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Mayoral K, Lizano-Barrantes C, Zamora V, Pont A, Miret C, Barrufet C, Caballero-Rabasco MA, Praena-Crespo M, Bercedo A, Valdesoiro-Navarrete L, Guerra MT, Pardo Y, Martínez Zapata MJ, Garin O, Ferrer M. Montelukast in paediatric asthma and allergic rhinitis: a systematic review and meta-analysis. Eur Respir Rev 2023; 32:230124. [PMID: 37852659 PMCID: PMC10582929 DOI: 10.1183/16000617.0124-2023] [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: 06/21/2023] [Accepted: 08/10/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND We aim to assess the impact of montelukast on paediatric patients with asthma/allergic rhinitis, measured using patient-reported outcome measures, compared with other treatments or placebo. METHODS Protocol registration CRD42020216098 (www.crd.york.ac.uk/PROSPERO). MEDLINE and Embase databases were used to conduct the search. Two authors independently selected studies and extracted data, and a third reviewer resolved discrepancies. Meta-analyses were constructed to estimate the standardised mean difference (SMD) using a random-effects model. RESULTS Out of 3937 articles identified, 49 studies met the inclusion criteria, mostly randomised clinical trials (sample sizes: 21-689 patients). The SMD of change pooled estimators for the global, mental and physical domains of health-related quality of life were not statistically significant. For daytime and night-time symptoms scores, the SMD (95% CI) was in favour of inhaled corticosteroids (-0.12, -0.20- -0.05 and -0.23, -0.41- -0.06, respectively). The pooled estimator for global asthma symptoms was better for montelukast when compared with placebo (0.90, 0.44-1.36). CONCLUSIONS The synthesis of the available evidence suggests that, in children and adolescents, montelukast was effective in controlling asthma symptoms when compared with placebo, but inhaled corticosteroids were superior in controlling symptoms, especially at night-time. These findings of our systematic review concur with current guidelines for asthma treatment.
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Affiliation(s)
- Karina Mayoral
- Health Services Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
- Co-first authors
| | - Catalina Lizano-Barrantes
- Health Services Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
- Department of Pharmaceutical Care and Clinical Pharmacy, Faculty of Pharmacy, Universidad de Costa Rica, San Jose, Costa Rica
- Co-first authors
| | - Víctor Zamora
- Health Services Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Angels Pont
- Health Services Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Carme Miret
- Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain
- Preventive Medicine and Public Health Training Unit PSMar-UPF-ASPB, Parc de Salut Mar, Agència de Salut Pública de Barcelona, Pompeu Fabra University, Barcelona, Spain
- Health Services Evaluation and Clinical Epidemiology Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Barrufet
- Health Services Evaluation and Clinical Epidemiology Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Araceli Caballero-Rabasco
- Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain
- Paediatric Pulmonology and Allergy Unit, Paediatric Department, Hospital Del Mar, Barcelona, Spain
| | - Manuel Praena-Crespo
- Centro de Salud La Candelaria, Servicio Andaluz de Salud, Seville, Spain
- Grupo de Vías Respiratorias de la Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
| | - Alberto Bercedo
- Grupo de Vías Respiratorias de la Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
- Centro de Salud Los Castros, Servicio Cántabro de Salud, Cantabria, Spain
| | | | - Maria Teresa Guerra
- Centro de Salud de Jerez Sur, Servicio Andaluz de Salud, Jerez de la Frontera, Spain
| | - Yolanda Pardo
- Health Services Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
- Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mª José Martínez Zapata
- CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau, Barcelona, Spain
| | - Olatz Garin
- Health Services Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Montse Ferrer
- Health Services Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
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Alzayadneh EM, Al Bdour SA, Elayeh ER, Ababneh MM, Al-ani RA, Shatanawi A, Al-Iede M, Al-Zayadneh E. Assessment of Fraction of Exhaled Nitric Oxide and Soluble Receptor for Advanced Glycation End Products Biomarkers for Jordanian Asthmatic Children. J Asthma Allergy 2023; 16:793-811. [PMID: 37559895 PMCID: PMC10408658 DOI: 10.2147/jaa.s415481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/12/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE Fraction of exhaled nitric oxide (FeNO) and soluble advanced glycation end-product receptor (sRAGE) are proposed as biomarkers of asthma, therefore we sought to assess their use in asthmatic children of Jordan. PATIENTS AND METHODS We conducted a case-control study at The University of Jordan Hospital. A total of 141 asthmatic children followed by respiratory pediatricians and 118 healthy children aged 4-18 years were recruited. FeNO was measured by NObreath device and serum sRAGE by ELISA that detect endogenously soluble isoform (esRAGE) and total soluble RAGE (sRAGE). RESULTS sRAGE in asthmatic was half of the control (p <0.001). In addition, ratio of esRAGE/sRAGE was two-fold higher in asthmatic (p = <0.001). Neither FeNO nor esRAGE levels were significantly different between groups. FeNO and asthma control test (ACT) score were negatively correlated corrected for age and body mass index (BMI), (r = -0.180, p= 0.034). For the uncontrolled asthma group, esRAGE/sRAGE negatively correlated with ACT score (r = -.329, p = 0.038). Receiver operating curve (ROC) analysis revealed significant predictive value (PV) for sRAGE and esRAGE/sRAGE in asthma detection with area under the curve (AUC) of (0.751 ± 0.031) and (0.711±.033), consequently. However, no biomarker had a significant PV for lack of control. CONCLUSION The current study supports utilizing sRAGE as a marker for asthma and present a potential therapeutic target. However, our results indicate that both FeNO and sRAGE have a limited role in the management of asthmatic children or assessment of asthma control.
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Affiliation(s)
- Ebaa M Alzayadneh
- Department of Physiology and Biochemistry, School of Medicine, The University of Jordan, Amman, Jordan
| | - Suzan A Al Bdour
- Department of Physiology and Biochemistry, School of Medicine, The University of Jordan, Amman, Jordan
| | - Eman R Elayeh
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Mai M Ababneh
- Department of Pediatrics, School of Medicine, The University of Jordan, Amman, Jordan
| | - Ruqaya A Al-ani
- Department of Pediatrics, School of Medicine, The University of Jordan, Amman, Jordan
| | - Alia Shatanawi
- Department of Pharmacology, School of Medicine, The University of Jordan, Amman, Jordan
| | - Montaha Al-Iede
- Department of Pediatrics, School of Medicine, The University of Jordan, Amman, Jordan
| | - Enas Al-Zayadneh
- Department of Pediatrics, School of Medicine, The University of Jordan, Amman, Jordan
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Asthma Management in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:9-18. [PMID: 36334702 DOI: 10.1016/j.jaip.2022.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
Asthma is a common, complex heterogeneous disease often beginning in early life and is characterized by reversible airflow obstruction. The phenotypic differences that exist in children with asthma may impact underlying comorbid conditions and pharmacologic treatment choices. Prenatal factors for increased risk of asthma could include maternal diet and the maternal microbiome. Evidence also suggests that postnatal microbial exposures and colonization contribute to the risk of allergic diseases and asthma. After confirming the diagnosis, asthma management in children centers on 3 broad areas: pharmacologic treatment, treatment of underlying comorbidities, and education of the patient and caregivers on the importance of adherence and device technique. Moreover, social determinants of health significantly impact on symptom burden and treatment response.
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Khan S, Ouaalaya EH, Chamberlain JD, Dufourg MN, Charles MA, Semjen CR. The external validation of the asthma prediction tool in the French ELFE cohort. Pediatr Pulmonol 2022; 57:2696-2706. [PMID: 35927215 DOI: 10.1002/ppul.26085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/13/2022] [Accepted: 07/16/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Existing predictive scores for early identification of children at high risk of developing asthma include invasive procedures, and hence have limited utility in a primary care setting. The Leicestershire respiratory cohort (LRC) has developed a noninvasive asthma prediction tool (APT) for children with promising results. We aimed to perform its external validation in the French general population Étude Longitudinale Française depuis l'Enfance (ELFE) cohort. METHODS Predictive scores were determined at Age 1 and the primary outcome of asthma was defined as parental reporting of "asthma ever or "wheezing in the past 12 months" at Age 5. Logistic regression was used to calculate the odds ratio (OR) and performance measures, and discriminative performance was reported using the receiver operating curve and area under curve (AUC). Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and visualized with a calibration plot. Overall performance was determined using Brier scores. RESULTS Of the 10,689 children analyzed: 84.9% were at low, 13.1% medium, and 2% at high risk of developing asthma at Age 5. Children in the medium-risk category were three times more likely to develop asthma (OR = 3.3, 95% confidence interval [CI] = 2.97-3.78) whereas 13 times more likely in the high-risk category (OR = 13.8, 95% CI = 10.2-18.8). The tool's AUC was comparable: LRC 0.74 versus ELFE 0.68; as were the Brier scores LRC 0.16 versus ELFE 0.14. The tool's performance was robust to changes in inclusion criteria and outcome definitions. CONCLUSIONS AND RELEVANCE Results of the present study and previous validation studies performed in high-risk populations provide a comprehensive measure of the effectiveness of the APT, providing encouragement for its application by general practitioners.
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Affiliation(s)
- Sadia Khan
- Bordeaux Population Health Research Center, EPICENE Team, INSERM, UMR 1219, Bordeaux University, Bordeaux, France
| | - El Hassane Ouaalaya
- Bordeaux Population Health Research Center, EPICENE Team, INSERM, UMR 1219, Bordeaux University, Bordeaux, France
| | - Jonviea D Chamberlain
- Bordeaux Population Health Research Center, Inserm UMR 1219, University of Bordeaux, Bordeaux, France.,CIC1401-EC, Inserm, Bordeaux, France
| | | | | | - Chantal R Semjen
- Bordeaux Population Health Research Center, EPICENE Team, INSERM, UMR 1219, Bordeaux University, Bordeaux, France
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Allergic Asthma in the Era of Personalized Medicine. J Pers Med 2022; 12:jpm12071162. [PMID: 35887659 PMCID: PMC9321181 DOI: 10.3390/jpm12071162] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 01/17/2023] Open
Abstract
Allergic asthma is the most common asthma phenotype and is characterized by IgE sensitization to airborne allergens and subsequent typical asthmatic symptoms after exposure. A form of type 2 (T2) airway inflammation underlies allergic asthma. It usually arises in childhood and is accompanied by multimorbidity presenting with the occurrence of other atopic diseases, such as atopic dermatitis and allergic rhinitis. Diagnosis of the allergic endotype is based on in vivo (skin prick tests) and/or in vitro (allergen-specific IgE levels, component-resolved diagnosis (CRD)) documentation of allergic sensitization. Biomarkers identifying patients with allergic asthma include total immunoglobulin E (IgE) levels, fractional exhaled nitric oxide (FeNO) and serum eosinophil counts. The treatment of allergic asthma is a complex procedure and requires a patient-tailored approach. Besides environmental control involving allergen avoidance measurements and cornerstone pharmacological interventions based on inhaled drugs, allergen-specific immunotherapy (AIT) and biologics are now at the forefront when it comes to personalized management of asthma. The current review aims to shed light on the distinct phenotype of allergic asthma, ranging over its current definition, clinical characteristics, pathophysiology and biomarkers, as well as its treatment options in the era of precision medicine.
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Krishnan JA, Lazarus SC, Blake KV, Sorkness CA, Covar R, Dyer AM, Lang JE, Lugogo NL, Mauger DT, Wechsler ME, Wenzel SE, Cardet JC, Castro M, Israel E, Phipatanakul W, King TS. Biomarkers to Predict Response to Inhaled Corticosteroids and Long-Acting Muscarinic Antagonists in Adolescents and Adults with Mild Persistent Asthma. Ann Am Thorac Soc 2022; 19:372-380. [PMID: 34793687 PMCID: PMC8937224 DOI: 10.1513/annalsats.202105-613oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/17/2021] [Indexed: 01/09/2023] Open
Abstract
Rationale: Whether biomarkers can be used to predict response to inhaled corticosteroids (ICS) or long-acting muscarinic antagonists (LAMA) in mild persistent asthma is unclear. Objectives: In a prespecified exploratory analysis of a randomized clinical trial of 295 participants 12 years of age or older with uncontrolled mild persistent asthma, we sought to identify biomarkers of treatment response after 12 weeks of ICS (mometasone, 200 μg or 220 μg twice/d), LAMA (tiotropium, 5 μg/d), or placebo in adults (⩾18 yr) and adolescents (12-17 yr) separately. Methods: The primary outcome was a composite outcome of asthma control (treatment failure, asthma control days, and forced expiratory volume in 1 second [FEV1]). Analyses examined type 2 inflammatory biomarkers and physiologic biomarkers. We assessed the area under the receiver operating characteristic curve (AUC) for response to ICS and LAMA (each versus placebo). An AUC of 0.5 suggests no discrimination, 0.7-0.8 is considered acceptable, more than 0.8-0.9 is considered excellent, and more than 0.9 is considered outstanding. Results: In 237 adults, sputum and blood eosinophil levels and fractional exhaled nitric oxide (FeNO) each predicted ICS response (AUCs: 0.61 [95% confidence interval (CI), 0.53-0.69], 0.64 [95% CI, 0.56-0.72], and 0.62 [95% CI, 0.54-0.70], respectively; all P < 0.01); the AUC for blood eosinophil levels and FeNO together was 0.66 (95% CI, 0.58-0.74; P < 0.001). In 58 adolescents, the number of positive aeroallergens and total serum immunoglobulin E each predicted ICS response (AUCs: 0.69 [95% CI, 0.52-0.85] and 0.73 [95% CI, 0.58-0.87], respectively; both P < 0.03); the AUC for both together was 0.73 (95% CI, 0.58-0.87; P = 0.003). After ipratropium bromide, FEV1 reversibility predicted LAMA response in adults (AUC: 0.61 [95% CI, 0.53-0.69], P = 0.007) but not in adolescents. Conclusions: The AUCs of the type 2 inflammatory biomarkers and physiological biomarkers we examined may not be high enough to confidently identify individuals with asthma who respond to ICS and LAMA. However, our findings indicate that the biomarkers that predict response to ICS or LAMA may differ in adults versus adolescents with uncontrolled mild persistent asthma. Prospective, biomarker-stratified clinical trials are needed to confirm these findings and to identify first-line controllers tailored for each population.
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Affiliation(s)
| | | | | | | | | | | | - Jason E. Lang
- Duke University School of Medicine, Durham, North Carolina
| | | | | | | | | | | | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Kansas
| | - Elliot Israel
- Harvard Medical School Brigham & Women’s Hospital, Boston, Massachusetts; and
| | | | - Tonya S. King
- Pennsylvania State University, Hershey, Pennsylvania
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Using FeNO Measurement in Clinical Asthma Management. Chest 2021; 161:906-917. [PMID: 34673021 DOI: 10.1016/j.chest.2021.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/30/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Abstract
Asthma is a common and heterogeneous disease, characterised by lower airway inflammation and airflow limitation. Critical factors in asthma management include establishing an accurate diagnosis and ensuring appropriate selection and dosage of anti-inflammatory therapies. The majority of asthma patients exhibit type 2 (T2) inflammation, with increased interleukin (IL)-4, IL-5, and IL-13 signalling, often with associated eosinophilia. Identifying lower airway eosinophilia with sputum induction improves asthma outcomes, but is time consuming and costly. Increased T2-inflammation leads to upregulation of nitric oxide (NO) release into the airway, with increasing fractional exhaled NO (FeNO) reflecting greater T2-inflammation. FeNO can be easily and quickly measured in the clinic, offering a point of care surrogate measure of the degree of lower airway inflammation. FeNO testing can be used to help confirm an asthma diagnosis, to guide inhaled corticosteroid therapy, to assess adherence to treatment, and to aid selection of appropriate biologic therapy. However, FeNO levels may also be influenced by a variety of intrinsic and extrinsic factors other than asthma, including nasal polyposis and cigarette smoking, and must be interpreted in the broader clinical context rather than viewed in isolation. This review discusses the clinical application of FeNO measurement in asthma care, from diagnosis to treatment selection, and describes its place in current international expert guidelines.
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Diamant N, Amirav I, Armoni-Domany K, Sadot E, Shapira U, Cahal M, Be'er M, Rochman M, Lavie M. High fractional exhaled nitric oxide levels in asthma patients: Does size matter? Pediatr Pulmonol 2021; 56:1449-1454. [PMID: 33730452 DOI: 10.1002/ppul.25333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a biomarker for eosinophilic inflammation used for diagnosis and monitoring of asthma. High FeNO indicates significant airway eosinophilia and steroid-responsive airway inflammation. Some children with asthma have extremely high FeNO levels, but whether these levels represent a different asthma phenotype compared with those with mildly elevated FeNO is unclear. The objective of this study is to investigate whether the extent of high FeNO levels correlates with clinical phenotype, asthma control, comorbidity, and pulmonary function test (PFT) findings in children with asthma. METHODS Anthropometric data, daytime and nighttime symptoms, controller treatment, comorbidity, and PFT findings were retrieved from the Pediatric Pulmonology Unit database (2014-2020) and correlated with FeNO levels in pediatric asthma patients with high FeNO levels. RESULTS Two-hundred children and adolescents with high FeNO levels (range 36-227 ppb) were included. Within this range, higher FeNO levels positively correlated with increased daytime and nighttime symptoms (p = .013 and p = .01, respectively) and poorly controlled asthma (p = .034). A FeNO level of ≥80 ppb was the cutoff for significantly more severe daytime and nighttime symptoms and very poorly controlled asthma compared with levels <80 ppb (p = .004, p = .005, and p = .036, respectively). No correlation was found between FeNO and controller treatment, comorbidity, and PFT performance. CONCLUSION In pediatric asthma patients, high FeNO levels correlate with increased symptom severity and poor asthma control. A FeNO level of ≥80 ppb may serve as an objective indicator for severe asthma.
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Affiliation(s)
- Nir Diamant
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Amirav
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren Armoni-Domany
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efraim Sadot
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Udi Shapira
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Cahal
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moria Be'er
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mika Rochman
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moran Lavie
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cao H, Gu J, Dai J, Yang G, Tang H, Ding A. Comparison of the effect of fluticasone combined with salmeterol and fluticasone alone in the treatment of pediatric asthma: review and meta-analysis. Minerva Pediatr (Torino) 2021; 73:452-459. [PMID: 33988019 DOI: 10.23736/s2724-5276.21.05939-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A systematic review and meta-analysis was performed to investigate the effect of fluticasone + salmeterol and fluticasone alone in the treatment of pediatric asthma. METHODS Studies meeting specific selection criteria were selected from online databases, including Pubmed, Embase, and the Cochrane Library. The quality of randomized controlled trials was assessed using the Cochrane Library. Weighted mean difference (WMD) and 95% CI were used to evaluate the effect size of continuous variables, while rate ratio (RR) and 95% CI were used for dichotomous variables. RESULTS A total of 11 studies, including 8,272 pediatric asthma patients, were included in this meta-analysis. Among these, 4,133 patients were in the salmeterol + fluticasone group. The changes in forced expiratory volume in 1 second in children with asthma in the salmeterol + fluticasone and fluticasone alone groups were significantly different (fixed effects model, WMD = 3.26, 95% CI: 1.52-5.00, P = 0.0002). Asthma exacerbation between two groups were significantly different (fixed effects model, RR = 0.85, 95% CI: 0.73-0.98, Z = 2.18, P = 0.03). There was no difference in the incidence of adverse events between salmeterol + fluticasone and fluticasone alone in the treatment of pediatric asthma (P > 0.05). When the control group was treated with double dose fluticasone, the difference of changes in FEV1 and asthma exacerbation in children with asthma between the two groups were not significant. CONCLUSIONS The efficacy of salmeterol + fluticasone is better than fluticasone alone, and the efficacy of salmeterol + fluticasone is equal to doubling the dose of fluticasone in the treatment of pediatric asthma.
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Affiliation(s)
- Huling Cao
- Pediatric Ward, the Second Affiliated Hospital of Nantong University, Nantong City, China
| | - Junhua Gu
- Department of Radioiogy, the Second Affiliated Hospital of Nantong University, Nantong City, China
| | - Juan Dai
- Pediatric Ward, the Second Affiliated Hospital of Nantong University, Nantong City, China
| | - Guihong Yang
- Pediatric Ward, the Second Affiliated Hospital of Nantong University, Nantong City, China
| | - Hui Tang
- Pediatric Ward, the Second Affiliated Hospital of Nantong University, Nantong City, China
| | - Aiming Ding
- Department of Nursing, the Second Affiliated Hospital of Nantong University, Nantong City, China -
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Truong-Thanh T, Vo-Thi-Kim A, Vu-Minh T, Truong-Viet D, Tran-Van H, Duong-Quy S. The beneficial role of FeNO in association with GINA guidelines for titration of inhaled corticosteroids in adult asthma: A randomized study. Adv Med Sci 2020; 65:244-251. [PMID: 32276003 DOI: 10.1016/j.advms.2020.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/16/2019] [Accepted: 03/19/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE This study aimed to demonstrate the role of fractional concentration of exhaled nitric oxide (FeNO) in association with Global Initiative for Asthma (GINA) guidelines for treatment of adult patients with asthma. METHODS It was a prospective and randomized study. The symptomatic asthmatic patients were randomly divided into two groups: GINA group (followed GINA guidelines; N = 86) or GINA + FeNO group (followed GINA guidelines + FeNO for titration of inhaled corticosteroids - ICS; N = 90). They were followed-up for 9 months. RESULTS In GINA group, 37.2% patients had no treatment and 62.8% patients discontinued treatment vs. 40.0% and 60.0% in GINA + FeNO, respectively. After 3, 6 and 9 months of treatment, the percentage of mild, moderate and severe asthma showed no significant difference between the two groups. At 9th month, Δ moderate asthma (reduction) in GINA + FeNO group was significantly higher than in the GINA group (-22.0% vs. -11.6%; P = 0.018). The improvement of asthma control test (ACT) score was not different between the groups at 9th month (12 ± 6 vs. 10 ± 5; P > 0.05); the level of FeNO reduction in GINA + FeNO group was significantly higher than that in GINA group (-42 ± 11 vs. -35 ± 9; P = 0.022). The daily dose of ICS in GINA + FeNO group was significantly lower than that in GINA group (397 ± 171 vs. 482 ± 240 mcg and 375 ± 203 vs. 424 ± 221 mcg; respectively) at the end of 6 and 9 months. CONCLUSION The use of FeNO in association with GINA guidelines has a beneficial role for accurate daily dose of ICS in adult patients with asthma.
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Rodriguez-Martinez CE, Sossa-Briceño MP, Castro-Rodriguez JA. Predictors of response to medications for asthma in pediatric patients: A systematic review of the literature. Pediatr Pulmonol 2020; 55:1320-1331. [PMID: 32297708 DOI: 10.1002/ppul.24782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/08/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES There has been no systematic review of studies aimed to predict differential responses to medication regimens for asthma controller therapies in pediatric patients. The aim of the present study was to summarize those identifying biomarkers for the different asthma controller therapies. METHODS Studies published by June 2019 that report phenotypic or genotypic characteristics or biomarkers that could potentially serve as response predictors to asthma controller therapies in pediatric patients were included. The quality of studies was assessed using the Cochrane Risk of Bias tool and the Newcastle-Ottawa Scale tool. RESULTS Of 385 trials identified, 30 studies were included. Children with asthma and a positive family history of asthma, with more severe disease, of the white race, with allergy biomarkers, nonobese, with lower lung function, high bronchial hyperresponsiveness to methacholine, or having variants in the FCER2 and CRHR1 gene respond better to inhaled corticosteroids (ICS). Younger age (<10 years), short disease duration (<4 years), high cotinine and urinary leukotriene E4 (LTE4) levels, and 5/5 ALOX5 were associated with a better response to leukotriene receptor antagonist (LTRA). For patients that remain symptomatic, white Hispanics were more likely to respond to LTRA, blacks to ICS, white non-Hispanics to LTRA or LABA, and children without a history of eczema, regardless of race or ethnicity to LABA set-up therapy. In severe persistent asthma, those with atopy and body mass index greater than or equal 25 were more likely to benefit from omalizumab. CONCLUSION Several phenotypic characteristics, biomarkers, or pharmacogenomics markers could be useful for predicting the best drug for asthma treatment.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Jose A Castro-Rodriguez
- Department of Pediatric Pulmonology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
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12
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Crimi C, Ferri S, Campisi R, Crimi N. The Link between Asthma and Bronchiectasis: State of the Art. Respiration 2020; 99:463-476. [PMID: 32464625 DOI: 10.1159/000507228] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/09/2020] [Indexed: 11/19/2022] Open
Abstract
The nonrecognition of asthma-associated comorbidities is often responsible for the therapeutic failure and the worsening of symptoms, and it is associated with frequent exacerbations, higher disease severity, and increased health costs. Bronchiectasis, one of the most frequent asthma-associated comorbidities, can increase airways inflammation and exacerbation rates and cause respiratory functional impairment. The aim of this article is to review the interactions between bronchiectasis and asthma, in order to better identify patients in the overlap between the 2 diseases and to select an "ad hoc" therapy. A literature search on PubMed/MEDLINE was performed using the following search terms: bronchiectasis in asthma, the association between asthma and bronchiectasis, comorbidities in asthma, and severe asthma. This review analyzed the following items: incorrect or underestimated diagnosis of asthma and bronchiectasis, prevalence of bronchiectasis in asthma, the impact of bronchiectasis in asthma, radiological imaging features of the 2 diseases, etiopathogenesis, and common causes (such as gastroesophageal reflux disease, immune deficits, chronic rhinosinusitis and allergic bronchopulmonary aspergillosis, and treatment of asthma and bronchiectasis). The concomitant presence of bronchiectasis and asthma should be suspected and investigated in patients with severe asthma, frequent exacerbations, and not responding to standard therapy. This clinical phenotype, characterized by a more severe disease, worse outcomes, and functional decline, must be readily recognized in order to choose the most appropriate therapeutic approach, able to potentially improve the management of bronchial asthma, to prevent the onset of exacerbations as well the functional decline, and to reduce health costs.
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Affiliation(s)
- Claudia Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy,
| | - Sebastian Ferri
- Personalized Medicine, Asthma and Allergy, Humanitas Research Center IRCCS, Rozzano, Italy
| | - Raffaele Campisi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy
| | - Nunzio Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy.,Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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13
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Abstract
PURPOSE OF REVIEW Childhood asthma is a heterogeneous disease and many children have uncontrolled disease. Therefore an individualized approach is needed to improve asthma outcomes in children. Precision medicine using clinical characteristics, biomarkers, and the rapidly involving field of genomics and pharmacogenomics aims to achieve asthma control and reduce future risks with less side-effects in individual children with asthma. RECENT FINDINGS It is not yet possible to select treatment options on clinical characteristics. Novel monoclonal antibodies are efficacious in patients with severe, eosinophilic asthma. Reduced lung function growth and early decline is a prevalent finding in children with persistent asthma. Pharmacogenetic studies have identified children at risk for cortisol suppression when using inhaled corticosteroids. SUMMARY Clinical characteristics and simple biomarkers like eosinophils, IgE, and the fraction of exhaled nitric oxide may be used in clinical practice for a basic precision medicine approach, deciding which children will have the best chance to respond to inhaled corticosteroids and to the biologicals omalizumab and mepolizumab.Further application of pharmacogenomics and breathomics needs additional studies before they can be applied as tools for precision medicine in individual children with asthma.
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14
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Fitzpatrick AM, Bacharier LB, Jackson DJ, Szefler SJ, Beigelman A, Cabana M, Covar R, Guilbert T, Holguin F, Lemanske RF, Martinez FD, Morgan W, Phipatanakul W, Pongracic JA, Raissy HH, Zeiger RS, Mauger DT. Heterogeneity of Mild to Moderate Persistent Asthma in Children: Confirmation by Latent Class Analysis and Association with 1-Year Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2617-2627.e4. [PMID: 32156610 DOI: 10.1016/j.jaip.2020.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Compared with adults, phenotypic characterization of children with asthma is still limited and it remains difficult to predict which children with asthma are at highest risk for poor outcomes. OBJECTIVE To identify latent classes in a large population of treatment-adherent children with mild to moderate asthma enrolled in clinical trials and determine whether latent class assignment predicts future lung function abnormalities and exacerbation rate. METHODS Latent class analysis was performed on 2593 children with mild to moderate asthma aged 5 18 years, with 19 variables encompassing demographic characteristics, medical history, symptoms, lung function, allergic sensitization, and type 2 inflammation. Outcomes included lung function and the annualized exacerbation rate at 12 months of follow-up. RESULTS Five latent classes were identified with differing demographic features, asthma control, sensitization, type 2 inflammatory markers, and lung function. Exacerbation rates were 1.30 ± 0.12 for class 1 (multiple sensitization with partially reversible airflow limitation), 0.90 ± 0.05 for class 2 (multiple sensitization with reversible airflow limitation), 0.87 ± 0.08 for class 3 (lesser sensitization with reversible airflow limitation), 0.87 ± 0.05 for class 4 (multiple sensitization with normal lung function), and 0.71 ± 0.06 for class 5 (lesser sensitization with normal lung function). Lung function abnormalities persisted in class 1 at 12 months. CONCLUSIONS Children with mild to moderate asthma are a heterogeneous group. Allergic sensitization and lung function may be particularly useful in identifying children at the greatest risk for future exacerbation. Additional studies are needed to determine whether latent classes correspond to meaningful phenotypes for the purpose of personalized treatment.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Daniel J Jackson
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stanley J Szefler
- Children's Hospital Colorado and Department of Pediatrics, University of Colorado, Aurora, Colo
| | - Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Michael Cabana
- Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York, NY
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Theresa Guilbert
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | | | - Robert F Lemanske
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Wayne Morgan
- Department of Pediatrics, The University of Arizona, Tucson, Ariz
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital and Harvard Medical School Department of Pediatrics, Boston, Mass
| | | | | | - Robert S Zeiger
- Kaiser Permanente, Southern California Region and Department of Pediatrics, University of California San Diego, San Diego, Calif
| | - David T Mauger
- Department of Public Health Sciences, Penn State University, Hershey, Pa
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15
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Ramadan AA, Gaffin JM, Israel E, Phipatanakul W. Asthma and Corticosteroid Responses in Childhood and Adult Asthma. Clin Chest Med 2020; 40:163-177. [PMID: 30691710 DOI: 10.1016/j.ccm.2018.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Corticosteroids are the most effective treatment for asthma; inhaled corticosteroids (ICSs) are the first-line treatment for children and adults with persistent symptoms. ICSs are associated with significant improvements in lung function. The anti-inflammatory effects of corticosteroids are mediated by both genomic and nongenomic factors. Variation in the response to corticosteroids has been observed. Patient characteristics, biomarkers, and genetic features may be used to predict response to ICSs. The existence of multiple mechanisms underlying glucocorticoid insensitivity raises the possibility that this might indeed reflect different diseases with a common phenotype.
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Affiliation(s)
- Amira Ali Ramadan
- Division of Allergy and Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Beth Israel Deaconess Center, Cardiovascular institute, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Jonathan M Gaffin
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Elliot Israel
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Brigham and Women's Hospital, 15 Francis Street, Boston, MA 02115, USA
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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16
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Pajor NM, Guilbert TW. Personalized Medicine and Pediatric Asthma. Immunol Allergy Clin North Am 2019; 39:221-231. [PMID: 30954172 DOI: 10.1016/j.iac.2018.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Asthma is a heterogeneous disorder described by a large number of clinical features. A growing body of literature on more specific asthma phenotypes provides evidence for a phenotype-based approach to management in which specific therapies are recommended based on patient and disease characteristics. This understanding, coupled with an increase in the number of available therapies for children with asthma, as well as emerging therapies and phenotypic markers, will allow for improved asthma management in the future.
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Affiliation(s)
- Nathan M Pajor
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH 45229, USA
| | - Theresa W Guilbert
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Pulmonary Division, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH 45229, USA.
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17
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Duong-Quy S. Clinical Utility Of The Exhaled Nitric Oxide (NO) Measurement With Portable Devices In The Management Of Allergic Airway Inflammation And Asthma. J Asthma Allergy 2019; 12:331-341. [PMID: 31632093 PMCID: PMC6789173 DOI: 10.2147/jaa.s190489] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/12/2019] [Indexed: 01/11/2023] Open
Abstract
Nitric oxide (NO) is a potential bioactive gas produced continuously and constantly in the airways of healthy subjects. In allergic airway inflammation, the level of exhaled NO is usually increased and mediated by inducible nitric oxide synthase (iNOS) enzyme presenting in the epithelium and different inflammatory cells. The measurement of NO concentration in the airway is possible with portable devices which use an electroluminescence technique. In subjects with upper airway with allergic inflammation such as in allergic rhinitis, the measurement of nasal NO (nNO) may help to diagnose and manage the disease. In the lower airway, increased fractional exhaled NO (FENO) reflects directly the inflammatory process that occurs in the airways that are typically seen in asthma. It has been shown that there is a strong correlation between FENO levels and increased activity of airway inflammation mediated by immuno-allergic cells and mediators. Thus, FENO has higher specificity and sensitivity than other methods in diagnosing the severity of inflammation in asthmatic patients. Moreover, the correlation between increased FENO levels and a high risk of bronchial hyperresponsiveness has also been demonstrated. FENO is also a relevant biomarker to evaluate asthma status due to the change of its values occurring earlier than clinical manifestations and spirometry parameters. In addition, the measurement of FENO with portable devices helps to support the diagnosis of asthma, to follow-up the control of asthma and to personalize asthmatic patients for target treatment with biologic therapy. Therefore, measuring FENO with portable devices in the diagnosis and treatment of allergic airway inflammation, especially in asthma, is one of the most essential applications of NO biomarkers in exhaled breath.
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Affiliation(s)
- Sy Duong-Quy
- Department of Respiratory Diseases, Medical and Biological Research Centre, Lam Dong Medical College, Dalat City, Lam Dong Province, Vietnam
- Department of Immuno-Allergology, Penn State Medical College, Hershey, PA, USA
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18
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Kalayci O, Abdelateef H, Pozo Beltrán CF, El-Sayed ZA, Gómez RM, Hossny E, Morais-Almeida M, Nieto A, Phipatanakul W, Pitrez P, Wong GW, Xepapadaki P, Papadopoulos NG. Challenges and choices in the pharmacological treatment of non-severe pediatric asthma: A commentary for the practicing physician. World Allergy Organ J 2019; 12:100054. [PMID: 31641403 PMCID: PMC6796770 DOI: 10.1016/j.waojou.2019.100054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/23/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022] Open
Abstract
In recent years, asthma research has focused intensely on the severe part of the disease spectrum, leading to new treatments, mostly therapeutic monoclonal antibodies. However, severe asthma accounts for not more than 2% of asthma in the pediatric population. Therefore, non-severe asthma remains a major health problem in children, not only for patients and parents but also for healthcare professionals such as general practitioners, pediatricians and allergists who take care of these patients. It is thus essential to identify and put in context novel concepts, applicable to the treatment of these patients. Recent evidence suggests benefits from using anti-inflammatory treatment even for the mildest cases, for whom until now only symptomatic bronchodilation was recommended. Likewise, “reliever” medication may be better combined with an inhaled corticosteroid (ICS). Among “new” treatments (for children), ICS formulation in ultrafine particles has showed promise and tiotropium is gaining access to the pediatric population. Maintenance and reliever therapy (MART) is an option for moderate disease. Most importantly, personalized response to medications appears to be considerable, therefore, it may need to be taken into account. Overall, these new options provide opportunities for multiple new management strategies. The deployment of such strategies in different populations remains to be evaluated.
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Affiliation(s)
- Omer Kalayci
- Pediatric Allergy and Asthma, Hacettepe University, School of Medicine, Ankara, Turkey
- Corresponding author.
| | - Hanan Abdelateef
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Zeinab A. El-Sayed
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Elham Hossny
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Antonio Nieto
- Pediatric Pulmonology & Allergy Unit Children's Hospital la Fe, 46026, Valencia, Spain
| | - Wanda Phipatanakul
- Pediatric Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Paulo Pitrez
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Gary Wk. Wong
- Department of Paediatrics, The Chinese University of Hong Kong, China
| | | | - Nikolaos G. Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
- Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
- Corresponding author. Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
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19
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Duffey H, Anderson WC. It's Time to Start Phenotyping Our Patients with Asthma. Immunol Allergy Clin North Am 2019; 39:561-572. [PMID: 31563189 DOI: 10.1016/j.iac.2019.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Advances in the management of pediatric asthma, including biologics, offer practitioners the ability to tailor therapies to individual patients. However, asthma treatment guidelines have not kept up with current studies. This review explores the current literature incorporating the use of phenotyping in pediatric patients with asthma to provide precision therapy. Biomarkers can be used to more accurately predict the development of asthma, identify features that may be associated with difficult-to-control or severe asthma, and forecast response to therapies. Biomarkers and other phenotypic data can also be helpful in patients with uncontrolled, severe asthma in the selection of a biologic therapy.
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Affiliation(s)
- Hannah Duffey
- Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA
| | - William C Anderson
- Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA.
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20
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Ross KR, Teague WG, Gaston BM. Life Cycle of Childhood Asthma: Prenatal, Infancy and Preschool, Childhood, and Adolescence. Clin Chest Med 2018; 40:125-147. [PMID: 30691707 DOI: 10.1016/j.ccm.2018.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Asthma is a heterogeneous developmental disorder influenced by complex interactions between genetic susceptibility and exposures. Wheezing in infancy and early childhood is highly prevalent, with a substantial minority of children progressing to established asthma by school age, most of whom are atopic. Adolescence is a time of remission of symptoms with persistent lung function deficits. The transition to asthma in adulthood is not well understood.
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Affiliation(s)
- Kristie R Ross
- Division of Pediatric Pulmonology, Allergy, Immunology and Sleep Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - W Gerald Teague
- Pediatric Asthma Center of Excellence, Department of Pediatrics, University of Virginia School of Medicine, 409 Lane Road, Building MR4, Room 2112, PO Box 801349, Charlottesville, VA 22908, USA
| | - Benjamin M Gaston
- Division of Pediatric Pulmonology, Allergy, Immunology and Sleep Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Children's Lung Foundation, 2109 Adelbert Road, BRB 827, Cleveland, OH 44106, USA
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21
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Fitzpatrick AM, Bacharier LB, Guilbert TW, Jackson DJ, Szefler SJ, Beigelman A, Cabana MD, Covar R, Holguin F, Lemanske RF, Martinez FD, Morgan W, Phipatanakul W, Pongracic JA, Zeiger RS, Mauger DT. Phenotypes of Recurrent Wheezing in Preschool Children: Identification by Latent Class Analysis and Utility in Prediction of Future Exacerbation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:915-924.e7. [PMID: 30267890 DOI: 10.1016/j.jaip.2018.09.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recurrent preschool wheezing is a heterogeneous disorder with significant morbidity, yet little is known about phenotypic determinants and their impact on clinical outcomes. OBJECTIVE Latent class analysis (LCA) was used to identify latent classes of recurrent preschool wheeze and their association with future exacerbations and inhaled corticosteroid (ICS) treatment response. METHODS Data from 5 clinical trials of 1708 children aged 12 to 71 months with recurrent wheezing were merged. LCA was performed on 10 demographic, exposure, and sensitization variables to determine the optimal number of latent classes. The primary outcome was the annualized rate of wheezing exacerbations requiring systemic corticosteroids during the study intervention period; the secondary outcome was the time to first exacerbation. Exploratory analyses examined the effect of daily ICS treatment on exacerbation outcomes. RESULTS Four latent classes of recurrent wheezing were identified; these were not distinguished by current symptoms or historical exacerbations but differed with regard to allergen sensitization and/or exposures. Annualized exacerbation rates (mean ± SEM/year) were 0.65 ± 0.06 for class 1 ("minimal sensitization"), 0.93 ± 0.10 for class 2 ("sensitization with indoor pet exposure"), 0.60 ± 0.07 for class 3 ("sensitization with tobacco smoke exposure"), and 0.81 ± 0.10 for class 4 ("multiple sensitization and eczema") (P < .001). In a research setting of high adherence, daily ICS treatment improved exacerbation rates in classes 2 and 4 but not the other groups. CONCLUSIONS Sensitization and exposure assessments are useful in the prediction of future exacerbation and may identify children most likely to respond favorably to daily ICS treatment.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | | | - Theresa W Guilbert
- Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | | | - Stanley J Szefler
- Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado, Aurora, Colo
| | | | - Michael D Cabana
- Department of Pediatrics, University of California San Francisco, San Francisco, Calif
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Fernando Holguin
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pa
| | | | | | - Wayne Morgan
- Department of Pediatrics, University of Arizona, Tucson, Ariz
| | - Wanda Phipatanakul
- Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | | | - Robert S Zeiger
- Kaiser Permanente, Southern California Region, San Diego, Calif; Department of Pediatrics, University of California San Diego, San Diego, Calif
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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22
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Chipps BE, Bacharier LB, Farrar JR, Jackson DJ, Murphy KR, Phipatanakul W, Szefler SJ, Teague WG, Zeiger RS. The pediatric asthma yardstick: Practical recommendations for a sustained step-up in asthma therapy for children with inadequately controlled asthma. Ann Allergy Asthma Immunol 2018; 120:559-579.e11. [PMID: 29653238 DOI: 10.1016/j.anai.2018.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/31/2018] [Accepted: 04/03/2018] [Indexed: 12/29/2022]
Abstract
Current asthma guidelines recommend a control-based approach to management involving assessment of impairment and risk followed by implementation of treatment strategies individualized according to the patient's needs and preferences. However, for children with asthma, achieving control can be elusive. Although tools are available to help children (and families) track and manage day-to-day symptoms, when and how to implement a longer-term step-up in care is less clear. Furthermore, treatment is challenged by the 3 age groups of childhood-adolescence (12-18 years old), school age (6-11 years old), and young children (≤5 years old)-and what works for 1 age group might not be the best approach for another. The Pediatric Asthma Yardstick provides an in-depth assessment of when and how to step-up therapy for the child with not well or poorly controlled asthma. Development of this tool follows others in the Yardstick series, presenting patient profiles and step-up strategies based on current guidance documents, but modified according to newer data and the authors' combined clinical experience. The objective is to provide clinicians who treat children with asthma practical and clinically relevant recommendations for each step-up and each intervention, with the intent of helping practitioners better treat their pediatric patients with asthma, particularly those who do not always respond to recommended therapies.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri
| | | | - Daniel J Jackson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin R Murphy
- Boys Town National Research Hospital, Boys Town, Nebraska
| | - Wanda Phipatanakul
- Allergy, Asthma, Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital of Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - W Gerald Teague
- Division of Pediatric Respiratory Medicine and Allergy, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Robert S Zeiger
- Department of Allergy and Research and Evaluation, Kaiser Permanente Southern California Region, San Diego and Pasadena, California
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23
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Ramratnam SK, Bacharier LB, Guilbert TW. Severe Asthma in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:889-898. [PMID: 28689839 DOI: 10.1016/j.jaip.2017.04.031] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/18/2017] [Accepted: 04/19/2017] [Indexed: 12/28/2022]
Abstract
Severe asthma in children is associated with significant morbidity and is a highly heterogeneous disorder with multiple clinical phenotypes. Cluster analyses have been performed in several groups to explain some of the heterogeneity of pediatric severe asthma, which is reviewed in this article. The evaluation of a child with severe asthma includes a detailed diagnostic assessment and excluding other possible diagnoses and addressing poor control due to comorbidities, lack of adherence to asthma controller medications, poor technique, and other psychological and environmental factors. Children with severe asthma require significant resources including regular follow-up appointments with asthma education, written asthma action plan, and care by a multidisciplinary team. Management of pediatric severe asthma now includes emerging phenotypic-directed therapies; however, continued research is still needed to further study the long-term outcomes of pediatric severe asthma and its treatment.
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Affiliation(s)
- Sima K Ramratnam
- University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Leonard B Bacharier
- Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Theresa W Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Cincinnati, Ohio
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24
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Inoue Y, Sato S, Manabe T, Makita E, Chiyotanda M, Takahashi K, Yamamoto H, Yanagida N, Ebisawa M. Measurement of Exhaled Nitric Oxide in Children: A Comparison Between NObreath® and NIOX VERO® Analyzers. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2018; 10:478-489. [PMID: 30088368 PMCID: PMC6082813 DOI: 10.4168/aair.2018.10.5.478] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 05/08/2018] [Indexed: 11/22/2022]
Abstract
Purpose Few studies have compared fractional exhaled nitric oxide (FeNO) measurement by NIOX VERO® (NOV) and other devices in children. Moreover, there is no agreement between differences in FeNO values obtained using different devices in adults. Here, we compared FeNO values obtained using NOV and NObreath® (NOB) systems to derive a correction equation for children. Methods Eighty-eight participants (age 7–15 years) who were diagnosed with atopic bronchial asthma and visited Sagamihara National Hospital as outpatients between January and April of 2017 were included. We measured FeNO values obtained using NOB and NOV, and analyzed them using Wilcoxon tests and Altman-Bland plots. Results The median age of the participants was 11.5 years, and the scored Asthma Control Test (ACT) or Childhood ACT (C-ACT) was 25 (interquartile range, 24–25) or 26 (24–27). NOB and NOV values were significantly different (31 [14–52] versus 36 [20–59] ppb; P = 0.020) and strongly correlated (r = 0.92). An equation to convert NOB values into NOV values was derived using linear regression as follows: log NOV = 0.7329 × log NOB + 0.4704; NOB for 20, 40, 58, 80 and 100 ppb corresponded to NOV for 27, 44, 59, 73 and 86 ppb. Thus, NOB < 58 ppb suggested NOB < NOV, whereas NOB > 58 ppb suggested NOB > NOV. Conclusions NOB and NOV values were strongly correlated. Participants whose FeNO values were relatively low represented NOB < NOV, whereas those whose FeNO values were relatively high represented NOB > NOV.
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Affiliation(s)
- Yoko Inoue
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan.,Department of Pediatrics, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tetsuharu Manabe
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Eishi Makita
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Masako Chiyotanda
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Kyohei Takahashi
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hitoshi Yamamoto
- Department of Pediatrics, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan.
| | - Motohiro Ebisawa
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Lang JE, Fitzpatrick AM, Mauger DT, Guilbert TW, Jackson DJ, Lemanske RF, Martinez FD, Strunk RC, Zeiger RS, Phipatanakul W, Bacharier LB, Pongracic JA, Holguin F, Cabana MD, Covar RA, Raissy HH, Tang M, Szefler SJ. Overweight/obesity status in preschool children associates with worse asthma but robust improvement on inhaled corticosteroids. J Allergy Clin Immunol 2017; 141:1459-1467.e2. [PMID: 29273557 PMCID: PMC6675020 DOI: 10.1016/j.jaci.2017.09.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/31/2017] [Accepted: 09/27/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Overweight/obesity (OW) is linked to worse asthma and poorer inhaled corticosteroid (ICS) response in older children and adults. OBJECTIVE We sought to describe the relationships between OW and asthma severity and response to ICS in preschool children. METHODS This post hoc study of 3 large multicenter trials involving 2- to 5-year-old children compared annualized asthma symptom days and exacerbations among normal weight (NW) (body mass index: 10th-84th percentiles) versus OW (body mass index: ≥85th percentile) participants. Participants had been randomized to daily ICS, intermittent ICS, or daily placebo. Simple and multivariable linear regression was used to compare body mass index groups. RESULTS Within the group not treated with a daily controller, OW children had more asthma symptom days (90.7 vs 53.2, P = .020) and exacerbations (1.4 vs 0.8, P = .009) thanNW children did. Within the ICS-treated groups, OW and NW children had similar asthma symptom days (daily ICS: 47.2 vs 44.0 days, P = .44; short-term ICS: 61.8 vs 52.9 days, P = .46; as-needed ICS: 53.3 vs 47.3 days, P = .53), and similar exacerbations (daily ICS: 0.6 vs 0.8, P = .10; short-term ICS: 1.1 vs 0.8 days, P = .25; as-needed ICS: 1.0 vs 1.1, P = .72). Compared with placebo, daily ICS in OW led to fewer annualized asthma symptom days (90.7 vs 41.2, P = .004) and exacerbations (1.4 vs 0.6, P = .006), while similar protective ICS effects were less apparent among NW. CONCLUSIONS In preschool children off controller therapy, OW is associated with greater asthma impairment and exacerbations. However, unlike older asthmatic patients, OW preschool children do not demonstrate reduced responsiveness to ICS therapy.
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Affiliation(s)
- Jason E Lang
- Department of Pediatrics, Duke University School of Medicine, Durham, NC.
| | | | - David T Mauger
- Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pa
| | | | - Daniel J Jackson
- Pediatrics Section of Allergy, Immunology, and Rheumatology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Robert F Lemanske
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | | | - Robert S Zeiger
- Kaiser Permanente Medical Center, University of California-San Diego, San Diego, Calif
| | | | | | | | - Fernando Holguin
- University of Pittsburgh School of Medicine, Pittsburgh, Pittsburgh, Pa
| | | | | | | | - Monica Tang
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Stanley J Szefler
- Children's Hospital Colorado, The Breathing Institute, and University of Colorado School of Medicine, Aurora, Colo
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26
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Wu YF, Su MW, Chiang BL, Yang YH, Tsai CH, Lee YL. A simple prediction tool for inhaled corticosteroid response in asthmatic children. BMC Pulm Med 2017; 17:176. [PMID: 29216859 PMCID: PMC5721661 DOI: 10.1186/s12890-017-0533-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 11/29/2017] [Indexed: 01/05/2023] Open
Abstract
Background Inhaled corticosteroids are recommended as the first-line controller medication for childhood asthma owing to their multiple clinical benefits. However, heterogeneity in the response towards these drugs remains a significant clinical problem. Methods Children aged 5 to 18 years with mild to moderate persistent asthma were recruited into the Taiwanese Consortium of Childhood Asthma Study. Their responses to inhaled corticosteroids were assessed based on their improvements in the asthma control test and peak expiratory flow. The predictors of responsiveness were demographic and clinical features that were available in primary care settings. We have developed a prediction model using logistic regression and have simplified it to formulate a practical tool. We assessed its predictive performance using the area under the receiver operating characteristic curve. Results Of the 73 asthmatic children with baseline and follow-up outcome measurements for inhaled corticosteroids treatment, 24 (33%) were defined as non-responders. The tool we have developed consisted of three predictors yielding a total score between 0 and 5, which are comprised of the following parameters: the age at physician-diagnosis of asthma, sex, and exhaled nitric oxide. Sensitivity and specificity of the tool for prediction of inhaled corticosteroids non-responsiveness, for a score of 3, were 0.75 and 0.69, respectively. The areas under the receiver operating characteristic curve for the prediction tool was 0.763. Conclusions Our prediction tool represents a simple and low-cost method for predicting the response of inhaled corticosteroids treatment in asthmatic children.
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Affiliation(s)
- Yi-Fan Wu
- Department of Family Medicine, Taipei City Hospital, Renai Branch, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Ming-Wei Su
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Hsu Yang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hui Tsai
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yungling L Lee
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan. .,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan.
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27
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Bakirtas A, Kutlu A, Baccioglu A, Erkekol FO, Bavbek S, Kalayci O. Physicians' preference for controller medication in mild persistent asthma. Respir Med 2017; 131:236-240. [PMID: 28947037 DOI: 10.1016/j.rmed.2017.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/06/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although the asthma guidelines recommend inhaled corticosteroids(ICS) or leukotriene receptor antagonists-(LTRAs) for the treatment of mild persistent asthma, factors governing the physicians' preference are unknown. We aimed to investigate the preference of physicians for the controller medication and the factors governing their choice. METHODS A self-administered questionnaire composed of 16 questions that aimed to determine the preference of the physicians for the first choice controller medication in mild persistent asthma and physician and patient related factors that may be associated with this selection was e-mailed to the members of the Turkish National Society of Allergy and Clinical Immunology and distributed to participants in the 21st congress. RESULTS Of the 670 questionnaires, there were 51% participants and 336 of them were complete enough to be included in the analysis. Low dose ICS was preferred as the first choice controller medication for mild persistent asthma by 84.5% of the physicians. The reasons for physicians' preference were different for ICS and LTRA. In the logistic regression analysis, use of asthma guidelines (OR:3.5, 95%CI:1.3-9.3, p = 0.01), alignment in guidelines (OR:2.9, 95%CI:1.4-5.8, p = 0.002) and the opinion that it is a more effective (OR:2.3, 95%CI:1.1-4.8, p = 0.02) were independently associated with ICS preference. Being a pediatrician (OR:5.4, 95%CI: 2.7-10.5, p < 0.001) and the opinion that it has better patient compliance (OR:4.4, 95%CI: 1.6-12.0, p = 0.004) were independently associated with LTRA preference. CONCLUSION Surveyed Turkish physicians, the majority of whom were specialists, preferred ICS over LTRA as controller medication in mild persistent asthma. Asthma guidelines, training background (pediatrician versus not) and perceived efficacy and patient compliance appeared to influence their preferences.
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Affiliation(s)
- Arzu Bakirtas
- Department of Pediatric Allergy and Asthma, Gazi University School of Medicine, Ankara, Turkey.
| | - Ali Kutlu
- Department of Emergency Medicine, Uskudar University, Istanbul, Turkey
| | - Ayse Baccioglu
- Department of Clinical Immunology and Allergic Diseases, Kirikkale University School of Medicine, Ankara, Turkey
| | - Ferda Oner Erkekol
- Department of Clinical Immunology and Allergic Diseases, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Sevim Bavbek
- Department of Clinical Immunology and Allergic Diseases, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Omer Kalayci
- Department of Pediatric Allergy and Asthma, Hacettepe University School of Medicine, Ankara, Turkey
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- Turkish National Society of Allergy and Clinical Immunology, Turkey
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28
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Harnan SE, Essat M, Gomersall T, Tappenden P, Pavord I, Everard M, Lawson R. Exhaled nitric oxide in the diagnosis of asthma in adults: a systematic review. Clin Exp Allergy 2017; 47:410-429. [PMID: 27906490 DOI: 10.1111/cea.12867] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 10/24/2016] [Accepted: 11/01/2016] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To identify and synthesize evidence on the diagnostic accuracy of FE NO for asthma in adults. MATERIALS AND METHODS Systematic searches (nine key biomedical databases and trial registers) were carried out on November 2014. Records were included if they recruited patients with the symptoms of asthma; used a single set of inclusion criteria; measured FE NO50 in accordance with American Thoracic Society guidelines, 2005 (off-line excluded); reported/allowed calculation of true-positive, true-negative, false-positive and false-negative patients as classified against any reference standard. Study quality was assessed using QUADAS II. Meta-analysis was planned where clinical study heterogeneity allowed. Rule-in and rule-out uses of FE NO were considered. RESULTS A total of 4861 records were identified originally and 1312 in an update. Twenty-seven studies were included. Heterogeneity precluded meta-analysis. Results varied even within subgroups of studies. Cut-off values for the best sum of sensitivity and specificity varied from 12 to 55 p.p.b., but did not produce high accuracy. 100% sensitivity or 100% specificity was reported by some studies indicating potential use as a rule-in or rule-out strategy. CONCLUSIONS AND CLINICAL RELEVANCE FE NO50 had variable diagnostic accuracy even within subgroups of studies with similar characteristics. Diagnostic accuracy, optimal cut-off values and best position for FE NO50 within a pathway remain poorly evidenced.
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Affiliation(s)
- S E Harnan
- Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield, UK
| | - M Essat
- Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield, UK
| | - T Gomersall
- Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield, UK
| | - P Tappenden
- Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield, UK
| | - I Pavord
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M Everard
- School of Paediatrics & Child Health, Princess Margaret Hospital, University of Western Australia, Crawley, WA, Australia
| | - R Lawson
- Department of Respiratory Medicine, Royal Hallamshire Hospital, Sheffield, UK
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29
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Iordanidou M, Loukides S, Paraskakis E. Asthma phenotypes in children and stratified pharmacological treatment regimens. Expert Rev Clin Pharmacol 2016; 10:293-303. [PMID: 27936975 DOI: 10.1080/17512433.2017.1271322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Asthma is the most common inflammatory disease in childhood. The interaction of genetic, environmental and host factors may contribute to the development of childhood asthma and defines its progress, including persistence and severity. Until now, various classifications of childhood asthma phenotypes have been suggested based on patient's age during onset of symptoms, type of inflammatory cells, response to treatment and disease severity. Many efforts have been carried out to identify childhood asthma phenotypes and to clarify which are the risk factors that define asthma prediction and the response to therapy. The identification of asthma phenotypes has not only prognostic but also therapeutic role. However, the classification of asthma phenotypes is complex due to the heterogeneity of the disease. Areas covered: The current childhood asthma phenotypes and the new therapeutic strategies for each phenotype are reviewed. Expert commentary: There are multiple phenotypes in childhood asthma and it is crucial to define them before the initiation of personalized treatment. Both the therapeutic strategy and monitoring should follow the recent guidelines.
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Affiliation(s)
- Maria Iordanidou
- a Paediatric Respiratory Unit, Department of Pediatrics , University Hospital of Alexandroupolis , Alexandroupolis , Greece
| | - Stelios Loukides
- b 2nd Respiratory Medicine Department , National and Kapodistrian University of Athens Medical School, Attiko University Hospital , Athens , Greece
| | - Emmanouil Paraskakis
- a Paediatric Respiratory Unit, Department of Pediatrics , University Hospital of Alexandroupolis , Alexandroupolis , Greece
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30
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Cohen RT, Rodeghier M, Kirkham FJ, Rosen CL, Kirkby J, DeBaun MR, Strunk RC. Exhaled nitric oxide: Not associated with asthma, symptoms, or spirometry in children with sickle cell anemia. J Allergy Clin Immunol 2016; 138:1338-1343.e4. [PMID: 27521278 PMCID: PMC5330622 DOI: 10.1016/j.jaci.2016.06.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/25/2016] [Accepted: 06/13/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND The significance of fractional exhaled nitric oxide (Feno) levels in children with sickle cell anemia (SCA) is unclear, but increased levels can be associated with features of asthma and thus increased morbidity. OBJECTIVES We sought to determine factors associated with Feno and whether Feno levels are associated with increased rates of acute chest syndrome (ACS) and pain. METHODS All participants had SCA, were part of the prospective observational Sleep and Asthma Cohort study, and had the following assessments: Feno levels, spirometry, blood samples analyzed for hemoglobin, white blood cell counts, eosinophil counts and total serum IgE levels, questionnaires about child medical and family history, and review of medical records. RESULTS The analytic sample included 131 children with SCA (median age, 11.2 years; age range, 6-18 years) followed for a mean of 16.2 years, including a mean of 5.1 years after baseline Feno data measurements. In multivariable analyses higher Feno levels were associated with ln(IgE) levels (P < .001) and the highest quartile of peripheral eosinophil counts (P = .03) but not wheezing symptoms, baseline spirometric indices, or response to bronchodilator. Multivariable analyses identified that the incident rate of ACS was associated with ln(Feno) levels (P = .03), as well as male sex (P = .025), wheezing causing shortness of breath (P = .002), and ACS at less than 4 years of age (P < .001). Feno levels were not associated with future pain episodes. CONCLUSIONS Steady-state Feno levels were not associated with an asthma diagnosis, wheezing symptoms, lung function measures, or prior sickle cell morbidity but were associated with markers of atopy and increased risk of future ACS events.
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Affiliation(s)
- Robyn T. Cohen
- Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
| | | | - Fenella J. Kirkham
- Neurosciences Unit, University College London, Institute of Child Health, London, United Kingdom
| | - Carol L. Rosen
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jane Kirkby
- Portex Respiratory Unit, University College London, Institute of Child Health, London, UK
| | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Robert C. Strunk
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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31
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Individualized therapy for persistent asthma in young children. J Allergy Clin Immunol 2016; 138:1608-1618.e12. [PMID: 27777180 DOI: 10.1016/j.jaci.2016.09.028] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/25/2016] [Accepted: 09/09/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Phenotypic presentations in young children with asthma are varied and might contribute to differential responses to asthma controller medications. METHODS The Individualized Therapy for Asthma in Toddlers study was a multicenter, randomized, double-blind, double-dummy clinical trial in children aged 12 to 59 months (n = 300) with asthma necessitating treatment with daily controller (Step 2) therapy. Participants completed a 2- to 8-week run-in period followed by 3 crossover periods with daily inhaled corticosteroids (ICSs), daily leukotriene receptor antagonists, and as-needed ICS treatment coadministered with albuterol. The primary outcome was differential response to asthma medication based on a composite measure of asthma control. The primary analysis involved 2 stages: determination of differential response and assessment of whether 3 prespecified features (aeroallergen sensitization, previous exacerbations, and sex) predicted a differential response. RESULTS Seventy-four percent (170/230) of children with analyzable data had a differential response to the 3 treatment strategies. Within differential responders, the probability of best response was highest for a daily ICS and was predicted by aeroallergen sensitization but not exacerbation history or sex. The probability of best response to daily ICS was further increased in children with both aeroallergen sensitization and blood eosinophil counts of 300/μL or greater. In these children daily ICS use was associated with more asthma control days and fewer exacerbations compared with the other treatments. CONCLUSIONS In young children with asthma necessitating Step 2 treatment, phenotyping with aeroallergen sensitization and blood eosinophil counts is useful for guiding treatment selection and identifies children with a high exacerbation probability for whom treatment with a daily ICS is beneficial despite possible risks of growth suppression.
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Brouwer ML, Wijngaart LSVD, Hugen CAC, Gerrits GPJM, Roukema J, Merkus PJFM. Evaluation of monitoring strategies for childhood asthma. Expert Rev Respir Med 2016; 10:1199-1209. [PMID: 27666112 DOI: 10.1080/17476348.2016.1240034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The goal of monitoring pediatric asthma is to obtain and maintain asthma control, which is defined as minimizing asthma symptoms, restrictions to daily activities and the use of rescue medication. Long term goals include reducing the risk of fixed airflow limitation, and preventing asthma exacerbations and side effects of treatment. Several monitoring tools are available but no consensus exists on how to monitor patients in the most optimal way. Areas covered: In this review, we provide an overview of different tools and address general considerations on monitoring childhood asthma. Asthma care should be tailored to the individual patient. The health care professional should decide which monitoring strategy and frequency is optimal for the individual patient. Expert commentary: Personalized medicine should be the key issue in monitoring asthma in children. It is crucial to monitor disease activity and deterioration but there is no monitoring strategy that is clearly superior compared to others: The optimal strategy and frequency will vary between patients. Actually, both treatment and monitoring of pediatric asthma probably benefit from a personalized approach.
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Affiliation(s)
- M L Brouwer
- a Department of pediatrics , Canisius Wilhelmina Hospital , Nijmegen , The Netherlands
| | - L S van den Wijngaart
- b Amalia children's hospital, department of pediatrics, division of respiratory medicine , Radboud University Medical Centre , Nijmegen , The Netherlands
| | - C A C Hugen
- c Department of pediatrics , University Centre for Chronic Diseases (Dekkerswald) , Nijmegen , The Netherlands
| | - G P J M Gerrits
- a Department of pediatrics , Canisius Wilhelmina Hospital , Nijmegen , The Netherlands
| | - J Roukema
- b Amalia children's hospital, department of pediatrics, division of respiratory medicine , Radboud University Medical Centre , Nijmegen , The Netherlands
| | - P J F M Merkus
- a Department of pediatrics , Canisius Wilhelmina Hospital , Nijmegen , The Netherlands.,b Amalia children's hospital, department of pediatrics, division of respiratory medicine , Radboud University Medical Centre , Nijmegen , The Netherlands
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33
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Zeiger RS, Schatz M, Dalal AA, Chen W, Sadikova E, Suruki RY, Kawatkar AA, Qian L. Blood Eosinophil Count and Outcomes in Severe Uncontrolled Asthma: A Prospective Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:144-153.e8. [PMID: 27665383 DOI: 10.1016/j.jaip.2016.07.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/11/2016] [Accepted: 07/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Severe uncontrolled asthma (SUA) is associated with increased asthma exacerbations. Whether high blood eosinophil counts are related to this burden is uncertain. OBJECTIVES To determine the relationship of blood eosinophil counts to asthma exacerbations, utilization, and cost in patients with SUA. METHODS Patients with persistent asthma (age ≥ 12 years) were identified administratively with SUA in phase I by evidencing (1) 2 or more asthma exacerbations; (2) 6 or more medium- or high-dose dispensed canisters of inhaled corticosteroid (ICS) as monotherapy or with long-acting β2-agonist; and (3) 3 or more dispensed non-ICS controllers. Of the 541 patients with SUA invited to participate in the prospective phase II follow-up study, 261 (48.2%) had blood tests (index date) to determine eosinophil count and other atopic biomarkers. The relationship of blood eosinophil cutoff points to asthma exacerbations and direct costs 1 year after the index date were determined by multivariable regression. RESULTS A blood eosinophil cutoff point of greater than or equal to 400 cells/mm3 compared with less than 400 cells/mm3, but not 150 cells/mm3 or 300 cells/mm3, was a risk factor in the outcome year in adjusted analyses for 2 or more asthma exacerbations (risk ratio, 1.55; 95% CI, 1.02-2.35; P =.04) and any asthma emergency department visit or hospitalization (risk ratio, 2.29; 95% CI, 1.16-4.55; P =.02), but not for rate of asthma exacerbations or incremental total direct asthma costs per patient ($202; 95% CI, -286 to 691). CONCLUSIONS A high blood eosinophil count was an independent risk factor for 2 or more asthma exacerbations or any asthma emergency department visit or hospitalization, but not direct costs in patients with SUA, possibly constrained by limited power.
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Affiliation(s)
- Robert S Zeiger
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif.
| | - Michael Schatz
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | | | - Wansu Chen
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | - Ekaterina Sadikova
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | | | - Aniket A Kawatkar
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
| | - Lei Qian
- Kaiser Permanente Southern California Region, San Diego and Pasadena, Calif
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Abstract
El asma es la enfermedad crónica infantil más frecuente. El diagnóstico es fácil en la mayoría de las ocasiones por la aparición de episodios de disnea espiratoria con sibilancias reversibles espontáneamente o por el efecto de broncodilatadores. En el momento del diagnóstico, se requieren tres pruebas complementarias: las radiografías de tórax, las pruebas funcionales respiratorias y un estudio alergológico. El tratamiento de las exacerbaciones se basa en los beta2-adrenérgicos inhalados y, si es preciso, en la corticoterapia oral. El objetivo del tratamiento de fondo es mantener el control, prevenir las exacerbaciones y restaurar o mantener las funciones pulmonares normales. Se debe adaptar al nivel de control del asma y en él tiene un lugar destacado la corticoterapia inhalada y los broncodilatadores de acción prolongada. En los menores de tres años, el asma se diagnostica a partir de tres episodios de sibilancias. Se debe buscar la presencia de antecedentes particulares, de manifestaciones atípicas o persistentes y de anomalías en la radiografía de tórax para descartar las demás causas de manifestaciones sibilantes recidivantes. Cuando es necesario un tratamiento de fondo, se basa en la corticoterapia inhalada. Las cohortes prospectivas han permitido demostrar que la atopia, la gravedad clínica y la persistencia de una obstrucción clínica son los factores principales tanto de la persistencia como de la gravedad del asma durante la vida.
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Affiliation(s)
- J de Blic
- Service de pneumologie et d'allergologie pédiatriques, Centre de référence des maladies respiratoires rares, Hôpital universitaire Necker-Enfants Malades, 149, rue de Sèvres, 75015 Paris, France.,Université Paris Descartes, 12, rue de l'École-de-Médecine, 75006 Paris, France
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Abstract
PURPOSE OF REVIEW Asthma guidelines recognize the presence of different asthma endotypes and phenotypes but treatment recommendations are limited to age groups rather than phenotypes, as the phenotype literature is regarded as emerging evidence. This review will examine the current evidence regarding the management of asthma in school age children (5-18 years old) by endotype and phenotype. RECENT FINDINGS A number of studies have examined the effect of endotypes and phenotypes on response to conventional asthma therapy, omalizumab and specific allergen immunotherapy, and response in children with severe asthma. Emerging therapies, namely biologics and immunomodulators, have attracted considerable attention and appear to have favorable effects in adults with asthma, but additional pediatric studies are needed. SUMMARY The optimal treatment strategy for children with asthma is not yet defined and likely dependent on many patient and disease characteristics. Much of the phenotypic response literature presented in this review was constrained by a limited number of pediatric and adult studies available and as such should be regarded as preliminary. Better definition of asthma phenotypes and better targeting of therapy based on individual patient phenotypes are likely to improve asthma treatment in the future.
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Ciółkowski J, Mazurek H, Hydzik P, Stasiowska B. Inflammatory markers as exacerbation risk factors after asthma therapy switch from inhaled steroids to montelukast. Pulm Pharmacol Ther 2016; 39:7-13. [PMID: 27234706 DOI: 10.1016/j.pupt.2016.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/20/2016] [Accepted: 05/23/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asthma guidelines allow anti-leukotriene medications to be used as an alternative to inhaled corticosteroids (ICS) in second-step intensity therapy. The aim of the study was to analyze the risk factors of exacerbations, particularly inflammatory markers, during the 12-month period following therapy reduction from an ICS to montelukast in young patients with mild asthma. METHODS A total of 84 patients (aged 7-18 years old) with mild asthma controlled by low-dose ICS, had their treatment switched to montelukast. Exhaled nitric oxide (eNO), sputum eosinophils (sEos), and bronchial hyperreactivity (BHR) were assessed at the beginning and then every three months throughout the one-year period. The patients with asthma exacerbations (first severe or third mild) were discontinued from the study. RESULTS Over the study period, 22 patients (26%) discontinued montelukast due to asthma exacerbations. An increased risk of exacerbations was noted among patients with initial sEos above 2.5% (relative risk, RR 36.6; 95% CI: 7.1-189.3; p < 0.001), as well as those with augmented BHR (RR 9.5; 2.8-31.6; p < 0.001), or eNO greater than 20 ppb (RR 3.7; 95% CI: 1.3-10.7; p = 0.013). An increase in BHR and eNO was observed during the last visit before exclusion. CONCLUSIONS After switching treatment from a low-dose ICS, montelukast maintained control of asthma symptoms in 75% of patients. High sEos before the treatment change was the strongest exacerbation risk factor. In patients with asthma controlled by low-dose ICS and low inflammatory markers, treatment could be safely switched to montelukast.
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Affiliation(s)
- Janusz Ciółkowski
- The Regional Public Hospital, 38-600 Lesko, ul.Kochanowskiego 2, Poland.
| | - Henryk Mazurek
- Department of Pneumonology and Cystic Fibrosis, Institute of Tuberculosis and Lung Disorders, ul.Prof.Rudnika 3b, 34-700 Rabka - Zdrój, Poland.
| | - Paweł Hydzik
- Department of Quantitative Methods, Rzeszów University of Technology, al.Powstańców Warszawy 8, 35-959 Rzeszów, Poland.
| | - Barbara Stasiowska
- The Regional Public Hospital, 38-600 Lesko, ul.Kochanowskiego 2, Poland.
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Lin J, Yin K, Su N, Huang M, Qiu C, Liu C, Cai S, Hao C. Chinese expert consensus on clinical use of non-invasive airway inflammation assessment in bronchial asthma. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:302. [PMID: 26697462 PMCID: PMC4669313 DOI: 10.3978/j.issn.2305-5839.2015.11.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | - on behalf of the Chinese Society of Chest Physicians
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
| | - Chinese Medical Doctor Association
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
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38
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Lin J, Yin K, Su N, Huang M, Qiu C, Liu C, Cai S, Hao C. Chinese expert consensus on clinical use of non-invasive airway inflammation assessment in bronchial asthma. J Thorac Dis 2015; 7:2061-78. [PMID: 26716047 PMCID: PMC4669291 DOI: 10.3978/j.issn.2072-1439.2015.11.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | - on behalf of the Chinese Society of Chest Physicians
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
| | - Chinese Medical Doctor Association
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
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Gerald JK, Gerald LB, Vasquez MM, Morgan WJ, Boehmer SJ, Lemanske RF, Mauger DT, Strunk RC, Szefler SJ, Zeiger RS, Bacharier LB, Bade E, Covar RA, Guilbert TW, Heidarian-Raissy H, Kelly HW, Malka-Rais J, Sorkness CA, Taussig LM, Chinchilli VM, Martinez FD. Markers of Differential Response to Inhaled Corticosteroid Treatment Among Children with Mild Persistent Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2015; 3:540-6.e3. [PMID: 25783161 PMCID: PMC4500671 DOI: 10.1016/j.jaip.2015.01.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 01/16/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Inhaled corticosteroids are recommended as first-line therapy for children with mild persistent asthma; however, specific patient characteristics may modify the treatment response. OBJECTIVE Identify demographic, clinical, and atopic characteristics that may modify the inhaled corticosteroid treatment response among children enrolled in the Treating Children to Prevent Exacerbations of Asthma trial. METHODS Children aged 6 to 18 years with mild persistent asthma were randomized to 44 weeks of combined, daily, rescue, or placebo treatment. Daily treatment consisted of 40 μg of beclomethasone twice daily. Rescue treatment consisted of 40 μg of beclomethasone accompanying each symptom-driven albuterol actuation. Combined treatment consisted of both. Outcomes included time to first exacerbation and proportion of asthma control days. Fourteen baseline characteristics were selected for interaction testing on the basis of their clinical relevance. RESULTS Two hundred eighty-eight children were randomized. Seventy-five percent were white, and 55% were male. As measured by time to first exacerbation, 4 characteristics identified children who received greater benefit from treatment: non-Hispanic ethnicity, positive aeroallergen skin test result, serum immunoglobulin E level of 350 K/μL or more, and history of oral corticosteroid use in the year before enrollment. As measured by asthma control days, 4 characteristics identified children who received greater benefit from treatment: male sex, positive aeroallergen skin test result, serum immunoglobulin E level of 350 K/μL or more, and incomplete run-in asthma control. CONCLUSIONS Children with mild persistent asthma who have markers of atopic asthma or who have greater asthma burden may obtain greater benefit from beclomethasone therapy. Additional study is needed to confirm whether these markers can guide individualized therapy.
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Affiliation(s)
- Joe K Gerald
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Ariz, Tucson.
| | - Lynn B Gerald
- Mel and Enid Zuckerman College of Public Health and Arizona Respiratory Center, University of Arizona, Tucson, Ariz
| | - Monica M Vasquez
- Mel and Enid Zuckerman College of Public Health and Arizona Respiratory Center, University of Arizona, Tucson, Ariz
| | - Wayne J Morgan
- Arizona Respiratory Center, College of Medicine, University of Arizona, Tucson, Ariz
| | - Susan J Boehmer
- Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, Pa
| | - Robert F Lemanske
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - David T Mauger
- Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, Pa
| | - Robert C Strunk
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Stanley J Szefler
- Department of Pediatrics, Pulmonary Section, The Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, and Department of Pediatrics, University of California, San Diego, San Diego and La Jolla, Calif
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Elizabeth Bade
- University of Wisconsin, Aurora UW Medical Group, Milwaukee, Wis
| | - Ronina A Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Theresa W Guilbert
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - H William Kelly
- Department of Pediatrics, University of New Mexico, Albuquerque, NM
| | | | | | | | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, Pa
| | - Fernando D Martinez
- Arizona Respiratory Center, College of Medicine, University of Arizona, Tucson, Ariz
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Hoshino Y, Koya T, Kagamu H, Tsukioka K, Toyama M, Sakagami T, Hasegawa T, Narita I, Arakawa M, Suzuki E. Effect of inhaled corticosteroids on bronchial asthma in Japanese athletes. Allergol Int 2015; 64:145-9. [PMID: 25838089 DOI: 10.1016/j.alit.2014.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 08/25/2014] [Accepted: 09/28/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Asthma has a higher prevalence in athlete populations such as Olympic athletes than in the general population. Correct diagnosis and management of asthma in athletes is important for symptom control and avoidance of doping accusations. However, few reports are available on asthma treatment in the athlete population in clinical practice. In this study, we focused on the clinical efficacy of inhaled corticosteroid (ICS) for asthma in a Japanese athlete population. METHODS The study subjects included athletes who visited the Niigata Institute for Health and Sports Medicine, Niigata, Japan for athletic tests and who were diagnosed with asthma on the basis of respiratory symptoms and positive results in a bronchodilator or bronchial provocation test such as exercise, hypertonic saline, or methacholine provocation. The athletes received ICS alone for at least 3 months, and the clinical background, sports type, and treatment efficacy were analyzed. RESULTS The study population comprised 80 athletes (59 men and 21 women) with a median age of 16.0 years. Regarding sports type, 28 athletes engaged in winter sports (35%), 22 in endurance sports (27.5%), and 25 in indoor sports (31.3%). Although ICS is the primary treatment in athlete asthma, 16.3% of the athletes showed an unsatisfactory response to treatment according to the Global Evaluation of Treatment Effectiveness (GETE). These subjects were characterized by a decreased response to methacholine and lower values for FEV1/FVC and type 2 helper T cell (Th2)-associated biomarkers relative to responsive athletes. In multivariate analysis, FEV1/FVC and the logarithm to the base 10 of the IgE level were independently associated with the ICS response. CONCLUSIONS These data suggest that ICS is effective for asthma in most athletes. However, certain asthmatic athletes are less responsive to ICS than expected. The pathogenesis in these subjects may differ from that of conventional asthma characterized by chronic allergic airway inflammation.
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Affiliation(s)
- Yoshifumi Hoshino
- Division of Respiratory Medicine, Department of Homeostatic Regulation and Development, Course in Biological Functions and Medical Control, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Toshiyuki Koya
- Division of Respiratory Medicine, Department of Homeostatic Regulation and Development, Course in Biological Functions and Medical Control, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Hiroshi Kagamu
- Division of Respiratory Medicine, Department of Homeostatic Regulation and Development, Course in Biological Functions and Medical Control, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Keisuke Tsukioka
- Division of Respiratory Medicine, Department of Homeostatic Regulation and Development, Course in Biological Functions and Medical Control, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Mio Toyama
- Division of Respiratory Medicine, Department of Homeostatic Regulation and Development, Course in Biological Functions and Medical Control, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takuro Sakagami
- Division of Respiratory Medicine, Department of Homeostatic Regulation and Development, Course in Biological Functions and Medical Control, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takashi Hasegawa
- Department of General Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Ichiei Narita
- Division of Respiratory Medicine, Department of Homeostatic Regulation and Development, Course in Biological Functions and Medical Control, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Masaaki Arakawa
- Niigata Institute for Health and Sports Medicine, Niigata, Japan
| | - Eiichi Suzuki
- Department of General Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
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The importance of atopy on exhaled nitric oxide levels in African American children. Ann Allergy Asthma Immunol 2015; 114:399-403. [PMID: 25752733 DOI: 10.1016/j.anai.2015.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/05/2015] [Accepted: 02/09/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND For physicians to be maximally effective in managing asthma in minority populations, a better understanding of the factors that affect fractional exhaled nitric oxide (FeNO) measurements in African Americans is needed. OBJECTIVE To examine demographic, environmental, and physiologic factors that influence FeNO measurements in African American children with and without asthma. METHODS A cross-sectional study of 128 African American children aged 7 to 18 years (44% with asthma) was conducted. FeNO measurements, skin prick tests (as a measure of atopy), spirometry, and questionnaire data were obtained from all participants. Regression models were constructed after identifying factors significantly associated on univariate analysis. RESULTS Among all study participants, the mean FeNO measurement at baseline was 24.4 ppb. Children with asthma had a higher level than those without (30.9 vs 19.3 ppb, P = .002). When examining all children through logistic regression analysis, an elevated FeNO level was significantly associated with atopy, lower spirometric values, and current asthma (P < .05 for all). Among asthmatic children, univariate analysis revealed that an elevated FeNO level was associated with inhaled corticosteroid use, recent respiratory infection, and atopy (P < .05 for all). However, only atopy remained significant after regression analysis. For asthmatic and nonasthmatic children, FeNO levels were directly correlated with the number of positive skin test results. CONCLUSION In African American children with and without asthma, FeNO levels are strongly influenced by atopy. Guidelines for FeNO measurements that incorporate atopic status are needed.
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Pijnenburg MW, Szefler S. Personalized medicine in children with asthma. Paediatr Respir Rev 2015; 16:101-7. [PMID: 25458797 DOI: 10.1016/j.prrv.2014.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/02/2014] [Indexed: 12/16/2022]
Abstract
Personalized medicine for children with asthma aims to provide a tailored management of asthma, which leads to faster and better asthma control, has less adverse events and may be cost saving. Several patient characteristics, lung function parameters and biomarkers have been shown useful in predicting treatment response or predicting successful reduction of asthma medication. As treatment response to the main asthma therapies is partly genetically determined, pharmacogenetics may open the way for personalized medicine in children with asthma. However, the number of genes identified for the various asthma drug response phenotypes remains small and randomized controlled trials are lacking. Biomarkers in exhaled breath or breath condensate remain promising but did not find their way from bench to bedside yet, except for the fraction of exhaled nitric oxide. E-health will most likely find its way to clinical practice and most interventions are at least non-inferior to usual care. More studies are needed on which interventions will benefit most individual children.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics/ Paediatric Respiratory Medicine, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Stanley Szefler
- The Breathing Institute / Pulmonary Medicine, Department of Pediatrics, Children's Hospital Colorado; University of Colorado Denver School of Medicine, Aurora (CO), USA.
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Bush A. Montelukast in paediatric asthma: where we are now and what still needs to be done? Paediatr Respir Rev 2015; 16:97-100. [PMID: 25499571 DOI: 10.1016/j.prrv.2014.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 10/29/2014] [Indexed: 11/30/2022]
Abstract
Leukotriene receptor antagonists were introduced as an entirely new concept in asthma therapy, which indeed they are. However, although an intellectually new concept, they have largely disappointed in clinical practice. A small minority of school age asthmatics may respond better to these medications as against inhaled corticosteroids as prophylactic therapy. In children not responding to low dose inhaled corticosteroids, the best add-on therapy is salmeterol, but a small number respond better to Montelukast. In pre-school wheeze, intermittent Montelukast may be an effective strategy in some children who wheeze just with viral colds, but the clinical trial data are controversial. Pre-schoolers with multiple trigger wheeze are probably best treated with inhaled corticosteroids. What is clear is that clinically, a higher proportion of children are prescribed Montelukast than would be predicted from the lterature to respond to the medication. No biomarker to predict response to Montelukast has reached clinical practice, so N of 1 clinical trials should be performed. It is important not to leave children on Montelukast if there is no convincing response to this treatment.
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Affiliation(s)
- Andrew Bush
- Professor of Paediatrics and Head of Section (Paediatrics), Imperial College, Professor of Paediatric Respirology, National Heart and Lung Institute, Consultant Paediatric Chest Physician, Royal Brompton Harefield NHS Foundation Trust.
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Stelmach I, Ożarek-Hanc A, Zaczeniuk M, Stelmach W, Smejda K, Majak P, Jerzynska J, Anna J. Do children with stable asthma benefit from addition of montelukast to inhaled corticosteroids: randomized, placebo controlled trial. Pulm Pharmacol Ther 2015; 31:42-8. [PMID: 25640020 DOI: 10.1016/j.pupt.2015.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 12/02/2014] [Accepted: 01/21/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND To determine the effects of montelukast added to maintenance inhaled steroids (ICS) therapy during the school year in children with stable asthma on the ICS use, frequency of exacerbations, lung function, asthma symptoms, fractional exhaled nitric oxide (FeNO) level and exercise-induced bronchoconstriction (EIB). METHODS Seventy six asthmatic children aged 6-14 years, allergic to house dust mites were randomized to a double-blinded trial comparing montelukast therapy to a matching placebo. We studied following end-points: the reduction in the ICS dose, the frequency of exacerbations, lung function, asthma control test score, and the change from baseline in FEV1 during a standardized exercise treadmill challenge. ICS dose was adjusted in a stepwise fashion to determine the lowest dose necessary to control asthma symptoms. RESULTS We showed that children with baseline value of FeNO above 31 ppb and well controlled asthma symptoms on low doses of ICS, benefit the most from additive therapy with montelukast; their cumulative ICS dose is lower than in children treated with ICS only. Also, the addition of montelukast to regular treatment in asthmatic children resulted in a significant reduction in the frequency of exacerbations and EIB protection. CONCLUSION It is reasonable to add montelukast to ICS therapy in asthmatic children during the school year, to lower cumulative ICS dose in children with well controlled asthma symptoms, as well as to reduce number of exacerbations, and to achieve better control of EIB. TRIAL REGISTRATION NCT01266772.
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Affiliation(s)
- Iwona Stelmach
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland.
| | - Agata Ożarek-Hanc
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Magdalena Zaczeniuk
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Wlodzimierz Stelmach
- Department of Social and Preventive Medicine, Medical University of Lodz, Lodz, Poland
| | - Katarzyna Smejda
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Pawel Majak
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Joanna Jerzynska
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Janas Anna
- Department of Social and Preventive Medicine, Medical University of Lodz, Lodz, Poland; Institute of Dental Surgery, Faculty of Medicine and Dentistry, Medical University of Lodz, Poland
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Fractional Exhaled Nitric Oxide: Indications and Interpretation. DIAGNOSTIC TESTS IN PEDIATRIC PULMONOLOGY 2015. [DOI: 10.1007/978-1-4939-1801-0_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Galant SP, Morphew T, Guijon O, Pham L. The bronchodilator response as a predictor of inhaled corticosteroid responsiveness in asthmatic children with normal baseline spirometry. Pediatr Pulmonol 2014; 49:1162-9. [PMID: 24532409 DOI: 10.1002/ppul.22957] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 10/16/2013] [Indexed: 11/09/2022]
Abstract
RATIONALE Although inhaled corticosteroids (ICS) are considered first line controller therapy in children with persistent asthma, heterogeneity of the ICS response can be an important clinical problem. The purpose of this study is to determine the value of the bronchodilator response (BDR) in identifying the ICS responder and establish the optimal BDR cut-point that could be particularly useful in the clinic setting when baseline spirometry is normal. METHODS Mexican American asthmatic children, 5-18 years, with normal baseline spirometry who required low dose (step 2), or medium dose (step 3) ICS therapy were evaluated by skin prick test for atopy, and pre- and post-bronchodilator spirometry. ICS responders were defined by a ≥7.5% improvement in the FEV1 following 4-6 weeks of therapy. The optimal cut-point was determined by Receiver Operator Characteristic (ROC) curves as the best balance between sensitivity and specificity. RESULTS There were 34.8% of the 132 study patients who were ICS responders. ROC curves showed the BDR ≥10% to be an optimal cut-point with sensitivity 46%, specificity 76%, positive predictive value (PPV) 50%, and negative predictive value (NPV) 72%. Atopic females with a BDR ≥10% had a PPV of 73%. CONCLUSIONS The composite phenotype of female gender, atopic, and the BDR of ≥10% identified 73% as ICS responders compared to 50% in our overall population with a BDR of ≥10% alone, with minimal false positives. We suggest that the BDR in conjunction with gender and atopic status be considered as potentially useful predictors of the ICS responder, particularly when baseline spirometry is normal.
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Affiliation(s)
- Stanley P Galant
- Breathmobile, CHOC Children's Hospital, Orange County, Orange, California
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Huffaker MF, Phipatanakul W. Pediatric asthma: guidelines-based care, omalizumab, and other potential biologic agents. Immunol Allergy Clin North Am 2014; 35:129-44. [PMID: 25459581 DOI: 10.1016/j.iac.2014.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Over the past several decades, the evidence supporting rational pediatric asthma management has grown considerably. As more is learned about the various phenotypes of asthma, the complexity of management will continue to grow. This article focuses on the evidence supporting the current guidelines-based pediatric asthma management and explores the future of asthma management with respect to phenotypic heterogeneity and biologics.
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Affiliation(s)
- Michelle Fox Huffaker
- Division of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Wanda Phipatanakul
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Nobakht M Gh BF, Aliannejad R, Rezaei-Tavirani M, Taheri S, Oskouie AA. The metabolomics of airway diseases, including COPD, asthma and cystic fibrosis. Biomarkers 2014; 20:5-16. [PMID: 25403491 DOI: 10.3109/1354750x.2014.983167] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic obstructive pulmonary disease (COPD), asthma and cystic fibrosis (CF) are characterized by airway obstruction and an inflammatory process. Reaching early diagnosis and discrimination of subtypes of these respiratory diseases are quite a challenging task than other chronic illnesses. Metabolomics is the study of metabolic pathways and the measurement of unique biochemical molecules generated in a living system. In the last decade, metabolomics has already proved to be useful for the characterization of several pathological conditions and offers promises as a clinical tool. In this article, we review the current state of the metabolomics of COPD, asthma and CF with a focus on the different methods and instrumentation being used for the discovery of biomarkers in research and translation into clinic as diagnostic aids for the choice of patient-specific therapies.
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Affiliation(s)
- B Fatemeh Nobakht M Gh
- Faculty of Paramedical Sciences, Proteomics Research Center, Shahid Beheshti University of Medical Sciences , Tehran , Iran
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49
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Ciółkowski J, Mazurek H, Stasiowska B. Evaluation of step-down therapy from an inhaled steroid to montelukast in childhood asthma. Allergol Immunopathol (Madr) 2014; 42:282-8. [PMID: 23684855 DOI: 10.1016/j.aller.2013.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 12/21/2012] [Accepted: 01/02/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Asthma guidelines allow antileukotriene medications to be used as an alternative to inhaled corticosteroids (ICSs) in second-step intensity therapy. The aim of this study was to determine whether asthma control can be maintained after reducing treatment from low-dose ICS to montelukast. METHODS In this prospective, real-life 12-week trial, 84 young patients with asthma (7-18 years) controlled by low-dose ICS, had treatment switched to montelukast. Symptoms and PEF were monitored daily; exhaled nitric oxide (eNO) and spirometry every four weeks; sputum eosinophil (sEo) and bronchial hyperreactivity (BHR) assessed at the beginning and at the end of the study. The primary endpoint was number of patients discontinued from the study due to asthma exacerbations. RESULTS Eleven patients (13.1%) were discontinued due to asthma exacerbations. At the beginning, patients with elevated percentage of sEo had increased risk of exacerbations (relative risk RR, 6.6; 95% CI, 1.2-35.6), as well as those with augmented BHR (RR, 4.24; 95% CI, 1.1-16.2) as compared to patients who completed the study. An intensification of symptoms and increased use of beta-adrenergics were observed during the last visit before exclusion from the study, but not changes in spirometry, PEF, and eNO. No change in clinical parameters, inflammatory markers or BHR was observed in patients remaining in the study. CONCLUSIONS After treatment switch from low-dose ICS to montelukast, asthma control was maintained in the majority of patients during the 12-week observation period. Sputum eosinophilia or BHR before the treatment switch was exacerbation risk factor.
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Affiliation(s)
| | - H Mazurek
- Department of Pneumonology and Cystic Fibrosis, National Institute of Tuberculosis and Lung Disorders, Rabka Branch, Poland
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Hon KLE, Leung TF, Leung AKC. Clinical effectiveness and safety of montelukast in asthma. What are the conclusions from clinical trials and meta-analyses? DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:839-50. [PMID: 25061277 PMCID: PMC4079631 DOI: 10.2147/dddt.s39100] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Asthma is a common childhood atopic disease associated with chronicity and impaired quality of life. As there is no cure for this disease, treatment relies on avoidance of triggers such as food and aeroallergens, the use of inhaled bronchodilators/corticosteroids and antiallergic or immunomodulating therapies. Inhaled corticosteroids (ICSs) and bronchodilators have been the mainstay. However, in Asia, myths and fallacies regarding Western medicine and corticosteroids are prevalent and lead to nonadherence to treatment. Also, use of traditional and proprietary herbal medicines is popular. In the past decades, a novel class of nonsteroidal immunomodulating montelukasts has become available. This article reviews the evidence for the effectiveness and clinical efficacy of these medications. A number of randomized and controlled trials have been performed over the years. The majority of studies confirm the usefulness of montelukast as monotherapy and add-on therapy to ICS in mild to moderate childhood asthma across all age groups. ICSs are generally superior to montelukasts for asthma management. However, montelukast has a place in the treatment of young children with viral-triggered wheezing diseases, exercise-induced asthma, and in children whose parents are steroid-phobic and find ICS unacceptable.
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Affiliation(s)
- Kam Lun Ellis Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - Ting Fan Leung
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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