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Erceg D, Jakirović M, Prgomet L, Madunić M, Turkalj M. Conducting Drug Treatment Trials in Children: Opportunities and Challenges. Pharmaceut Med 2024; 38:179-204. [PMID: 38730200 DOI: 10.1007/s40290-024-00523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 05/12/2024]
Abstract
Children were often referred to as "therapeutic orphans" in the past due to different reasons such as ethical, regulatory, economic, scientific, etc., ones. They were exposed to avoidable risks while missing out on therapeutic advances. Pediatric patients have suffered from a lack of scientific and regulatory standards (e.g., proper drug testing, authorization of medicines for their use, etc.), although the pharmaceutical legislative framework, which ensures the high standards of safety, quality, and efficacy of medicinal products for use in adults, was developed primarily in response to past "drug disasters," mainly involving children. The adoption of pediatric regulatory initiatives first in the USA and then in Europe and other countries and regions has significantly changed the worldwide frameworks and permanently changed pediatric drug research and development. This article tries to give various perspectives with historical context, a review of the different challenges and opportunities as well as important stakeholders in pediatric drug development. The pediatric trial networks are probably the most important stakeholder that enables efficient patient recruitment, access to better resource utilization, and global collaboration of different stakeholders necessary for performing quality and well-designed clinical trials.
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Affiliation(s)
- Damir Erceg
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia.
- School of Medicine, Catholic University of Croatia, 10000, Zagreb, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, "Josip Juraj Strossmayer", 31000, Osijek, Croatia.
- Medical School, University of Osijek "Josip Juraj Strossmayer", 31000, Osijek, Croatia.
| | - Marina Jakirović
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia
| | - Luka Prgomet
- Institute of Emergency Medicine of Zagreb County, 10410, Velika Gorica, Croatia
| | - Marina Madunić
- Emergency Department, General Hospital Zabok, 49210, Zabok, Croatia
| | - Mirjana Turkalj
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, 10000, Zagreb, Croatia
- Medical School, University of Osijek "Josip Juraj Strossmayer", 31000, Osijek, Croatia
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Wu D, Zhang X, Zimmerly KM, Wang R, Wang C, Hunter R, Wu X, Campen M, Liu M, Yang XO. Unfolded protein response factor ATF6 augments T helper cell responses and promotes mixed granulocytic airway inflammation. Mucosal Immunol 2023; 16:499-512. [PMID: 37209959 PMCID: PMC10530451 DOI: 10.1016/j.mucimm.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
The unfolded protein response (UPR) is associated with the risk of asthma, including treatment-refractory severe asthma. Recent studies demonstrated a pathogenic role of activating transcription factor 6a (ATF6a or ATF6), an essential UPR sensor, in airway structural cells. However, its role in T helper (TH) cells has not been well examined. In this study, we found that ATF6 was selectively induced by signal transducer and activator of transcription6 (STAT6) and STAT3 in TH2 and TH17 cells, respectively. ATF6 upregulated UPR genes and promoted the differentiation and cytokine secretion of TH2 and TH17 cells. T cell-specific Atf6-deficiency impaired TH2 and TH17 responses in vitro and in vivo and attenuated mixed granulocytic experimental asthma. ATF6 inhibitor Ceapin A7 suppressed the expression of ATF6 downstream genes and TH cell cytokines by both murine and human memory clusters of differentiation 4 (CD4)+ T cells. At the chronic stage of asthma, administration of Ceapin A7 lessened TH2 and TH17 responses, leading to alleviation of both airway neutrophilia and eosinophilia. Thus, our results demonstrate a critical role of ATF6 in TH2 and TH17 cell-driven mixed granulocytic airway disease, suggesting a novel option to combat steroid-resistant mixed and even T2-low endotypes of asthma by targeting ATF6.
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Affiliation(s)
- Dandan Wu
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Xing Zhang
- Department of Biochemistry and Molecular Biology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Kourtney M Zimmerly
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Ruoning Wang
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Chunqing Wang
- Department of Biochemistry and Molecular Biology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Russell Hunter
- Department of Pharmaceutical Sciences, University of New Mexico College of Pharmacy, Albuquerque, USA
| | - Xiang Wu
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, USA; Department of Parasitology, School of Basic Medical Sciences, Xiangya School of Medicine, Central South University, Changsha, China
| | - Matthew Campen
- Department of Pharmaceutical Sciences, University of New Mexico College of Pharmacy, Albuquerque, USA
| | - Meilian Liu
- Department of Biochemistry and Molecular Biology, University of New Mexico School of Medicine, Albuquerque, USA.
| | - Xuexian O Yang
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, USA.
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Wu D, Zhang X, Zimmerly KM, Wang R, Livingston A, Iwawaki T, Kumar A, Wu X, Mandell MA, Liu M, Yang XO. Unconventional Activation of IRE1 Enhances TH17 Responses and Promotes Neutrophilic Airway Inflammation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.30.547286. [PMID: 37461622 PMCID: PMC10349957 DOI: 10.1101/2023.06.30.547286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
Treatment-refractory severe asthma manifests a neutrophilic phenotype associated with TH17 responses. Heightened unfolded protein responses (UPRs) are associated with the risk of asthma, including severe asthma. However, how UPRs participate in the deregulation of TH17 cells leading to this type of asthma remains elusive. In this study, we investigated the role of the UPR sensor IRE1 in TH17 cell function and neutrophilic airway inflammation. We found that IRE1 is induced in fungal asthma and is highly expressed in TH17 cells relative to naïve CD4+ T cells. Cytokine (e.g. IL-23) signals induce the IRE1-XBP1s axis in a JAK2-dependent manner. This noncanonical activation of the IRE1-XBP1s pathway promotes UPRs and cytokine secretion by TH17 cells. Ern1 (encoding IRE1)-deficiency decreases the expression of ER stress factors and impairs the differentiation and cytokine secretion of TH17 cells. Genetic ablation of Ern1 leads to alleviated TH17 responses and airway neutrophilia in a Candida albicans asthma model. Consistently, IL-23 activates the JAK2-IRE1-XBP1s pathway in vivo and enhances TH17 responses and neutrophilic infiltration into the airway. Taken together, our data indicate that IRE1, noncanonically activated by cytokine signals, promotes neutrophilic airway inflammation through the UPRmediated secretory function of TH17 cells. The findings provide a novel insight into the fundamental understanding of IRE1 in TH17-biased TH2-low asthma.
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Affiliation(s)
- Dandan Wu
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Xing Zhang
- Department of Biochemistry and Molecular Biology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Kourtney M. Zimmerly
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Ruoning Wang
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Amanda Livingston
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Takao Iwawaki
- Division of Cell Medicine, Medical Research Institute, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Ashok Kumar
- Department of Pharmacological and Pharmaceutical Sciences, University of Houston College of Pharmacy, Houston, TX 77204, USA
| | - Xiang Wu
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
- Department of Parasitology, School of Basic Medical Sciences, Xiangya School of Medicine, Central South University, Changsha, China
| | - Michael A. Mandell
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Meilian Liu
- Department of Biochemistry and Molecular Biology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Xuexian O. Yang
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
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Louis R, Harrison TW, Chanez P, Menzella F, Philteos G, Cosio BG, Lugogo NL, de Luiz G, Burden A, Adlington T, Keeling N, Kwiatek J, Garcia Gil E. Severe Asthma Standard-of-Care Background Medication Reduction With Benralizumab: ANDHI in Practice Substudy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1759-1770.e7. [PMID: 36948488 DOI: 10.1016/j.jaip.2023.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 02/22/2023] [Accepted: 03/05/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND The phase IIIb, randomized, parallel-group, placebo-controlled ANDHI double-blind (DB) study extended understanding of the efficacy of benralizumab for patients with severe eosinophilic asthma. Patients from ANDHI DB could join the 56-week ANDHI in Practice (IP) single-arm, open-label extension substudy. OBJECTIVE Assess potential for standard-of-care background medication reductions while maintaining asthma control with benralizumab. METHODS Following ANDHI DB completion, eligible adults were enrolled in ANDHI IP. After an 8-week run-in with benralizumab, there were 5 visits to potentially reduce background asthma medications for patients achieving and maintaining protocol-defined asthma control with benralizumab. Main outcome measures for non-oral corticosteroid (OCS)-dependent patients were the proportions with at least 1 background medication reduction (ie, lower inhaled corticosteroid dose, background medication discontinuation) and the number of adapted Global Initiative for Asthma (GINA) step reductions at end of treatment (EOT). Main outcomes for OCS-dependent patients were reductions in daily OCS dosage and proportion achieving OCS dosage of 5 mg or lower at EOT. RESULTS For non-OCS-dependent patients, 53.3% (n = 208 of 390) achieved at least 1 background medication reduction, increasing to 72.6% (n = 130 of 179) for patients who maintained protocol-defined asthma control at EOT. A total of 41.9% (n = 163 of 389) achieved at least 1 adapted GINA step reduction, increasing to 61.8% (n = 110 of 178) for patients with protocol-defined EOT asthma control. At ANDHI IP baseline, OCS dosages were 5 mg or lower for 40.4% (n = 40 of 99) of OCS-dependent patients. Of OCS-dependent patients, 50.5% (n = 50 of 99) eliminated OCS and 74.7% (n = 74 of 99) achieved dosages of 5 mg or lower at EOT. CONCLUSIONS These findings demonstrate benralizumab's ability to improve asthma control, thereby allowing background medication reduction.
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Affiliation(s)
- Renaud Louis
- Department of Pneumology CHU Liége, GIGAI3, University of Liége, Liége, Belgium
| | - Tim W Harrison
- Respiratory Research Unit, Nottingham Respiratory NIHR BRC, University of Nottingham, Nottingham, UK; Global Medical Affairs, AstraZeneca, Cambridge, UK.
| | - Pascal Chanez
- Department of Respiratory CIC Nord INSERMINRAE C2VN, Aix Marseille University, Marseille, France
| | - Francesco Menzella
- Pulmonology Unit, S. Valentino Hospital, Local Health Authority, Montebelluna, Italy
| | - George Philteos
- Royal University Hospital, University of Saskatchewan, Saskatoon, Sask, Canada
| | - Borja G Cosio
- Hospital Son Espases-IdISBa and Ciberes, Palma de Mallorca, Spain
| | | | - Gustavo de Luiz
- Clinical Research and Respiratory Medicine Department, Vithas Xanit International Hospital, Benalmadena, Málaga, Spain
| | - Annie Burden
- Biometrics, Late-stage Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Timothy Adlington
- Biometrics, Late-stage Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Nanna Keeling
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Justin Kwiatek
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, Del
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Mohamed AZELA, Shaaban LH, Gad SF, Azeem EA, Gamal Elddin W. Acute severe asthma in emergency department: clinical characteristics, risk factors, and predictors for poor outcome. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2022. [DOI: 10.1186/s43168-022-00160-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Severe asthma exacerbation can be a frightening experience to the patient and physician. Despite continuous efforts to frame management guidelines and advances in treatment, severe exacerbations still occur. In order to prevent and judicious management of asthma exacerbations, we should predict them first. This study aims to evaluate distinct clinical trajectories and management outcome of patients with severe asthma exacerbations and also evaluate predictors for poor outcome.
Methods
Patients suffering from acute asthma exacerbation and presented to emergency room (forty patients) were grouped into 2 groups (groups A and B) according to severity of exacerbation. Assessment included full clinical history, laboratory investigations (including eosinophil cell count and serum IgE level), Beck’s anxiety and depression inventory scales, assessment of asthma medication adherence and control level, and peak expiratory flow measurement (at presentation, 1 and 6 h after).
Results
Fifty-five percent of patients suffered from severe and life-threatening asthma exacerbations, 63.6% of them were females. The most important predictors for severe exacerbations were SO2 < 90% at baseline (OR = 4.56; 95% CI = 3.45–7.56; P < 0.001), PEFR after 1 h (OR= 3.34; 95%CI = 1.90–4.90; P < 0.001), and uncontrolled asthma (OR= 3.33; 95%CI = 2.50–5.05; P < 0.001). Predictors for hospitalization were old age (OR = 1.11; 95%CI = 1.09–2.11; P < 0.001), uncontrolled asthma (OR = 2.34; 95%CI = 2.01–4.40; P < 0.001), PEFR after 1 h (OR= 4.44; 95%CI= 3.24–7.68; P < 0.001), and SO2 <90% at baseline (OR= 5.67; 95%CI= 3.98–8.50; P < 0.001).
Conclusions
Severe asthma exacerbations can be predicted by old age, previous history of mechanical ventilation, obstructive sleep apnea, overuse of SABA, uncontrolled asthma, moderate to severe depression, eosinophilia, SO2 <90%, and low peak expiratory flow rates.
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Kim J, Im YN, Chung Y, Youm J, Im SY, Han MK, Lee HK. Glutamine deficiency shifts the asthmatic state toward neutrophilic airway inflammation. Allergy 2022; 77:1180-1191. [PMID: 34601745 PMCID: PMC9293426 DOI: 10.1111/all.15121] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/27/2021] [Indexed: 12/04/2022]
Abstract
Background The administration of L‐glutamine (Gln) suppresses allergic airway inflammation via the rapid upregulation of MAPK phosphatase (MKP)‐1, which functions as a negative regulator of inflammation by deactivating p38 and JNK mitogen‐activated protein kinases (MAPKs). However, the role of endogenous Gln remains to be elucidated. Therefore, we investigated the mechanism by which endogenous Gln regulates MKP‐1 induction and allergic airway inflammation in an ovalbumin‐based murine asthma model. Methods We depleted endogenous Gln levels using L‐γ‐glutamyl‐p‐nitroanilide (GPNA), an inhibitor of the Gln transporter ASCT2 and glutamine synthetase small interfering siRNA. Lentivirus expressing MKP‐1 was injected to achieve overexpression of MKP‐1. Asthmatic phenotypes were assessed using our previously developed ovalbumin‐based murine model, which is suitable for examining sequential asthmatic events, including neutrophil infiltration. Gln levels were analyzed using a Gln assay kit. Results GPNA or glutamine synthetase siRNA successfully depleted endogenous Gln levels. Importantly, homeostatic MKP‐1 induction did not occur at all, which resulted in prolonged p38 MAPK and cytosolic phospholipase A2 (cPLA2) phosphorylation in Gln‐deficient mice. Gln deficiency augmented all examined asthmatic reactions, but it exhibited a strong bias toward increasing the neutrophil count, which was not observed in MKP‐1‐overexpressing lungs. This neutrophilia was inhibited by a cPLA2 inhibitor and a leukotriene B4 inhibitor but not by dexamethasone. Conclusion Gln deficiency leads to the impairment of MKP‐1 induction and activation of p38 MAPK and cPLA2, resulting in the augmentation of neutrophilic, more so than eosinophilic, airway inflammation.
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Affiliation(s)
- June‐Mo Kim
- Department of Immunology and Institute for Medical Science Jeonbuk National University Medical School Jeonju South Korea
| | - Yoo Na Im
- Department of Immunology and Institute for Medical Science Jeonbuk National University Medical School Jeonju South Korea
| | - Yun‐Jo Chung
- Center for University‐wide Research Facilities Jeonbuk National University Medical School Jeonju South Korea
| | - Jung‐ho Youm
- Department of Preventive Medicine Jeonbuk National University Medical School Jeonju South Korea
| | - Suhn Young Im
- Department of Biological Sciences College of Natural Sciences Chonnam National University Gwangju South Korea
| | - Myung Kwan Han
- Department of Microbiology and Institute for Medical Science Jeonbuk National University Medical School Jeonju South Korea
| | - Hern Ku Lee
- Department of Immunology and Institute for Medical Science Jeonbuk National University Medical School Jeonju South Korea
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Effective Management of Severe Asthma with Biologic Medications in Adult Patients: A Literature Review and International Expert Opinion. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:422-432. [PMID: 34763123 DOI: 10.1016/j.jaip.2021.10.059] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 12/11/2022]
Abstract
Severe asthma often remains uncontrolled despite effective treatments and evidence-based guidelines. A group of global experts in asthma and biologic medications from 9 countries considered the most relevant clinical variables to manage severe asthma in adult patients and guide treatment choice. The resulting recommendations address the investigation of biomarker levels (blood eosinophil count along with fractional concentration of exhaled nitric oxide [FeNO]), clinical features (oral corticosteroid [OCS] dependence, specific comorbid disease entities associated with severe type 2 asthma), and safety considerations. Current evidence suggests that biomarkers, including both blood or sputum eosinophil counts as well as FeNO, add prognostic and predictive value and should be measured in all patients with severe asthma. OCS use is an important factor in biologic selection, especially given the documented ability of some biologics to reduce OCS dependence. Comorbid diseases and relevant safety considerations to each biologic should also be considered. More data are needed to determine whether biomarker profiles identify patients suited to one biologic versus another as limited data support differential predictors of response. Further prospective head-to-head trials and post hoc analyses of clinical trial data are warranted. The authors believe that these recommendations have value as they offer expert opinion to assist health care providers in making difficult decisions regarding the quality of care in severe, type 2 asthma with biologic medications. They remain conditional and are based on limited data owing to a lack of head-to-head comparisons.
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Raff LA, Schneider AB, Charles AG, Gallaher JR. Treatment of Acute Severe Asthma Exacerbation with Extracorporeal Membrane Oxygenation and Inhaled Volatile Anesthetic. Am Surg 2021:31348211047489. [PMID: 34645290 DOI: 10.1177/00031348211047489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Severe asthma affects approximately 1-2% of all asthmatic patients. Acute exacerbations are associated with high mortality in this population. There are many treatment options for asthma exacerbation; however, if these treatments fail, patients can develop progressive hypoxia, hypercarbia, respiratory acidosis, and hemodynamic instability. Extracorporeal membrane oxygenation (ECMO) and inhaled anesthetic both have a role in the management of acute severe refractory asthma exacerbation, though there is limited information about the use of both together. We present the case of a patient with severe asthma who suffered a refractory asthma exacerbation and was successfully managed with veno-venous ECMO and inhaled anesthetic. ECMO and inhaled volatile anesthetic both have a role in the management of severe refractory asthma exacerbations. It is safe and beneficial to use these therapies together and more benefit is noted if initiated early in the course of the patient's illness.
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Affiliation(s)
- Lauren A Raff
- Division of Acute Care and Trauma Surgery, Department of General Surgery, 6797University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Andrew B Schneider
- Division of Acute Care and Trauma Surgery, Department of General Surgery, 6797University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Anthony G Charles
- Division of Acute Care and Trauma Surgery, Department of General Surgery, 6797University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Jared R Gallaher
- Division of Acute Care and Trauma Surgery, Department of General Surgery, 6797University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Kyriakopoulos C, Gogali A, Bartziokas K, Kostikas K. Identification and treatment of T2-low asthma in the era of biologics. ERJ Open Res 2021; 7:00309-2020. [PMID: 34109244 PMCID: PMC8181790 DOI: 10.1183/23120541.00309-2020] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/08/2020] [Indexed: 12/25/2022] Open
Abstract
Currently, and based on the development of relevant biologic therapies, T2-high is the most well-defined endotype of asthma. Although much progress has been made in elucidating T2-high inflammation pathways, no specific clinically applicable biomarkers for T2-low asthma have been identified. The therapeutic approach of T2-low asthma is a problem urgently needing resolution, firstly because these patients have poor response to steroids, and secondly because they are not candidates for the newer targeted biologic agents. Thus, there is an unmet need for the identification of biomarkers that can help the diagnosis and endotyping of T2-low asthma. Ongoing investigation is focusing on neutrophilic airway inflammation mediators as therapeutic targets, including interleukin (IL)-8, IL-17, IL-1, IL-6, IL-23 and tumour necrosis factor-α; molecules that target restoration of corticosteroid sensitivity, mainly mitogen-activated protein kinase inhibitors, tyrosine kinase inhibitors and phosphatidylinositol 3-kinase inhibitors; phosphodiesterase (PDE)3 inhibitors that act as bronchodilators and PDE4 inhibitors that have an anti-inflammatory effect; and airway smooth muscle mass attenuation therapies, mainly for patients with paucigranulocytic inflammation. This article aims to review the evidence for noneosinophilic inflammation being a target for therapy in asthma; discuss current and potential future therapeutic approaches, such as novel molecules and biologic agents; and assess clinical trials of licensed drugs in the treatment of T2-low asthma.
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Affiliation(s)
- Chris Kyriakopoulos
- Respiratory Medicine Dept, University of Ioannina School of Medicine, Ioannina, Greece
| | - Athena Gogali
- Respiratory Medicine Dept, University of Ioannina School of Medicine, Ioannina, Greece
| | | | - Konstantinos Kostikas
- Respiratory Medicine Dept, University of Ioannina School of Medicine, Ioannina, Greece
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Grosbois JM, Coquart J, Fry S, Le Rouzic O, Grosbois T, Wallaert B, Chenivesse C. Long-term effect of home-based pulmonary rehabilitation in severe asthma. Respir Med 2019; 157:36-41. [PMID: 31479806 DOI: 10.1016/j.rmed.2019.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Home-based pulmonary rehabilitation (PR) has demonstrated its effectiveness amongst patients with chronic obstructive pulmonary disease (COPD) but has never been investigated in severe asthma. METHODS In a retrospective study, we included 28 patients with severe asthma (61.5 ± 16.2 years, FEV1: 51.4 ± 17.3%) and 164 matched COPD patients (64.3 ± 11.6 years, FEV1: 47.7 ± 15.5%) who had completed a home-based PR program and pursued at least 12 months of follow-up. The number of steps performed during a 6-min stepper test (6MST), the Hospital Anxiety and Depression (HAD) scores, and the Visual Simplified Respiratory Questionnaire score (VSRQ) were compared between baseline, the post-PR period (post-PR) and after 12 months of follow-up (M12) within each group. The evolution of the 6MST, HAD and VSRQ values between baseline, post-PR and M12 was compared between severe asthma and COPD patients. RESULTS In the severe asthma group, the 6MST was higher post-PR (504 ± 150, p = 0.043) and at M12 (538 ± 163, p = 0.016) compared with baseline (450 ± 148). The VSRQ score was higher at M12 (39.0 ± 18.6, p = 0.049) but not post-PR (38.7 ± 15.8, p = 0.119) in comparison with baseline (32.2 ± 12.4). There was no difference in the HAD scores between baseline, post-PR and M12. PR outcome was not significantly different between severe asthma and COPD patients at short and long term (p > 0.05). CONCLUSION In severe asthma, home-based PR is associated with improved exercise tolerance and quality of life on a long-term basis but does not modify anxiety and depression.
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Affiliation(s)
| | - Jeremy Coquart
- Univ Rouen, Faculté des Sciences du Sport, CETAPS, EA 3832, F-76821, Mont Saint Aignan, France
| | - Stephanie Fry
- CHU Lille, Service de Pneumologie et Immuno-Allergologie, Centre de Référence Constitutif des Maladies Pulmonaires Rares, F-59000, Lille, France; Inserm, CNRS, Institut Pasteur de Lille, U1019, UMR 8204, CIIL - Center for Infection and Immunity of Lille, F-59000, Lille, France
| | - Olivier Le Rouzic
- CHU Lille, Service de Pneumologie et Immuno-Allergologie, Centre de Référence Constitutif des Maladies Pulmonaires Rares, F-59000, Lille, France; Inserm, CNRS, Institut Pasteur de Lille, U1019, UMR 8204, CIIL - Center for Infection and Immunity of Lille, F-59000, Lille, France; Univ Lille, F-59000, Lille, France
| | - Thomas Grosbois
- CHU Lille, Service de Pneumologie et Immuno-Allergologie, Centre de Référence Constitutif des Maladies Pulmonaires Rares, F-59000, Lille, France
| | - Benoit Wallaert
- CHU Lille, Service de Pneumologie et Immuno-Allergologie, Centre de Référence Constitutif des Maladies Pulmonaires Rares, F-59000, Lille, France; Inserm, CNRS, Institut Pasteur de Lille, U1019, UMR 8204, CIIL - Center for Infection and Immunity of Lille, F-59000, Lille, France; Univ Lille, F-59000, Lille, France
| | - Cecile Chenivesse
- CHU Lille, Service de Pneumologie et Immuno-Allergologie, Centre de Référence Constitutif des Maladies Pulmonaires Rares, F-59000, Lille, France; Inserm, CNRS, Institut Pasteur de Lille, U1019, UMR 8204, CIIL - Center for Infection and Immunity of Lille, F-59000, Lille, France; Univ Lille, F-59000, Lille, France.
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Abstract
PURPOSE OF REVIEW Asthma is a heterogeneous disease not only on a clinical but also on a mechanistic level. For a long time, the molecular mechanisms of asthma were considered to be driven by type 2 helper T cells (Th2) and eosinophilic airway inflammation; however, extensive research has revealed that T2-low subtypes that differ from the dominant T2 paradigm are also common. RECENT FINDINGS Research into asthma pathways has led to the recognition that some asthma phenotypes show absence of T2 inflammation or alternate between T2 and non-T2 responses. Moreover, numerous immune response modifiers that block key-molecules such as interleukin (IL)-5, IL-13, and immunoglobulin E (IgE) have been identified. Along the way, these studies pointed that T2-low inflammation may also be responsible for lack of responsiveness to current treatment regimes. SUMMARY Asthma pathogenesis is characterized by two major endotypes, a T2-high featuring increased eosinophilic airway inflammation, and a T2-low endotype presenting with either neutrophilic or paucigranulocytic airway inflammation and showing greater resistance to steroids. This clearly presents an unmet therapeutic challenge. A precise definition and characterization of the mechanisms that drive this T2-low inflammatory response in each patient phenotype is necessary to help identify novel drug targets and design more effective and targeted treatments.
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12
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Zervas E, Samitas K, Papaioannou AI, Bakakos P, Loukides S, Gaga M. An algorithmic approach for the treatment of severe uncontrolled asthma. ERJ Open Res 2018. [PMID: 29531957 PMCID: PMC5838355 DOI: 10.1183/23120541.00125-2017] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
A small subgroup of patients with asthma suffers from severe disease that is either partially controlled or uncontrolled despite intensive, guideline-based treatment. These patients have significantly impaired quality of life and although they constitute <5% of all asthma patients, they are responsible for more than half of asthma-related healthcare costs. Here, we review a definition for severe asthma and present all therapeutic options currently available for these severe asthma patients. Moreover, we suggest a specific algorithmic treatment approach for the management of severe, difficult-to-treat asthma based on specific phenotype characteristics and biomarkers. The diagnosis and management of severe asthma requires specialised experience, time and effort to comprehend the needs and expectations of each individual patient and incorporate those as well as his/her specific phenotype characteristics into the management planning. Although some new treatment options are currently available for these patients, there is still a need for further research into severe asthma and yet more treatment options. Stepwise approach for the treatment of severe asthmahttp://ow.ly/rLPl30i0TyZ
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Affiliation(s)
- Eleftherios Zervas
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Konstantinos Samitas
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | | | - Petros Bakakos
- 1st Respiratory Medicine Dept, Athens Chest Hospital "Sotiria", University of Athens, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Dept, Attikon Hospital, University of Athens, Athens, Greece
| | - Mina Gaga
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
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13
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Thiriou D, Morianos I, Xanthou G, Samitas K. Innate immunity as the orchestrator of allergic airway inflammation and resolution in asthma. Int Immunopharmacol 2017; 48:43-54. [PMID: 28463786 DOI: 10.1016/j.intimp.2017.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 04/15/2017] [Accepted: 04/24/2017] [Indexed: 12/31/2022]
Abstract
The respiratory system is constantly in direct contact with the environment and, has therefore, developed strong innate and adaptive immune responses to combat pathogens. Unlike adaptive immunity which is mounted later in the course of the immune response and is naive at the outset, innate immunity provides the first line of defense against microbial agents, while also promoting resolution of inflammation. In the airways, innate immune effector cells mainly consist of eosinophils, neutrophils, mast cells, basophils, macrophages/monocytes, dendritic cells and innate lymphoid cells, which attack pathogens directly or indirectly through the release of inflammatory cytokines and antimicrobial peptides, and coordinate T and B cell-mediated adaptive immunity. Airway epithelial cells are also critically involved in shaping both the innate and adaptive arms of the immune response. Chronic allergic airway inflammation and linked asthmatic disease is often considered a result of aberrant activation of type 2 T helper cells (Th2) towards innocuous environmental allergens; however, innate immune cells are increasingly recognized as key players responsible for the initiation and the perpetuation of allergic responses. Moreover, innate cells participate in immune response regulation through the release of anti-inflammatory mediators, and guide tissue repair and the maintenance of airway homeostasis. The scope of this review is to outline existing knowledge on innate immune responses involved in allergic airway inflammation, highlight current gaps in our understanding of the underlying molecular and cellular mechanisms and discuss the potential use of innate effector cells in new therapeutic avenues.
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Affiliation(s)
- Despoina Thiriou
- 2(nd) Respiratory Medicine Dept., Athens Chest Hospital "Sotiria", Athens, Greece
| | - Ioannis Morianos
- Cellular Immunology Laboratory, Division of Cell Biology, Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece
| | - Georgina Xanthou
- Cellular Immunology Laboratory, Division of Cell Biology, Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece
| | - Konstantinos Samitas
- Cellular Immunology Laboratory, Division of Cell Biology, Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece; 7(th) Respiratory Medicine Dept. and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece.
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14
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Novel Biomarkers in Severe Asthma. Arch Bronconeumol 2017; 53:175-176. [PMID: 28283213 DOI: 10.1016/j.arbres.2016.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/13/2016] [Indexed: 02/01/2023]
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15
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Samitas K, Malmhäll C, Rådinger M, Ramos-Ramirez P, Lu Y, Deák T, Semitekolou M, Gaga M, Sjöstrand M, Lötvall J, Bossios A. Precursor B Cells Increase in the Lung during Airway Allergic Inflammation: A Role for B Cell-Activating Factor. PLoS One 2016; 11:e0161161. [PMID: 27513955 PMCID: PMC4981371 DOI: 10.1371/journal.pone.0161161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 08/01/2016] [Indexed: 11/18/2022] Open
Abstract
Background B cells, key cells in allergic inflammation, differentiate in the bone marrow and their precursors include pro-B, pre-B and immature B cells. Eosinophil progenitor cells increase in the lung after allergen exposure. However, the existence and possible role of B cell precursors in the lung during allergic inflammation remains elusive. Methods A BALB/c mouse model of allergic airway inflammation was utilized to perform phenotypic and quantification analyses of pro-B and pre-B cells in the lung by flow cytometry. B cell maturation factors IL-7 and B cell-activating factor (BAFF) and their receptors (CD127 and BAFFR, BCMA, TACI, respectively) were also evaluated in the lung and serum. The effect of anti-BAFF treatment was investigated both in vivo (i.p. administration of BAFF-R-Ig fusion protein) and in vitro (colony forming cell assay). Finally, BAFF levels were examined in the bronchoalveolar lavage (BAL) of asthmatic patients and healthy controls. Results Precursor pro and pre-B cells increase in the lung after allergen exposure, proliferate in the lung tissue in vivo, express markers of chemotaxis (CCR10 and CXCR4) and co-stimulation (CD40, CD86) and are resistant to apoptosis (Bax). Precursor B cells express receptors for BAFF at baseline, while after allergen challenge both their ligand BAFF and the BCMA receptor expression increases in B cell precursors. Blocking BAFFR in the lung in vivo decreases eosinophils and proliferating precursor B cells. Blocking BAFFR in bone marrow cultures in vitro reduces pre-B colony formation units. BAFF is increased in the BAL of severe asthmatics. Conclusion Our data support the concept of a BAFF-mediated role for B cell precursors in allergic airway inflammation.
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Affiliation(s)
- Konstantinos Samitas
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Cellular Immunology Laboratory, Division of Cell Biology, Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- 7th Respiratory Medicine Dept. and Asthma Center, Athens Chest Hospital “Sotiria”, Athens, Greece
| | - Carina Malmhäll
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Madeleine Rådinger
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Patricia Ramos-Ramirez
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - You Lu
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tünde Deák
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria Semitekolou
- Cellular Immunology Laboratory, Division of Cell Biology, Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Mina Gaga
- 7th Respiratory Medicine Dept. and Asthma Center, Athens Chest Hospital “Sotiria”, Athens, Greece
| | - Margareta Sjöstrand
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Lötvall
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Apostolos Bossios
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
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Samitas K, Poulos N, Semitekolou M, Morianos I, Tousa S, Economidou E, Robinson DS, Kariyawasam HH, Zervas E, Corrigan CJ, Ying S, Xanthou G, Gaga M. Activin-A is overexpressed in severe asthma and is implicated in angiogenic processes. Eur Respir J 2016; 47:769-82. [PMID: 26869672 DOI: 10.1183/13993003.00437-2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 12/04/2015] [Indexed: 02/06/2023]
Abstract
Activin-A is a pleiotropic cytokine that regulates allergic inflammation. Its role in the regulation of angiogenesis, a key feature of airways remodelling in asthma, remains unexplored. Our objective was to investigate the expression of activin-A in asthma and its effects on angiogenesis in vitro.Expression of soluble/immunoreactive activin-A and its receptors was measured in serum, bronchoalveolar lavage fluid (BALF) and endobronchial biopsies from 16 healthy controls, 19 patients with mild/moderate asthma and 22 severely asthmatic patients. In vitro effects of activin-A on baseline and vascular endothelial growth factor (VEGF)-induced human endothelial cell angiogenesis, signalling and cytokine release were compared with BALF concentrations of these cytokines in vivo.Activin-A expression was significantly elevated in serum, BALF and bronchial tissue of the asthmatics, while expression of its protein receptors was reduced. In vitro, activin-A suppressed VEGF-induced endothelial cell proliferation and angiogenesis, inducing autocrine production of anti-angiogenic soluble VEGF receptor (R)1 and interleukin (IL)-18, while reducing production of pro-angiogenic VEGFR2 and IL-17. In parallel, BALF concentrations of soluble VEGFR1 and IL-18 were significantly reduced in severe asthmatics in vivo and inversely correlated with angiogenesis.Activin-A is overexpressed and has anti-angiogenic effects in vitro that are not propagated in vivo, where reduced basal expression of its receptors is observed particularly in severe asthma.
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Affiliation(s)
- Konstantinos Samitas
- Cellular Immunology Laboratory, Division of Cell Biology, Centre for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece 7th Respiratory Medicine Department and Asthma Centre, Athens Chest Hospital "Sotiria", Athens, Greece These authors contributed equally
| | - Nikolaos Poulos
- Cellular Immunology Laboratory, Division of Cell Biology, Centre for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece These authors contributed equally
| | - Maria Semitekolou
- Cellular Immunology Laboratory, Division of Cell Biology, Centre for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece These authors contributed equally
| | - Ioannis Morianos
- Cellular Immunology Laboratory, Division of Cell Biology, Centre for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Sofia Tousa
- Cellular Immunology Laboratory, Division of Cell Biology, Centre for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Erasmia Economidou
- 7th Respiratory Medicine Department and Asthma Centre, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Douglas S Robinson
- Medical Research Council and Asthma UK Centre for Mechanisms of Allergic Asthma, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK
| | - Harsha H Kariyawasam
- Medical Research Council and Asthma UK Centre for Mechanisms of Allergic Asthma, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK Department of Allergy and Medical Rhinology, Royal National Throat, Nose and Ear Hospital, University College, London, UK
| | - Eleftherios Zervas
- 7th Respiratory Medicine Department and Asthma Centre, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Christopher J Corrigan
- Department of Asthma, Allergy and Respiratory Science, King's College London School of Medicine, London, UK
| | - Sun Ying
- Department of Asthma, Allergy and Respiratory Science, King's College London School of Medicine, London, UK
| | - Georgina Xanthou
- Cellular Immunology Laboratory, Division of Cell Biology, Centre for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece Both authors contributed equally
| | - Mina Gaga
- 7th Respiratory Medicine Department and Asthma Centre, Athens Chest Hospital "Sotiria", Athens, Greece Both authors contributed equally
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Bostantzoglou C, Delimpoura V, Samitas K, Zervas E, Kanniess F, Gaga M. Clinical asthma phenotypes in the real world: opportunities and challenges. Breathe (Sheff) 2015; 11:186-93. [PMID: 26632421 PMCID: PMC4666449 DOI: 10.1183/20734735.008115] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Asthma is a common, chronic and heterogeneous syndrome, affecting people of all ages, all races and both sexes. It may range from mild disease with barely noticeable symptoms, to very severe disease with constant symptoms that greatly hinder the life of the patient. Guidelines issued by various medical societies provide guidance on how to diagnose and manage asthmatic patients. It is now increasingly recognised that asthma management must be individualised, tailored not only to the severity of the disease but to the phenotypic characteristics of each patient. The aim of asthma treatment is control of asthma and the prevention of risk of exacerbations and fixed airflow limitation. Asthma control can be easily assessed clinically through simple screening tools such as the use of validated questionnaires and spirometry. The use of inflammatory biomarkers can be an alternative approach that, however, requires more time and resources. Asthma treatment involves the use of controllers, mainly inhaled corticosteroids and long-acting β2-agonists, and relievers, mainly rapid-acting β2-agonists. Controller medications reduce airway inflammation, lead to better symptom control and reduce the risk of future exacerbations. Reliever (rescue) medications alleviate symptoms and prevent exercise-induced bronchoconstriction. Treatment must be based on a "stepwise approach" in order to achieve good control of symptoms and to minimise future risks of exacerbations. That is, less treatment for mild disease, more treatment for severe, uncontrolled disease. Once good asthma control has been achieved and maintained, treatment should be stepped down. In severe asthmatics, phenotypic characterisation becomes more clinically useful and add-on treatment such as anti-immunoglobulin E monoclonal antibodies may be required. Despite our better understanding of asthma, there are still patients who will not respond to treatment and remain symptomatic. Dissemination of guidelines and national plans allowing early diagnosis of asthma as well as access to specialised primary and secondary care for asthmatic patients, personalised treatment and continuity of care may lead to excellence in care and controlled asthma for the majority of patients. Education of the patient in asthma is also very important, as in every chronic disease, as the patients live with the disease every day while they visit a healthcare professional a few times a year. Future planning for new treatments should focus on the needs of such severe asthma patients.
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Affiliation(s)
- Clementine Bostantzoglou
- 7th Respiratory Medicine Dept. and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Vicky Delimpoura
- 7th Respiratory Medicine Dept. and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Konstantinos Samitas
- 7th Respiratory Medicine Dept. and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Eleftherios Zervas
- 7th Respiratory Medicine Dept. and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Frank Kanniess
- FA Allgemeinmedizin, Allergologie, Bahnhofstrasse 5a, D-23858, Reinfeld
| | - Mina Gaga
- 7th Respiratory Medicine Dept. and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
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Abstract
Asthma is a common disease in the population and fatal asthma cases are not rare. Patients with fatal asthma not infrequently die outside of hospitals and become forensic cases. The pathologic features of asthma are very variable, but fatal asthma is always characterized by extensive mucous plugs in the airways and lungs that tend to remain inflated when the chest is opened. Other microscopic features that may be seen in asthma include increased amounts of airway smooth muscle, marked thickening of airway basement membranes, goblet cell hyperplasia, and various patterns of airway inflammation including eosinophils, neutrophils, and lymphocytes. Absent a history, a presumptive diagnosis of fatal asthma can be made in a patient whose lungs are hyperinflated and demonstrate numerous mucous plugs in the large airways, and this is usually accompanied by a markedly thickened basement membrane in the large airways on microscopic examination, but the possibility that the fatal asthma attack was precipitated by exogeneous factors such as drugs, fumes, or irritants should be borne in mind.
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Affiliation(s)
- Joanne L. Wright
- University of British Columbia, St. Paul's Hospital in Vancouver, BC
- Department of Pathology, University of British Columbia, Vancouver, BC (AC)
| | - Andrew M. Churg
- Department of Pathology, University of British Columbia, Vancouver, BC (AC)
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