Inhaled steroids are associated with reduced lung function decline in subjects with asthma with elevated total IgE

Risk Factors for Lung Function Decline in Pediatric Asthma under Treatment: A Retrospective, Multicenter, Observational Study

Background: Childhood asthma is a major risk for low lung function in later adulthood, but what factors in asthma are associated with the poor lung function during childhood is not known. Objective: To identify clinical factors in children with asthma associated with low or declining lung function during the treatment. Methods: We enrolled children with asthma who had been treated throughout three age periods, i.e., 6−9, 10−12, and 13−15 years old, at seven specialized hospitals in Japan. Clinical information and lung function measurements were retrieved from the electronic chart systems. To characterize the lung function trajectories during each age period, we evaluated the forced expiratory volume 1 (FEV1) with % predicted values and individual changes by the slope (S) from linear regression. We defined four trajectory patterns: normal (Group N) and low (Group L), showing %FEV1 ≥80% or <80% throughout all three periods; upward (Group U) and downward (Group D), showing S ≥ 0 or S < 0%. Logistic regression analysis was performed to compare factors associated with the unfavorable (D/L) versus favorable (N/U) groups. Results: Among 273 eligible patients, 197 (72%) were classified into Group N (n = 150)/U (n = 47), while 76 (28%) were in Group D (n = 66)/L (n = 10). A history of poor asthma control, long-acting beta2 agonist use, and a lower height Z-score during 13−15 years were associated with an unfavorable outcome (Group D/L). Conversely, inhaled corticosteroid (ICS) use during 10−12 years and high-dose ICS use during 13−15 years were associated with a favorable outcome (Group N/U). Conclusion: We identified several factors that are associated with unfavorable lung function changes in pediatric asthma. Attention should be paid to the possible relationship between yearly changes in lung function and poor asthma control, use of ICS (and its dose) and use of LABA.

Recent insights in the role of biomarkers in severe asthma management

Contemporary asthma management requires a proactive and individualized approach, combining precision diagnosis and personalized treatment. The introduction of biologic therapies for severe asthma to everyday clinical practice, increases the need for specific patient selection, prediction of outcomes and monitoring of these costly and long-lasting therapies. Several biomarkers have been used in asthma in disease identification, prediction of asthma severity and prognosis, and response to treatment. Novel advances in the area of personalized medicine regarding disease phenotyping and endotyping, encompass the development and application of reliable biomarkers, accurately quantified using robust and reproducible methods. The availability of powerful omics technologies, together with integrated and network-based genome data analysis, and microbiota changes quantified in serum, body fluids and exhaled air, will lead to a better classification of distinct phenotypes or endotypes. Herein, in this review we discuss on currently used and novel biomarkers for the diagnosis and treatment of asthma.

The coexistence of asthma and COPD: risk factors, clinical history and lung function trajectories

RATIONALE

Patients with concomitant features of asthma and chronic obstructive pulmonary disease (COPD) have a heavy disease burden.

OBJECTIVES

Using data collected prospectively in the European Community Respiratory Health Survey, we compared the risk factors, clinical history, and lung function trajectories from early adulthood to the late sixties of middle aged subjects having asthma+COPD (n=179), past (n=263) or current (n=808) asthma alone, COPD alone (n=111), or none of these (n=3477).

METHODS

Interview data and prebronchodilator FEV₁ and FVC were obtained during three clinical examinations in 1991-1993, 1999-2002, and 2010-2013. Disease status was classified in 2010-2013, when the subjects were aged 40-68, according to the presence of fixed airflow obstruction (postbronchodilator FEV₁/FVC below the lower limit of normal), a lifetime history of asthma, and cumulative exposure to tobacco or occupational inhalants. Previous lung function trajectories, clinical characteristics, and risk factors of these phenotypes were estimated.

MAIN RESULTS

Subjects with asthma+COPD reported maternal smoking (28.2%) and respiratory infections in childhood (19.1%) more frequently than subjects with COPD alone (20.9 and 14.0%, respectively). Subjects with asthma+COPD had an impairment of lung function at age 20 that tracked over adulthood, and more than half of them had asthma onset in childhood. Subjects with COPD alone had the highest lifelong exposure to tobacco smoking and occupational inhalants, and they showed accelerated lung function decline during adult life.

CONCLUSIONS

The coexistence between asthma and COPD seems to have its origins earlier in life compared to COPD alone. These findings suggest that prevention of this severe condition, which is typical at older ages, should start in childhood.

Does the use of inhaled corticosteroids in asthma benefit lung function in the long-term? A systematic review and meta-analysis

While asthma is known to be associated with an increased risk of progressive lung function impairments and fixed airflow obstruction, there is ongoing debate on whether inhaled corticosteroids (ICS) modify these long-term risks. Searches were performed of the PubMed, Embase and CENTRAL databases up to 22 July 2019 for studies with follow-up ≥1 year that investigated the effects of maintenance ICS on changes in lung function in asthma.Inclusion criteria were met by 13 randomised controlled trials (RCTs) (n=11 678) and 11 observational studies (n=3720). Median (interquartile range) follow-up was 1.0 (1-4) and 8.4 (3-28) years, respectively. In the RCTs, predominantly in individuals with mild asthma, ICS use was associated with improved pre-bronchodilator (BD) forced expiratory volume in 1 s (FEV1) across all age groups (2.22% predicted (95% CI 1.32-3.12), n=8332), with similar estimates of strength in association for children and adults. Improvements in post-BD FEV1 were observed in adults (1.54% (0.87-2.21), n=3970), but not in children (0.20% (-0.49-0.90), n=3924) (subgroup difference, p=0.006). Estimates were similar between smokers and nonsmokers. There were no RCT data on incidence of fixed airflow obstruction. In the observational studies, ICS use was associated with improved pre-BD FEV1 in children and adults. There were limited observational data for post-BD outcomes.In patients with mild asthma, maintenance ICS are associated with modest, age-dependent improvements in long-term lung function, representing an added benefit to the broader clinical actions of ICS in asthma. There is currently insufficient evidence to determine whether treatment reduces incidence of fixed airflow obstruction in later life.

Disease Burden and Long-Term Risk of Persistent Very Poorly Controlled Asthma: TENOR II

BACKGROUND

Severe/difficult-to-treat disease occurs in 5% to 10% of patients with asthma, but accounts for more than 50% of related economic costs. Understanding factors associated with persistent very poorly controlled (VPC) asthma may improve outcomes.

OBJECTIVE

To characterize persistent VPC asthma after more than 10 years of standard of care.

METHODS

The Epidemiology and Natural history of asthma: Outcomes and treatment Regimens (TENOR) II (N = 341) was a multicenter, observational study of patients with severe/difficult-to-treat asthma with a single, cross-sectional visit more than 10 years after TENOR I. Persistent VPC asthma was defined as VPC asthma at TENOR I and TENOR II enrollment; without VPC asthma was defined as well- or not well-controlled asthma at either or both visits. Multivariable logistic regression assessed long-term predictors of persistent VPC asthma using TENOR I baseline variables.

RESULTS

Of 327 patients, nearly half (48.0%, n = 157) had persistent VPC asthma. Comorbidities and asthma triggers were more frequent in patients with persistent VPC asthma than in patients without VPC asthma. Total geometric mean IgE was higher in patients with persistent VPC asthma (89.3 IU/mL vs 55.7 IU/mL); there was no difference in eosinophil levels. Lung function was lower in patients with persistent VPC asthma (mean % predicted pre- and postbronchodilator FEV₁, 63.0% vs 82.8% and 69.6% vs 87.2%, respectively). Exacerbations in the previous year were more likely in patients with persistent VPC asthma (29.7% vs 9.0%, respectively). Predictors of persistent VPC asthma were black versus white race/ethnicity, allergic trigger count (4 vs 0), systemic corticosteroid use, and postbronchodilator FEV₁ (per 10% decrease).

CONCLUSIONS

The burden of persistent VPC asthma is high in severe/difficult-to-treat disease; management of modifiable risk factors, maximization of lung function, and trigger avoidance may improve outcomes.

Effect of omalizumab on lung function and eosinophil levels in adolescents with moderate-to-severe allergic asthma

BACKGROUND

Omalizumab improves clinical outcomes in patients with asthma. Several studies have shown lung function improvements with omalizumab; however, this has not been examined exclusively in adolescents.

OBJECTIVE

To assess the effect of omalizumab on lung function and eosinophil counts in adolescents with uncontrolled moderate-to-severe allergic asthma.

METHODS

In this post hoc analysis, data from adolescents aged 12 to 17 years from 8 randomized trials of omalizumab were pooled (studies 008, 009, and 011, and SOLAR, INNOVATE, ALTO, ETOPA, and EXTRA). Changes from baseline to end of study in forced expiratory volume in 1 second (FEV₁), percent predicted FEV₁ (ppFEV₁), forced vital capacity (FVC), and blood eosinophil counts were assessed by fitting an analysis of covariance model and calculating least squares mean (LSM) difference for omalizumab vs placebo.

RESULTS

A total of 340 adolescents were identified (omalizumab, n = 203 [59.7%]; placebo, n = 137 [40.3%]). Omalizumab increased all baseline lung function variables more than placebo by end of study: LSM treatment differences (95% confidence interval) were 3.0% (0.2%-5.7%; P = .035), 120.9 mL (30.6-211.2 mL; P = .009), and 101.5 mL (8.3-194.6 mL; P = .033) for ppFEV₁, absolute FEV₁, and FVC, respectively. The LSM difference demonstrated a greater reduction in eosinophil counts for omalizumab vs placebo: -85.9 cells/μL (-137.1 to -34.6 cells/μL; P = .001).

CONCLUSION

Omalizumab was associated with lung function improvements and circulating eosinophil counts reductions in adolescents with moderate-to-severe uncontrolled asthma. Findings emphasize the effect of omalizumab in young patients and the need to optimize treatment early in the disease course. https://clinicaltrials.gov/: NCT00314574, NCT00046748, NCT00401596.

Atopy Modifies the Association Between Inhaled Corticosteroid Use and Lung Function Decline in Patients with Asthma

BACKGROUND

Inhaled corticosteroids (ICSs) are the mainstay of asthma treatment, but response to medication is variable. Patients with allergic inflammation generally show a better short-term response to ICSs; however, studies on predictors of long-term response are few.

OBJECTIVE

To assess whether allergic sensitization can modify the association between ICS use and lung function decline over 20 years in adult asthma.

METHODS

We used data from the 3 clinical examinations of the European Community Respiratory Health Survey. We measured ICS use (no use, and use for <1.3, 1.3-8, and >8 years) and FEV₁ decline among subjects with asthma over the 2 periods between consecutive examinations. We conducted a cohort study combining data of the 2 periods (906 observations from 745 subjects) to assess whether the association between ICS use and FEV₁ decline was modified by allergic sensitization (IgE > 0.35 kU/L for any of house-dust mite, timothy grass, cat, or Cladosporium).

RESULTS

FEV₁ decline was similar for non-ICS users, as well as ICS users for less than 1.3 years, with and without allergic sensitization. However, among subjects on ICSs for a longer period, sensitization was associated with an attenuated decline (P_interaction = .006): in the group treated for more than 8 years, FEV₁ decline was on average 27 mL/y (95% CI_{Bonferroni-adjusted}, 11-42) lower for subjects with sensitization compared with nonsensitized subjects.

CONCLUSIONS

Our study suggests that biomarkers of atopy can predict a more favorable long-term response to ICSs. Randomized controlled studies are needed to confirm these findings.

Linking COPD epidemiology with pediatric asthma care: Implications for the patient and the physician

What are the implications of a lower than expected forced expiratory volume in one second (FEV1) in childhood on respiratory health later in adulthood? Lung function is known to track with age, and there is evidence from recent epidemiologic studies that impaired lung function early in life is associated with later chronic airflow limitation, or even chronic obstructive pulmonary disease, COPD. This risk seems particularly strong in subjects with persistent and severe forms of childhood asthma. Can we translate findings from longitudinal cohort studies to individual risk predictions and preventive guidelines in our pediatric care? In this review, we discuss the clinical implementations of recent epidemiological respiratory studies and the importance of preserved lung health across the life course. Also, we evaluate available clinical tools, primarily lung function measures, and profiles of risk factors, including biomarkers, that may help identifying children at risk of chronic airway disease in adulthood. We conclude that translating population level results to the individual patient in the pediatric care setting is not straight forward, and that there is a need for studies specifically designed to evaluate performance of prediction of risk profiles for long-term sequelae of childhood asthma and lung function impairment.

Research highlights from the 2018 European Respiratory Society International Congress: airway disease

The annual European Respiratory Society (ERS) International Congress (held in Paris in 2018) was once again a platform for discussion of the highest-quality scientific research, cutting-edge techniques and innovative new therapies within the respiratory field. This article discusses only some of the high-quality research studies presented at this year's Congress, with a particular focus on airway diseases including asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis and cough, as presented through Assembly 5 of the ERS (Airway Diseases: Asthma and COPD). The authors establish the key take-home messages of these studies, compare their findings and place them in the context of current understanding.

Biomarkers in the Management of Difficult Asthma

Difficult asthma is a heterogeneous disease of the airways including various types of bronchial inflammation and various degrees of airway remodeling. Therapeutic response of severe asthmatics can be predicted by the use of biomarkers of Type2-high or Type2-low inflammation. Based on sputum cell analysis, four inflammatory phenotypes have been described. As induced sputum is time-consuming and expensive technique, surrogate biomarkers are useful in clinical practice.

Eosinophilic phenotype is likely to reflect ongoing adaptive immunity in response to allergen. Several biomarkers of eosinophilic asthma are easily available in clinical practice (blood eosinophils, serum IgE, exhaled nitric oxyde, serum periostin). Neutrophilic asthma is thought to reflect innate immune system activation in response to pollutants or infectious agents while paucigranulocytic asthma is thought to be not inflammatory and characterized by smooth muscle dysfunction. We currently lack of user-friendly biomarkers of neutrophilic asthma and airway remodeling.

In this review, we summarize the biomarkers available for the management of difficult asthma.

Majority of never-smokers with airflow limitation do not have asthma: the Copenhagen General Population Study

BACKGROUND

A substantial proportion of individuals with airflow limitation are never-smokers. However, whether never-smokers with airflow limitation have undiagnosed asthma is unknown. We hypothesised that the majority of never-smokers with respiratory symptoms and airflow limitation but without known asthma have undiagnosed asthma by comparing characteristics and prognosis in never-smokers with airflow limitation and asthma (NS+AFL+A) with never-smokers with airflow limitation but without asthma (NS+AFL-A).

METHODS

Among 94 079 participants aged 20-100 years from the general population, 39 102 (42%) were never-smokers. In this group, 13 719 (35%) reported to have respiratory symptoms of whom 1610 (12%) had airflow limitation. We investigated characteristics and risk of complications (asthma or COPD exacerbations, pneumonias and all-cause mortality) and comorbidities (lung cancer, ischaemic heart disease, myocardial infarction, deep venous thrombosis and PE) during 4.5 years median follow-up.

RESULTS

NS+AFL-A compared with NS+AFL+A reported less allergy and respiratory symptoms, and had higher FEV1 and lower levels of eosinophils and IgE in peripheral blood. NS+AFL+A had increased risk of asthma and COPD exacerbations, but not of pneumonias; adjusted HRs in NS+AFL+A compared with NS+AFL-A were 16 (95% CI 3.7 to 73) for asthma exacerbations and 15 (2.8 to 80) for COPD exacerbations. Still, NS+AFL-A had increased risk of COPD exacerbations and pneumonias, but not of asthma exacerbations; adjusted HRs in NS+AFL-A compared with never-smokers without airflow limitation or asthma (NS-AFL-A) were 7.7 (2.8 to 21) for COPD exacerbations and 1.7 (1.3 to 2.3) for pneumonias. Risk of comorbidities or all-cause mortality was not increased in NS+AFL-A or NS+AFL+A compared with NS-AFL-A.

CONCLUSIONS

Majority of NS+AFL-A do not seem to have undiagnosed asthma and may instead have airflow limitation caused by other risk factors.

Asthma, COPD and overlap syndrome: a longitudinal study in young European adults

We compared risk factors and clinical characteristics, 9-year lung function change and hospitalisation risk across subjects with the asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS), asthma or COPD alone, or none of these diseases.Participants in the European Community Respiratory Health Survey in 1991-1993 (aged 20-44 years) and 1999-2001 were included. Chronic airflow obstruction was defined as pre-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity<lower limit of normal on both occasions. Based on their history of respiratory symptoms, spirometry and risk factors, subjects were classified as having asthma alone (n=941), COPD alone (n=166), ACOS (n=218) and none of these (n=5659).Subjects with ACOS shared risk factors and clinical characteristics with subjects with asthma alone, but they had an earlier age of asthma onset. FEV1 change in the ACOS group (-25.9 mL·year(-1)) was similar to that in the asthma group (-25.3 mL·year(-1)), and lower (p<0.001) than in the COPD group (-37.3 mL·year(-1)). ACOS was associated with the highest hospitalisation rate.Among young adults aged 20-44 years, ACOS seems to represent a form of severe asthma, characterised by more frequent hospitalisations, and to be the result of early-onset asthma that has progressed to fixed airflow obstruction.

The relation of airway obstruction to asthma, chronic rhinosinusitis and age: results from a population survey of adults

RATIONALE

There is conflicting evidence on whether patients with asthma experience an accelerated decline in lung function with age. We examined the association between postbronchodilator lung function, asthma, chronic rhinosinusitis (CRS), and atopy with age using a large European sample.

METHODS

In 17 centers in 11 European countries, case-control studies were nested within representative cross-sectional surveys of adults aged less than 75 years. Representative samples of participants with asthma, CRS or both and controls were assessed for postbronchodilator ventilatory function, smoking history, atopy, and treatment. Multiple regression was used to assess the interactive effects of age and diagnostic group on decline in postbronchodilator ventilatory function.

RESULTS

A total of 3337 participants provided adequate data (778 with asthma, 399 with CRS, 244 with both asthma and CRS and 1916 controls who had neither asthma nor CRS). Participants with asthma had lower FEV1 /FVC (-4.09% (95% CI: -5.02, -3.15, P < 0.001) and a steeper slope of FEV1 /FVC against age (-0.14%/annum [95%CI: -0.19, -0.08]) equivalent to smoking 1-2 packs of cigarettes per day. Those with atopy had a slope equivalent to controls.

CONCLUSIONS

People with asthma have a steeper decline in postbronchodilator lung function with age, but neither CRS nor atopy alone were associated with such decline.

Long-term benefits of inhaled corticosteroids in asthma: the propensity score method

PURPOSE

The aim of this study was to apply a propensity score approach to assess the long-term benefits of inhaled corticosteroids (ICS) on respiratory health in asthma.

METHODS

This analysis was conducted on adults with persistent asthma from the Epidemiological study on the Genetics and Environment of Asthma, a 12-year follow-up study. ICS exposure was assessed by questionnaire. Change in lung function over the follow-up period, asthma control, and health-related quality of life (asthma quality of life questionnaire) were assessed by standardized and validated methods.

RESULTS

Among 245 adults with persistent asthma, 78 (31.8%) were regularly/continuously exposed to ICS (≥6 months/year, ICS++ ) and 167 never/irregularly exposed to ICS (<6 months/year, ICS+/- ) over the follow-up period. Compared with ICS+/- subjects, a nonsignificant trend for a slower lung function decline (mL/year) was observed in ICS++ subjects (β [95%CI] = -11.4 [-24.9; 2.0]). The ICS++ subjects did not have better controlled asthma and higher health-related quality of life as compared with ICS+/- subjects.

CONCLUSIONS

Applying a propensity score method did not offer evidence of a statistical significant long-term benefit of ICS on respiratory health in adults with persistent asthma regularly or continuously exposed to ICS over a long period.

Factors contributing to an accelerated decline in pulmonary function in asthma

Patients with asthma show a steeper age-related decline in pulmonary function than healthy subjects, which is often alleviated after the initiation of treatment with inhaled corticosteroids (ICS). However, there still are patients who develop irreversible airflow limitations despite receiving adequate ICS treatment. The identification of the characteristics of such patients and biomarkers of progression for airflow limitation, a functional consequence of airway remodeling, is considered important in the management of asthma. A variety of biomarkers are associated with the forced expiratory volume in 1s (FEV1) in asthma in a cross-sectional fashion. However, few biomarkers are known to reflect the decline in pulmonary function, particularly in patients with asthma who receive ICS treatment. Recently periostin, a matricellular protein that prolongs Th2/eosinophilic inflammation and reflects airway remodeling, was reported to be detected in serum. In a Kinki Hokuriku Airway disease Conference multicenter cohort study, we demonstrated that among several serum markers, high serum periostin level, particularly ≥95ng/mL, was the only marker associated with a greater annual decline in FEV1 and a decline in FEV1 of ≥30mL·yr-1. A variant (rs9603226) of the POSTN gene that encodes periostin was also involved in the frequency of a decline in FEV1 of ≥30mL·yr-1. Our results suggest that the serum periostin level is a useful marker reflecting pulmonary function decline in patients with asthma receiving ICS.

GLCCI1 variant accelerates pulmonary function decline in patients with asthma receiving inhaled corticosteroids

BACKGROUND

In steroid-naive patients with asthma, several gene variants are associated with a short-term response to inhaled corticosteroid (ICS) treatment; this has mostly been observed in Caucasians. However, not many studies have been conducted for other ethnicities. Here, we aimed to determine the relationship between the annual decline in forced expiratory flow volume in one second (FEV1 ) and the variant of the glucocorticoid-induced transcript 1 gene (GLCCI1) in Japanese patients with asthma receiving long-term ICS treatment, taking into account the effect of high serum periostin levels, a known association factor of pulmonary function decline and a marker of refractory eosinophilic/Th2 inflammation.

METHODS

In this study, 224 patients with asthma receiving ICS treatment for at least 4 years were enrolled. The effects of single-nucleotide polymorphisms (SNPs) in GLCCI1, stress-induced phosphoprotein 1 (STIP1), and T gene on the decline in FEV1 of 30 ml/year or greater were determined.

RESULTS

Besides the known contributing factors, that is, the most intensive treatment step, ex-smoking, and high serum periostin levels (≥95 ng/ml), the GG genotype of GLCCI1 rs37973, and not other SNPs, was independently associated with a decline in FEV1 of 30 ml/year or greater. When patients were stratified according to their serum periostin levels, the GG genotype of rs37973 was significantly associated with blood eosinophilia (≥250/μl) in the high serum periostin group.

CONCLUSIONS

A GLCCI1 variant is a risk factor of pulmonary function decline in Japanese patients with asthma receiving long-term ICS treatment. Thus, GLCCI1 may be associated with response to ICS across ethnicities.

Cluster analysis identifies characteristic phenotypes of asthma with accelerated lung function decline

OBJECTIVE

While the majority of individuals with asthma retain normal lung function over time, some exhibit accelerated lung function decline. Preservation of lung function is an important aspect of asthma management. Whether the asthma guidelines can prevent lung function decline remains controversial. This study was performed to determine the distribution of asthmatic subjects with greater lung function decline and to identify characteristic clinical features of such subjects treated in accordance with clinical guidelines by using hierarchical cluster analysis.

METHODS

Eighty-six asthmatic subjects without a history of smoking were assessed with respect to eight variables selected from clinical phenotypes by using step-wise multiple regression analysis. Hierarchical cluster analysis using Ward's method generated a dendrogram for estimation of the number of clusters within the population and the differences between them.

RESULTS

Three distinct clusters were identified. Cluster 1 (n = 40) comprised women with late-onset asthma. Cluster 2 (n = 17) comprised subjects with early-onset asthma, atopy and long disease duration. Cluster 3 (n = 29) predominantly comprised older men who had late-onset asthma, a lower prevalence of exacerbation and a lower predicted % forced expiratory volume in 1 s (FEV1) at baseline. Subjects in cluster 3 showed a mean decline in FEV1 of 69 mL/year, which was the greatest lung function decline among the three clusters.

CONCLUSION

We identified a subgroup of patients with accelerated lung function decline despite appropriate asthma treatment based on guidelines constructed by using subjective symptoms.

Increased periostin associates with greater airflow limitation in patients receiving inhaled corticosteroids

BACKGROUND

Periostin, an extracellular matrix protein, contributes to subepithelial thickening in asthmatic airways, and its serum levels reflect airway eosinophilic inflammation. However, the relationship between periostin and the development of airflow limitation, a functional consequence of airway remodeling, remains unknown.

OBJECTIVE

We aimed to determine the relationship between serum periostin levels and pulmonary function decline in asthmatic patients on inhaled corticosteroid (ICS) treatment.

METHODS

Two hundred twenty-four asthmatic patients (average age, 62.3 years) treated with ICS for at least 4 years were enrolled. Annual changes in FEV1, from at least 1 year after the initiation of ICS treatment to the time of enrollment or later (average, 16.2 measurements over 8 years per individual), were assessed. At enrollment, clinical indices, biomarkers that included serum periostin, and periostin gene polymorphisms were examined. Associations between clinical indices or biomarkers and a decline in FEV1 of 30 mL or greater per year were analyzed.

RESULTS

High serum periostin levels (≥ 95 ng/mL) at enrollment, the highest treatment step, higher ICS daily doses, a history of admission due to asthma exacerbation, comorbid or a history of sinusitis, and ex-smoking were associated with a decline in FEV1 of 30 mL or greater per year. Multivariate analysis showed that high serum periostin, the highest treatment step, and ex-smoking were independent risk factors for the decline. Polymorphisms of periostin gene were related to higher serum periostin levels (rs3829365) and a decline in FEV1 of 30 mL or greater per year (rs9603226).

CONCLUSIONS

Serum periostin appears to be a useful biomarker for the development of airflow limitation in asthmatic patients on ICS.

Fixed airflow obstruction among nonsmokers with asthma:a case-comparison study

BACKGROUND

Airflow obstruction in asthma is usually reversible, but fixed obstruction develops in some individuals. Little is known about risk factors for development of fixed airflow obstruction in nonsmokers with asthma.

METHODS

This case-comparison study recruited nonsmokers aged over 45 years with physician-diagnosed asthma from specialist outpatient clinics and primary care. Two age-matched groups were recruited on the basis of spirometry: anobstructed group (post-bronchodilator FEV(1) ≤ 70% predicted, FEV1/FVC ratio < lower limit of normal) and a control group with normal lung function. Subjects completed a questionnaire and interview, and underwent spirometry, venesection, exhaled nitric oxide (ENO) measurement, allergen skinprick testing, and formal lung function testing.

RESULTS

Thirty-four obstructed subjects and 40 controls participated in the study. Obstructed subjects exhibited greater evidence of systemic inflammation, abnormal glucose homeostasis, and central obesity than controls. Obstructed subjects reported longer duration of asthma, and childhood respiratory infection was commoner in that group. Metabolic syndrome prevalence was similar between groups, but several features of insulin resistance were associated with reduced FEV(1). Cough and sputum were common among controls.

CONCLUSIONS

Risk of fixed airflow obstruction may correlate with lifetime asthma duration. Individuals with coexisting asthma and fixed airflow obstruction have heightened systemic inflammation. A variety of chronic respiratory symptoms are common among "healthy" nonsmokers with asthma.

The role of smoking in allergy and asthma: lessons from the ECRHS

The European Community Respiratory Health Survey is an international multicenter cohort study of asthma, allergy, and lung function that began in the early-1990s with recruitment of population-based samples of 20- to 44-year-old adults, mainly in Europe. The aims of the study are broad ranging but include assessment of the role of in utero exposure to tobacco smoke, exposure to environmental tobacco smoke, and active smoking on the incidence, prevalence, and prognosis of allergy and asthma. Cross-sectional and longitudinal analyses looking at these associations have been conducted, sometimes only using information collected in one country, and on other occasions using information collected in all the participating centers. This article summarizes the results from these various publications from this large epidemiologic study.

Mental health among adults with asthma and chronic bronchitis. A population-based study in Spain

OBJECTIVES

To analyze the conditions of psychological dysfunction and positive mental health in patients with asthma and chronic bronchitis (CB), as compared to healthy individuals, and to identify the factors associated with these mental health indicators.

METHODS

Cross-sectional study based on data obtained from the European Health Interview Survey for Spain (EHISS, 2009). We identified individuals with asthma and CB using a specific questionnaire. In order to assess mental health, two indicators extracted from questionnaire SF-36 were used: psychological dysfunction and positive mental health status.

RESULTS

Out of 19,598 subjects included in the study, 8.3% were classified as asthmatic and 7.4% as CB. Healthy individuals had significantly higher psychological dysfunction scores than those with asthma and CB. The same occurred with positive mental health. The variables independently associated with lower scores out of these variables were gender female, a greater number of chronic diseases and obesity. On the contrary, alcohol consumption and physical exercise were associated with a higher score in the aforementioned variables.

CONCLUSIONS

Healthy individuals have significantly higher scores in psychological dysfunction and positive mental health than patients with asthma and CB. This suggests that their mental health is much better. The variables related with lower scores out of these variables, and therefore with worse mental health, are: being female, having a greater number of chronic diseases and obesity. On the contrary, alcohol consumption and the practicing of physical exercise are associated with a higher score in the aforementioned variables, thus indicating a greater degree of mental health.

The impact of cigarette smoking on asthma: a population-based international cohort study

BACKGROUND

The prevalence rates of smoking in subjects with asthma have frequently been reported as similar to those in the general population; however, available data are not up-to-date. There is only limited and somewhat conflicting information on the long-term effects of smoking on health outcomes among population-based cohorts of subjects with asthma. We aimed to investigate changes in smoking habits and their effects on forced expiratory volume in 1 s (FEV(1)) in subjects with asthma in comparison with the rest of the population, focusing on the healthy smoker effect.

METHODS

We studied 9,092 subjects without asthma and 1,045 with asthma at baseline who participated in both the European Community Respiratory Health Survey I (20-44 years old in 1991-1993) and II (1999-2002).

RESULTS

At follow-up, smoking was significantly less frequent among subjects with asthma than in the rest of the population (26 vs. 31%; p < 0.001). Subjects with asthma who were already ex-smokers at the beginning of the follow-up in the 1990 s had the highest mean asthma score (number of reported asthma-like symptoms, range 0-5), probably as a result of the healthy smoker effect (2.80 vs. 2.44 in never smokers, 2.19 in quitters and 2.24 in smokers; p < 0.001). The influence of smoking on FEV(1) decline did not depend on asthma status. Smokers had the highest proportion of subjects with chronic cough/phlegm (p < 0.01).

CONCLUSION

One out of 4 subjects with asthma continues smoking and reports significantly more chronic cough and phlegm than never smokers and ex-smokers. This stresses the importance of smoking cessation in all patients with asthma, even in those with less severe asthma.

Smoking and asthma: disentangling their mutual influences using a longitudinal approach

BACKGROUND

The association between smoking and asthma remains unclear and has mostly been assessed in cross-sectional studies, with potential selection bias ("healthy smoker effect").

AIMS

Using a longitudinal approach, the aims were to assess whether 1) childhood asthma modifies smoking initiation, 2) active smoking influences asthma incidence in adults and 3) active smoking among subjects with asthma influences the persistence of the disease or the 12-year evolution in lung function in children and adults.

METHODS

Subjects (513 children and 1190 adults) were recruited and followed-up for 12 years in the context of the EGEA study (Epidemiological study on the Genetics and Environment of Asthma).

RESULTS

Childhood asthma was not associated with a decreased probability of starting active smoking (Hazard Ratio, HR = 0.96; 95% confidence interval (CI): 0.72, 1.27). Smoking at baseline was associated with a higher risk for asthma incidence in adulthood (HR = 1.95, 95% CI: 1.00, 3.77). Among subjects with asthma, smoking was unrelated to lung function evolution; however, among children with moderate to severe asthma at inclusion, smoking tended to slow down the lung function growth (P = 0.04).

CONCLUSION

These findings support the hypothesis that childhood asthma does not prevent smoking initiation and confirm that active smoking has a deleterious role on asthma. Altogether this study emphasizes the importance of active smoking as a serious public health problem particularly for children and women.

Remodeling in asthma

Airway remodeling encompasses the structural alterations in asthmatic compared with normal airways. Airway remodeling in asthmatic patients involves a wide array of pathophysiologic features, including epithelial changes, increased smooth muscle mass, increased numbers of activated fibroblasts/myofibroblasts, subepithelial fibrosis, and vascular changes. Multiple cytokines, chemokines, and growth factors released from both inflammatory and structural cells in the airway tissue create a complex signaling environment that drives these structural changes. However, recent investigations have changed our understanding of asthma from a purely inflammatory disease to a disease in which both inflammatory and structural components are equally involved. Several reports have suggested that asthma primarily develops because of serious defects in the epithelial layer that allow environmental allergens, microorganisms, and toxins greater access to the airway tissue and that can also stimulate the release of mediators from the epithelium, thus contributing to tissue remodeling. Lung-resident fibroblasts and smooth muscle cells have also been implicated in the pathogenesis of airway remodeling. Remodeling is assumed to result in persistent airflow limitation, a decrease in lung function, and airway hyperresponsiveness. Asthmatic subjects experience an accelerated decrease in lung function compared with healthy subjects, which is proportionally related to the duration and severity of their disease.

The importance of airway remodelling in the natural course of asthma

INTRODUCTION

Asthma is associated with airflow limitation and increased decline in lung function. The underlying mechanism for this was probably that persisting inflammation leads to remodelling of the airways.

OBJECTIVES

To review the importance of different factors which are related to airflow limitation and lung function decline in asthma.

METHODS

Case report and literature review.

RESULTS

Asthma severity, smoking, bronchial hyperresponsiveness and eosinophil inflammation were the variables that were most convincingly related to decline in forced expiratory volume in 1 s (FEV(1)) in asthma. Treatment with inhaled corticosteroids probably decreased the rate of FEV(1) decline, although this was more uncertain because of the lack of randomised double blind studies that show such an effect. Progress in the field of the genetics of asthma may, in the near future, elucidate the role of gene-environment interaction in lung function decline in asthma.

CONCLUSION

Regular treatment with inhaled corticosteroids may partly have a beneficial effect on airway remodelling in asthma. Improved understanding of the processes leading to airway remodelling is, however, important in order to prevent a large number of asthmatics from developing irreversible airflow obstruction.

Lung function at 10 yrs is not improved by early corticosteroid treatment in asthmatic children

Early intervention with inhaled corticosteroid (ICS) treatment for lung function development in childhood is debated. In view of lung function at birth, we aimed to assess if early use of ICS influenced lung function at 10 yrs of age. A 10-yr follow-up study of 614/802 children (mean age 10.9 +/- 0.9 yrs) with lung function measurements at birth in the Environment and Childhood Asthma study in Oslo included information on ICS treatment (124 with history of asthma) obtained at 2 and 10 yrs by parental interviews. Main outcomes at 10 yrs were the best values (% predicted and Z-scores) of forced expiratory volume in 1 s (FEV(1)) and mid-expiratory flow. The main explanatory factors were never, past or current use of ICS and Z-scores of the tidal flow-volume ratio t(PTEF)/t(E) [time to peak expiratory flow (t(PTEF)) and total expiratory time (t(E))] at birth. ICS treatment, reported by 11.9% of children in the population sample and 71.6% with current asthma, did not significantly influence lung function from birth to 10 yrs. The best values (and Z-scores) of FEV(1), and mid-expiratory flow were similar (p > 0.1) in subjects receiving ICS during and after 0-3 yrs of age, after 3 yrs only or currently compared with steroid naïve children. Almost half of the change in lung function 0-10 yrs was explained by gender, a history of asthma and t(PTEF)/t(E) at birth. ICS treatment for asthma, reported in every eighth child by age 10 yrs, did not significantly improve lung function from birth to 10 yrs.

What can we learn about asthma and allergy from the follow-up of the RHINE and the ECRHS studies?

OBJECT

The international population-based studies RHINE and ECRHS have provided new insight in the epidemiology and management of asthma, allergy and rhinitis in young adults. The aim of the present review is to focus on longitudinal results with regard incidence and net change of asthma and asthma-like symptoms, risk factors and management of asthma, with special reference to the Nordic-Baltic countries.

RESULTS

Asthma and rhinitis are common conditions that are important in a public health perspective. There are gender differences in incidence and remission. A socio-economic gradient that non-atopic asthma is more strongly related to poverty seems to have developed in the last decade. These findings will challenge our welfare states in the future. In addition, occupational, as well as indoor and outdoor environmental exposures, influenced the onset of asthma. The population-attributable risk for adult asthma because of occupational exposures is equivalent to an incidence of new-onset asthma of 250-300 cases per million per year. Genetic factors, allergic sensitisation, gastro-oesophageal reflux, habitual snoring, diet and other factors may also contribute to the onset of asthma and rhinitis. Even though management of asthma has improved, there are still great variations throughout Europe. These findings highlight the key role doctors and nurses play in educating and reviewing management of patients.

Phenotypes of obstructive lung disease

Recently, there has been much emphasis on the fact that there are many different phenotypes in asthma and chronic obstructive pulmonary disease (COPD). The aim of this review is to investigate some aspects of phenotyping in these two diseases. Epidemiological studies show a quite different risk factor pattern in allergic and non-allergic asthma. Several studies also indicated that there are pathophysiological differences between these two types of asthma: such as eosinophil inflammation in allergic and neutrophil predominance in non-allergic asthma. Neutrophil inflammation may also be a marker of severe asthma. At least one study indicates that non-allergic asthmatics are less responsive to inhaled corticosteroids than allergic asthmatics. Recently, it has been emphasized that COPD also has manifestations other than lung function decline and that this also needs to be taken into account in severity characterisation. Dyspnea, weight loss, psychological status and co-morbidity are factors that seem to be of large prognostic importance independently of the level of airflow obstruction in COPD. Progress has been made in understanding how asthma develops, but effective measures for primary prevention is still lacking. Better phenotyping in asthma will hopefully enable us to make progress in this area. Phenotyping is also important for assessment of prognosis in both asthma and COPD.

Asthma in men and women: treatment adherence, anxiety, and quality of sleep

The aim of this study was to compare female and male asthmatics with special emphasis on reported adherence, anxiety, and quality of sleep. The study included 470 subjects with current asthma from the Nordic countries, who took part in the European Community Respiratory Health Survey (ECRHS) II. Subjects were investigated with a structured clinical interview, including questions on the presence of respiratory symptoms and therapy. They were also asked to fill in the self-reported Hospital Anxiety Depression scale and the Basic Nordic Sleep Questionnaire. Inhaled corticosteroids (OR=0.55) and a doctor's appointment in the last 12 months (OR=0.54) implied a significantly reduced risk for non-adherence in normal situations. At exacerbation in asthma, women had a significantly decreased risk for non-adherence (OR=0.46). Female gender and anxiety were independent risk factors for both insomnia (OR=3.67 and 2.53, respectively) and daytime sleepiness (OR=2.53 and 2.04, respectively). Women with asthma have a more positive attitude towards their medication, have a higher reported adherence, and use inhaled corticosteroids more often than men. At the same time women report more often anxiety and insomnia than men. Awareness of sex differences in the manifestations and attitudes towards treatment of asthma is important in order to improve asthma management.

Body mass index, weight gain, and other determinants of lung function decline in adult asthma

BACKGROUND

Little is known about factors associated with lung function decline in asthma.

OBJECTIVE

To identify the determinants of FEV(1) decline in adults with asthma with and without airflow obstruction at baseline.

METHODS

An international cohort of 638 subjects with asthma (20-44 years old) was identified in the European Community Respiratory Health Survey (1991-1993) and followed up from 1998 to 2002. Spirometry was performed on both occasions. FEV(1) decline was related to potential determinants evaluated at baseline and during the follow-up by random intercept linear regression models. The analyses were stratified by the presence of airflow obstruction (FEV(1)/forced vital capacity < 0.70) at baseline.

RESULTS

In the group of individuals without airflow obstruction (n = 544), a faster FEV(1) decline was observed for subjects with intermediate body mass index (BMI) than for lean and obese subjects. FEV(1) decline was associated with weight gain independently of baseline BMI, and this association was stronger in men (20; 95% CI, 10-30, mL/y/kg gained) than in women (6; 95% CI, 1-11, mL/y). In the group of individuals with airflow obstruction (n = 94), the absence of allergen sensitization and a low BMI at baseline were associated with a faster FEV(1) decline, whereas weight gain was not associated with decline.

CONCLUSIONS

The detrimental effect of weight gain on FEV(1) decline is particularly relevant in subjects with asthma who still do not have an established airflow obstruction. Our findings support the importance of weight management in asthma and recommend weight loss in overweight or obese individuals with asthma.

Risk factors associated with irreversible airflow limitation in asthma

PURPOSE OF REVIEW

Irreversible airflow limitation develops in some patients with asthma and is related to poorer prognosis. This paper reviews recent literature on natural course, risk factors, and potential mechanisms of persistent airflow limitation in asthma.

RECENT FINDINGS

The natural course of persistent airflow limitation in asthma is poorly known, but reduced lung function at disease onset and an increased rate of decline during adult life contribute to its development. Risk factors for progressive irreversible airway obstruction in asthma include adult onset, frequent exacerbations, smoking, occupational exposure, ongoing eosinophilic airway inflammation and airway hyperresponsiveness. Polymorphisms of the ADAM33 gene predict excess decline in lung function, in asthma as well as at population level. It is still not clear how different components of airway remodeling affect lung function in asthma. Airway epithelium and airway smooth muscle seem to be highly important, but the interrelationship between persistent airflow limitation, airway inflammation, remodeling and airway hyperresponsiveness has not been clearly defined.

SUMMARY

Whereas several factors have been implicated as being important in the development of fixed airway obstruction in asthma, we are just beginning to explore the different components of airway remodeling and their relevance, deleterious or beneficial, to clinical outcome.

The Inhaled Steroid Treatment As Regular Therapy in Early Asthma (START) study 5-year follow-up: effectiveness of early intervention with budesonide in mild persistent asthma

BACKGROUND

The Inhaled Steroid Treatment as Regular Therapy in Early Asthma (START) study enrolled 7241 patients aged 5 to 66 years with recent-onset, mild persistent asthma to assess early intervention with the inhaled corticosteroid budesonide on long-term asthma control.

OBJECTIVE

The open-label phase of the START study was included to determine the effect on lung function and asthma control of adding budesonide to the reference group patients who had not initially received inhaled corticosteroids.

METHODS

Patients were randomized to double-blind treatment with budesonide, 200 mug (those aged < 11 years) or 400 mug once daily, or placebo plus the usual asthma therapy for 3 years, after which all patients received 2 years of open-label treatment with budesonide once daily.

RESULTS

During the full 5-year study period, postbronchodilator FEV(1) percent predicted decreased, irrespective of randomized treatment during the double-blind phase, by an average of 2.22% (SE, 0.15%). However, patients with inhaled budesonide in the double-blind phase had a significantly lower risk (odds ratio, 0.61; P < .001) of a severe asthma-related event during the full 5-year study period than those in the reference group. Moreover, patients in the reference group used more additional asthma medications during both the open-label and double-blind phases.

CONCLUSIONS

In mild persistent asthma early intervention with inhaled budesonide was associated with improved asthma control and less additional asthma medication use.

Advances in the care of adults with asthma and allergy in 2007

In 2007 the National Asthma Education and Prevention Program published the Expert Panel Report 3, updating its 1997 and 2002 guidelines for the diagnosis and management of asthma with new emphasis on assessment and attainment of control. This review focuses on the Journal articles published in 2007 pertaining to risk and impairment in adult asthma and interventions to improve its control.

Eosinophilic airway inflammation and the prognosis of childhood asthma

BACKGROUND

Eosinophilic airway inflammation is a key pathophysiological feature of asthma that can predict treatment response. However, the prognostic value of sputum eosinophilia is not established.

OBJECTIVE

The aim of this study was to determine the influence of induced sputum eosinophilia on the prognosis of childhood asthma.

METHODS

A cohort of children with asthma was evaluated by induced sputum analysis at inception and classified as having either eosinophilic asthma (EA) (sputum eosinophils >2.5%) or non-eosinophilic asthma (NEA). After a mean follow-up period of 5 years, eligible subjects (n=83) were contacted and 69 subjects (33 EA, 36 NEA) evaluated. The children had a mean age of 15.9 years, and 61% were male.

RESULTS

Children with EA reported more wheeze during the follow-up period (27% vs. 6% wheezed most years; P<0.0001), increased night waking during the past 12 months (28% vs. 3% reported weekly waking; P=0.01), and greater impairment of quality of life due to asthma (P=0.04). Subsequent beta2-agonist use was increased in children with EA (P=0.02), although there was no difference in corticosteroid use. In EA, subsequent forced expiratory volume in 1 s/forced vital capacity was lower (79% vs. 86%; P=0.01) and grass pollen allergy was more prevalent (77% vs. 27%; P=0.006).

CONCLUSION

In children, eosinophilic airway inflammation is associated with deteriorating asthma over time. This is consistent with the hypothesis that airway inflammation has an adverse impact on the prognosis of childhood asthma, and suggests a role for monitoring inflammation in asthma management.

The socio-economic burden of asthma is substantial in Europe

BACKGROUND

Few data are available on the asthma burden in the general population. We evaluated the level and the factors associated with the asthma burden in Europe.

METHODS

In 1999-2002, 1152 adult asthmatics were identified in the European Community Respiratory Health Survey (ECRHS)-II and the socio-economic burden (reduced activity days and hospital services utilization in the past 12 months) was assessed.

RESULTS

The asthmatics with a light burden (only a few reduced activity days) were 13.2% (95% CI: 11.4-15.3%), whereas those with a heavy burden (many reduced activity days and/or hospital services utilization) were 14.0% (95% CI: 12.1-16.1%). The burden was strongly associated with disease severity and a lower quality of life. Obese asthmatics had a significantly increased risk of a light [relative risk ratio (RRR) = 2.17; 95% CI: 1.18-4.00] or a heavy burden (RRR = 2.77; 95% CI: 1.52-5.05) compared with normal/underweight subjects. The asthmatics with frequent respiratory symptoms showed a threefold (RRR = 2.74; 95% CI: 1.63-4.61) and sixfold (RRR = 5.76; 95% CI: 3.25-10.20) increased risk of a light or a heavy burden compared with asymptomatic asthmatics, respectively. Moreover, the lower the forced expiratory volume in 1 s % predicted, the higher the risk of a heavy burden. The coexistence with chronic cough/phlegm only increased the risk of a heavy burden (RRR = 1.88; 95% CI: 1.16-3.06). An interaction was found between gender and IgE sensitization, with nonatopic asthmatic females showing the highest risk of a heavy burden (21.6%; 95% CI: 16.9-27.1%).

CONCLUSIONS

The asthma burden is substantial in Europe. A heavy burden is more common in asthmatics with obesity, frequent respiratory symptoms, low lung function, chronic cough/phlegm and in nonatopic females.

Asthma control in Europe: a real-world evaluation based on an international population-based study

BACKGROUND

Epidemiologic evidence related to asthma control in patients from the general population is scanty.

OBJECTIVES

We sought to assess asthma control in several European centers according to the Global Initiative for Asthma (GINA) guidelines and to investigate its determinants.

METHODS

In the European Community Respiratory Health Survey II (1999-2002), 1241 adults with asthma were identified and classified into inhaled corticosteroid (ICS) users and non-ICS users in the last year. Control was assessed in both groups by using the GINA proposal (controlled, partly controlled, and uncontrolled asthma), and it was related to potential determinants.

RESULTS

Only 15% (95% CI, 12% to 19%) of subjects who had used ICSs in the last year and 45% (95% CI, 41% to 50%) of non-ICS users had their asthma under control; individuals with uncontrolled asthma accounted for 49% (95% CI, 44% to 53%) and 18% (95% CI, 15% to 21%), respectively. Among ICS users, the prevalence of uncontrolled asthma showed great variability across Europe, ranging from 20% (95% CI, 7% to 41%; Iceland) to 67% (95% CI, 35% to 90%; Italy). Overweight status, chronic cough and phlegm, and sensitization to Cladosporium species were associated with poor control in ICS users. About 65% and 87% of ICS users with uncontrolled and partly controlled asthma, respectively, were on a medication regimen that was less than recommended by the GINA guidelines.

CONCLUSION

Six of 7 European asthmatic adults using ICSs in the last year did not achieve good disease control. The large majority of subjects with poorly controlled asthma were using antiasthma drugs in a suboptimal way. A wide variability in asthma control emerged across Europe.

CLINICAL IMPLICATIONS

Greater attention should be paid to asthma management and to the implementation of the GINA guidelines.