels were extracted. The effectiveness was examined using metafor (registered in Prospero CRD42019127227). Ten trials including a total of 482 patients (baseline characteristics: mean FEV1 %pred 83.2%, I2 = 96.7%; mean PC20 4.93 mg/mL, I2 = 44.0%; mean AQLQ 4.67 [max. 7], I2 = 93.7%; mean FeNO 36.5 ppb, I2 = 0%) were included. We assessed the mean differences in the AQLQ scores as +0.36 (95% CI 0.10 to 0.62, p = 0.01, n = 302, I2 = 0%) and the FeNO levels as -6.67 ppb (95% CI -10.56 to -2.77, p = 0.0008, n = 304, I2 = 0%). The standardised mean differences in all other health outcomes were not significant (ASS -0.68, p = 0.20; medication use: -0.01, p = 0.94; FEV1 %pred -0.11, p = 0.34; PC20 +0.24, p = 0.53). We found statistically significant mean differences in the AQLQ scores and FeNO levels in patients with predominantly mild to moderate asthma at baseline. A large trial reported great improvement in the subgroup of patients receiving Global Initiative for Asthma step 4 therapy. We recommend that future studies on air purification focus on patients with severe and poorly controlled allergic asthma.
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Affiliation(s)
- Frank E van Boven
- Department of Internal Medicine, Section of Allergology and Clinical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands,
| | - Nicolette W de Jong
- Department of Internal Medicine, Section of Allergology and Clinical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gert Jan Braunstahl
- Department of Pulmonology, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands.,Department of Pulmonology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia R Arends
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Roy Gerth van Wijk
- Department of Internal Medicine, Section of Allergology and Clinical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
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Akar-Ghibril N, Casale T, Custovic A, Phipatanakul W. Allergic Endotypes and Phenotypes of Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:429-440. [PMID: 32037107 PMCID: PMC7569362 DOI: 10.1016/j.jaip.2019.11.008] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/30/2019] [Accepted: 11/16/2019] [Indexed: 12/12/2022]
Abstract
Allergic asthma is defined as asthma associated with sensitization to aeroallergens, which leads to asthma symptoms and airway inflammation. Allergic asthma is the most common asthma phenotype. The onset of allergic asthma is most often in childhood and is usually accompanied by other comorbidities including atopic dermatitis and allergic rhinitis. It is often persistent although there is a wide variation in disease severity. It is a TH2-driven process. Biomarkers have been identified to distinguish patients with allergic asthma, particularly serum IgE levels, tests to indicate sensitization to aeroallergens such as specific IgE or skin prick test positivity, blood and sputum eosinophil levels, fraction of exhaled nitric oxide, and periostin. Treatments for allergic asthma include environmental control measures, allergen immunotherapy, and glucocorticoids. Biologics, targeting the TH2 pathway, have been shown to be effective in the treatment of allergic asthma.
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Affiliation(s)
- Nicole Akar-Ghibril
- Division of Pediatric Allergy/Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Thomas Casale
- Division of Allergy and Immunology, University of South Florida Health Morsani College of Medicine, Tampa, Fla
| | - Adnan Custovic
- Respiratory Division, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Wanda Phipatanakul
- Division of Pediatric Allergy/Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
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Kalayci O, Abdelateef H, Pozo Beltrán CF, El-Sayed ZA, Gómez RM, Hossny E, Morais-Almeida M, Nieto A, Phipatanakul W, Pitrez P, Wong GW, Xepapadaki P, Papadopoulos NG. Challenges and choices in the pharmacological treatment of non-severe pediatric asthma: A commentary for the practicing physician. World Allergy Organ J 2019; 12:100054. [PMID: 31641403 PMCID: PMC6796770 DOI: 10.1016/j.waojou.2019.100054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/23/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022] Open
Abstract
In recent years, asthma research has focused intensely on the severe part of the disease spectrum, leading to new treatments, mostly therapeutic monoclonal antibodies. However, severe asthma accounts for not more than 2% of asthma in the pediatric population. Therefore, non-severe asthma remains a major health problem in children, not only for patients and parents but also for healthcare professionals such as general practitioners, pediatricians and allergists who take care of these patients. It is thus essential to identify and put in context novel concepts, applicable to the treatment of these patients. Recent evidence suggests benefits from using anti-inflammatory treatment even for the mildest cases, for whom until now only symptomatic bronchodilation was recommended. Likewise, “reliever” medication may be better combined with an inhaled corticosteroid (ICS). Among “new” treatments (for children), ICS formulation in ultrafine particles has showed promise and tiotropium is gaining access to the pediatric population. Maintenance and reliever therapy (MART) is an option for moderate disease. Most importantly, personalized response to medications appears to be considerable, therefore, it may need to be taken into account. Overall, these new options provide opportunities for multiple new management strategies. The deployment of such strategies in different populations remains to be evaluated.
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Affiliation(s)
- Omer Kalayci
- Pediatric Allergy and Asthma, Hacettepe University, School of Medicine, Ankara, Turkey
- Corresponding author.
| | - Hanan Abdelateef
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Zeinab A. El-Sayed
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Elham Hossny
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Antonio Nieto
- Pediatric Pulmonology & Allergy Unit Children's Hospital la Fe, 46026, Valencia, Spain
| | - Wanda Phipatanakul
- Pediatric Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Paulo Pitrez
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Gary Wk. Wong
- Department of Paediatrics, The Chinese University of Hong Kong, China
| | | | - Nikolaos G. Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
- Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
- Corresponding author. Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
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van Boven FE, Arends LR, Braunstahl G, van Wijk RG. A reintroduction of environmental mite allergen control strategies for asthma treatment and the debate on their effectiveness. Clin Exp Allergy 2019; 49:400-409. [PMID: 30659677 PMCID: PMC6850033 DOI: 10.1111/cea.13340] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/21/2018] [Accepted: 01/09/2019] [Indexed: 12/19/2022]
Abstract
Asthma affects three hundred million people worldwide. The effectiveness of house dust mite allergen control for asthma treatment is debatable. One aspect that has been little discussed in existing meta-analyses is the possible role of environmental strategies. Here, we reintroduce the previously defined strategies for mite allergen control and discuss their importance to the debate on clinical effectiveness. The strategy of concurrent bedroom interventions is related to the combined use of a priori defined interventions, while the strategy of exposure-based control relates to the treatment of relevant textiles after assessing exposure. The air purification strategy aims to purify the human breathing zone of airborne allergens. In Western European patient practice, the use of these strategies differs. A post hoc study of the dominant Cochrane review by Gøtzsche and Johansen (Cochrane Database of Systematic Reviews, 2008, Art. No: CD001187) appears to indicate that a majority of the underlying trials reported on the strategy of concurrent bedroom interventions, which were mainly executed in a minimal manner. Some trials have reported on the air purification strategy and may potentially alter the debate on effectiveness. No trial has reported on the strategy of exposure-based control. We therefore hypothesize that the absence of evidence for the effectiveness of mite allergen control for asthma treatment applies to the strategy of concurrent bedroom interventions. The evidence-based effectiveness of the exposure-based control strategy appears to be undetermined. The results of our post hoc reanalysis urge that future meta-analyses of mite allergen control should a priori define the environmental strategy under study. Future trials of mite allergen control are warranted to test the exposure-based strategy as well as the sparsely tested strategy of air purification.
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Affiliation(s)
- Frank E. van Boven
- Department of Internal MedicineSection of AllergologyErasmus Medical CenterRotterdamThe Netherland
| | - Lidia R. Arends
- Department of BiostatisticsErasmus Medical CenterRotterdamThe Netherlands
- Department of Psychology, Education & Child StudiesErasmus University RotterdamRotterdamThe Netherlands
| | - Gert‐Jan Braunstahl
- Department of PulmonologySint Franciscus Vlietland GroepRotterdamThe Netherlands
- Department of PulmonologyErasmus Medical CenterRotterdamThe Netherlands
| | - Roy Gerth van Wijk
- Department of Internal MedicineSection of AllergologyErasmus Medical CenterRotterdamThe Netherland
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Lanz MJ, Gilbert I, Szefler SJ, Murphy KR. Can early intervention in pediatric asthma improve long-term outcomes? A question that needs an answer. Pediatr Pulmonol 2019; 54:348-357. [PMID: 30609252 PMCID: PMC6590791 DOI: 10.1002/ppul.24224] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although many children with asthma do not experience persistence into adulthood, recent studies have suggested that poorly controlled asthma in childhood may be associated with significant airflow obstruction in adulthood. However, data regarding disease progression are lacking, and clinicians are not yet able to predict the course of a child's asthma. The goal of this article was to assess the current understanding of childhood asthma treatment and progression and to highlight gaps in information that remain. DATA SOURCES Nonsystematic PubMed literature search and authors' expertise. STUDY SELECTION Articles were selected at the authors' discretion based on areas of interest in childhood asthma treatment and progression into adulthood. RESULTS Uncontrolled asthma in early childhood can potentially have lasting effects on lung development, but it is unclear whether traditional interventions in very young children preserve lung function. Although not all children respond to standard interventions, certain asthma phenotypes have been identified that can help to understand which children may respond to a particular treatment. CONCLUSION Clinicians should monitor children's asthma control and pulmonary function over time to assess the long-term impact of an intervention and to minimize the effect of uncontrolled asthma, especially exacerbations, on lung development. New biologic therapies have shown promise in treating adults with severe, uncontrolled asthma, and some of these therapies are approved in the United States for children as young as age 6. However, knowledge gaps regarding the efficacy and safety of these treatments in younger children hamper our understanding of their effect on long-term outcomes.
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Affiliation(s)
- Miguel J Lanz
- Allergy and Asthma, AAADRS Clinical Research Center, Coral Gables, Florida
| | | | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Al-Jahdali H, Wali S, Salem G, Al-Hameed F, Almotair A, Zeitouni M, Aref H, Nadama R, Algethami MM, Al Ghamdy A, Dihan T. Asthma control and predictive factors among adults in Saudi Arabia: Results from the Epidemiological Study on the Management of Asthma in Asthmatic Middle East Adult Population study. Ann Thorac Med 2019; 14:148-154. [PMID: 31007767 PMCID: PMC6467022 DOI: 10.4103/atm.atm_348_18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
CONTEXT: Asthma control is suboptimal in the Middle East and North Africa (MENA). AIMS: The aim of this study is to assess the level of asthma control in Saudi patients as per the Global Initiative for Asthma 2012 classification and explore its potential predictive factors. SETTINGS AND DESIGN: Epidemiological Study on the Management of Asthma in Asthmatic Middle East Adult Population (ESMAA) is a multicentric, descriptive, epidemiological study assessing asthma management in the MENA region. In this article, we report the results of patients from Saudi Arabia included in the ESMAA study. METHODS: Adult patients diagnosed with asthma at least 1 year before study entry were considered for inclusion. Asthma control level and its predictive factors were explored. Treatment adherence and quality of life (QoL) were assessed by MMAS-4© and Short Form 8 Health Survey QoL questionnaires, respectively. STATISTICAL ANALYSIS USED: Descriptive statistics were done considering two-sided 95% confidence intervals. Logistic regression was used to explore the potential predictive factors of asthma control. All statistical tests were two-sided, and P < 0.05 was considered statistically significant. RESULTS: Data of 1009 patients from Saudi Arabia were analyzed. Less than one-third of patients (30.1%) were found to have controlled asthma with significantly higher QoL. High level of asthma control was reported among male patients and those with high educational level, while age, body mass index, and adherence to treatment were found to have no effect on asthma control. CONCLUSIONS: Asthma control remains suboptimal among Saudi population. This needs huge efforts to achieve acceptable levels of control and better QoL for asthma patients. Further studies are still needed in Saudi Arabia and the Middle East region.
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Affiliation(s)
- Hamdan Al-Jahdali
- McGill University, Québec, Canada.,King Saud University for Health Sciences, Riyadh, KSA.,Division of Pulmonary, Sleep Disorders Center, King Abdulaziz Medical City, Riyadh, KSA
| | - Siraj Wali
- Department of Medicine, King Abdulaziz University Hospital, Jeddah, KSA
| | - Gamal Salem
- King Abdulaziz Airbase Hospital, Dharan, KSA.,Ain Shams University, Cairo, Egypt
| | - Fahad Al-Hameed
- Department of ICU and Pulmonary, College of Medicine, King Saud ben Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Jeddah, KSA
| | | | | | - Hassan Aref
- Pulmonary Division, Suliman Fakeeh Hospital, Jeddah, KSA.,Faculty of Medicine, Cairo University, Giza, Egypt
| | - Rufai Nadama
- Pulmonary Division, King Khalid University Hospital, Riyadh, KSA
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Abstract
Asthma still causes considerable morbidity and mortality globally and minimal improvement has been seen in key outcomes over the last decade despite increasing treatment costs. This review summarizes recent advances in the management of asthma in children and adolescents. It focuses on the need for personalized treatment plans based on heterogenous asthma pathophysiology, the use of the terminology 'asthma attack' over exacerbation to instill widespread understanding of severity, and the need for every attack to trigger a structured review and focused strategy. The authors discuss difficulties in diagnosing asthma, accuracy and use of Fractional exhaled nitric oxide both as second line test and as a method to monitor treatment adherence or guide the choice of pharmacotherapy. The authors discuss acute and long-term management of asthma. Asthma treatment goals are to minimize symptom burden, prevent attacks and (where possible) reduce risk and impact of progressive pathophysiology and adverse outcomes. The authors discuss pharmacological management; optimal use of short acting β2 agonists, long acting muscarinic antagonist (tiotropium), use of which is relatively new in pediatrics, allergen specific immunotherapy, biological monoclonal antibody treatment, azalide antibiotic azithromycin, and the use of vitamin D. They also discuss electronic monitoring and adherence devices, direct observation of therapy via mobile device, temperature controlled laminar airflow device, and the importance of considering when symptoms may actually result from dysfunctional breathing rather than asthma.
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Affiliation(s)
- Atul Gupta
- Department of Pediatric Respiratory Medicine, NHS Foundation Trust, King's College Hospital, Denmark Hill, London, UK.
- King's College London, London, UK.
| | | | - Paolo Pianosi
- Department of Pediatric Respiratory Medicine, NHS Foundation Trust, King's College Hospital, Denmark Hill, London, UK
- King's College London, London, UK
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Abstract
PURPOSE OF REVIEW Despite currently available treatments, many asthma patients remain inadequately controlled, but identifying distinct patient populations (phenotypes/endotypes) may optimize their management. This review discusses some of the controversies and opportunities for improved disease control in severe asthma. RECENT FINDINGS Currently approved anti-immunoglobulin E and anti-interleukin 5 biologics, which target specific pathways instead of using a 'one size fits all' strategy, are efficacious and well tolerated therapies for severe asthma. The appropriate use of these biologics, and of those in development (e.g., benralizumab and dupilumab), should be aided by further understanding of asthma phenotypes and endotypes, utilizing appropriate biomarkers.Oral corticosteroids are often added as maintenance therapy for patients with severe uncontrolled asthma, but their use is associated with significant adverse effects and should be considered a last option. The true cost of this therapy, including the cost of morbidities associated with its use, remains to be determined.Severe asthma in pediatrics poses a unique opportunity for possible prevention strategies and the potential for primary prevention. Although several avenues for primary prevention are being explored and are out of the scope of this review, we focus our discussion on the use of omalizumab, which has been recently explored in clinical trials. SUMMARY Appropriate use of biologics in severe asthma should be supported by further understanding of biomarkers predicting response to targeted therapy. Because of their association with significant adverse effects, add-on oral corticosteroids should be considered a last treatment option for patients with uncontrolled severe asthma. Finally, severe asthma in pediatrics poses a unique opportunity for potential prevention strategies.
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12
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Carr TF, Kraft M. Management of Severe Asthma before Referral to the Severe Asthma Specialist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:877-886. [PMID: 28689838 PMCID: PMC5526085 DOI: 10.1016/j.jaip.2017.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 12/26/2022]
Abstract
Severe asthma is associated with significant morbidity and can be challenging to assess and control, due to heterogeneity of disease, complexity of diagnosis, and impact of comorbidities. A structured approach to the assessment and management of severe asthma may be helpful to the practicing clinician. First, it is important to confirm a diagnosis of asthma. In patients who are either not responding to treatment, or who require high doses of medication to control symptoms, it is highly possible that disease mimickers or comorbidities are present and can inhibit therapeutic responsiveness. The assessment and management of common comorbidities of asthma may dramatically impact disease control and thus medication requirement. Determining medication adherence and optimizing drug dose and delivery may separate out truly severe asthmatics from those not using medications regularly or properly. Next, although true personalized medicine for severe asthma is not yet realized, for those individuals with severe asthma, phenotypic characteristics of each patient may guide which therapeutic options may be most effective for that patient. Finally, evaluation and management of severe asthma at a referral center can add additional phenotyping, therapeutic, and diagnostic strategies.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz.
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
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13
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Kepil Özdemir S, Bavbek S. Prospects for new and emerging therapeutics in severe asthma: the role of biologics. Expert Rev Respir Med 2017; 11:505-512. [PMID: 28464704 DOI: 10.1080/17476348.2017.1326821] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Asthma is a common and heterogeneous disease. While current conventional therapies are effective in the majority of the patients, a significant subgroup remain uncontrolled despite these treatments. Different biological agents are currently approved or undergoing development for treatment of asthma, including anti-IgE, anti-interleukin (IL)-5, anti-IL-13, anti-IL-4 and anti-thymic stromal lymphopoietin agents. This review will focus on the currently available evidence regarding the new and emerging biological agents in severe asthma. Areas covered: A non-systematic review of the available English-language literature regarding severe asthma and biological agents was performed. We summarized and discussed the current evidence about the use of new and emerging biological agents in severe asthma. Expert commentary: Because of the heterogeneity of response to therapy in refractory asthma it is of utmost importance to correctly estimate patient outcomes before starting biological therapy to make patient selection more effective. Currently, the decision of which biologic to initiate in patients with uncontrolled severe asthma should be made based on the atopic status, blood eosinophil and total IgE levels, exacerbation history, safety profile, cost, frequency and route of administration.
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Affiliation(s)
- Seçil Kepil Özdemir
- a Department of Chest Diseases, Division of Allergy and Immunology , İzmir Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital , İzmir , Turkey
| | - Sevim Bavbek
- b Division of Immunology and Allergy, Department of Chest Diseases , Ankara University School of Medicine , Ankara , Turkey
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