1
|
Gallegos-Catalán J, Warnken Z, Bahamondez-Canas TF, Moraga-Espinoza D. Innovating on Inhaled Bioequivalence: A Critical Analysis of the Current Limitations, Potential Solutions and Stakeholders of the Process. Pharmaceutics 2021; 13:1051. [PMID: 34371741 PMCID: PMC8309038 DOI: 10.3390/pharmaceutics13071051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 12/23/2022] Open
Abstract
Orally inhaled drug products (OIDPs) are an important group of medicines traditionally used to treat pulmonary diseases. Over the past decade, this trend has broadened, increasing their use in other conditions such as diabetes, expanding the interest in this administration route. Thus, the bioequivalence of OIDPs is more important than ever, aiming to increase access to affordable, safe and effective medicines, which translates into better public health policies. However, regulatory agencies leading the bioequivalence process are still deciding the best approach for ensuring a proposed inhalable product is bioequivalent. This lack of agreement translates into less cost-effective strategies to determine bioequivalence, discouraging innovation in this field. The Next-Generation Impactor (NGI) is an example of the slow pace at which the inhalation field evolves. The NGI was officially implemented in 2003, being the last equipment innovation for OIDP characterization. Even though it was a breakthrough in the field, it did not solve other deficiencies of the BE process such as dissolution rate analysis on physiologically relevant conditions, being the last attempt of transferring technology into the field. This review aims to reveal the steps required for innovation in the regulations defining the bioequivalence of OIDPs, elucidating the pitfalls of implementing new technologies in the current standards. To do so, we collected the opinion of experts from the literature to explain these trends, showing, for the first time, the stakeholders of the OIDP market. This review analyzes the stakeholders involved in the development, improvement and implementation of methodologies that can help assess bioequivalence between OIDPs. Additionally, it presents a list of methods potentially useful to overcome some of the current limitations of the bioequivalence standard methodologies. Finally, we review one of the most revolutionary approaches, the inhaled Biopharmaceutical Classification System (IBCs), which can help establish priorities and order in both the innovation process and in regulations for OIDPs.
Collapse
Affiliation(s)
- Jonattan Gallegos-Catalán
- Escuela de Química y Farmacia, Facultad de Farmacia, Universidad de Valparaíso, Valparaíso 2340000, Chile; (J.G.-C.); (T.F.B.-C.)
| | | | - Tania F. Bahamondez-Canas
- Escuela de Química y Farmacia, Facultad de Farmacia, Universidad de Valparaíso, Valparaíso 2340000, Chile; (J.G.-C.); (T.F.B.-C.)
- Centro de Investigación Farmacopea Chilena, Universidad de Valparaíso, Valparaíso 2340000, Chile
| | - Daniel Moraga-Espinoza
- Escuela de Química y Farmacia, Facultad de Farmacia, Universidad de Valparaíso, Valparaíso 2340000, Chile; (J.G.-C.); (T.F.B.-C.)
- Centro de Investigación Farmacopea Chilena, Universidad de Valparaíso, Valparaíso 2340000, Chile
| |
Collapse
|
2
|
Karvonen T, Sepponen-Lavikko A, Holm K, Schultz R, Moilanen E, Lehtimäki L. Onset of action of inhaled glucocorticoids on bronchial and alveolar nitric oxide output. J Breath Res 2020; 15:016008. [PMID: 33045700 DOI: 10.1088/1752-7163/abc054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Fractional exhaled nitric oxide (FENO) is a marker of airway inflammation. Measuring FENO at multiple flow rates enables calculation of NO parameters: bronchial NO output (J awNO), bronchial wall (C awNO) and alveolar (C ANO) NO concentrations, and bronchial diffusion factor of NO (D awNO). FENO is known to rapidly reduce after the commencement of inhaled corticosteroid (ICS) treatment. However, little is known on the effect of ICS on the other NO parameters. We assessed (1) the onset of action of ICS treatment on the NO parameters and (2) whether the changes in bronchial NO output are due to changes in bronchial wall NO concentration or diffusion factor. FENO and other NO parameters were measured at baseline and after 1, 3 and 7 d of treatment with inhaled fluticasone propionate 250 μg b.i.d. in 23 allergic children with a history of asthma-like symptoms. There was a decrease in J awNO (from 680 (244/1791) (median (1st/3rd quartile)) to 357 (165/753) pl s-1, p < 0.001) and FENO50( from 13.8 (7.5/35) to 8.3 (5.36/17.0) ppb, p < 0.001) in 3 d from the first dose of ICS. Also, C awNO seemed to reduce after 3 d (from 171 (89/328) to 79 (54/157) ppb, p = 0.041), while D awNO remained unchanged. Furthermore, C ANO reduced during the 7 d treatment (from 3.0 (2.0/5.0) to 2.3 (1.9/2.6) ppb, p = 0.004). ICS treatment reduced FENO50 and J awNO rapidly and the decline was caused by decreased bronchial wall NO concentration while bronchial NO diffusion factor remained unchanged. These findings suggest that C awNO could be a more specific marker of airway inflammation and treatment response than J awNO or FENO50, which are both determined also by D awNO that seems to be resistant to the treatment with ICS.
Collapse
Affiliation(s)
- Tuomas Karvonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | | | | | | | | |
Collapse
|
3
|
Harrison T, Pavord ID, Chalmers JD, Whelan G, Fagerås M, Rutgersson A, Belton L, Siddiqui S, Gustafson P. Variability in airway inflammation, symptoms, lung function and reliever use in asthma: anti-inflammatory reliever hypothesis and STIFLE study design. ERJ Open Res 2020; 6:00333-2019. [PMID: 32550224 PMCID: PMC7276524 DOI: 10.1183/23120541.00333-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/24/2020] [Indexed: 11/05/2022] Open
Abstract
Asthma is a chronic inflammatory airway disease. Increase in airway inflammation is hypothesised to contribute to worsening of asthma symptoms and deterioration in lung function, resulting in the use of reliever medication. Short-acting β2-agonists only treat the symptoms, whereas an anti-inflammatory reliever is believed to treat both symptoms and the underlying inflammation, thereby arresting the progression to an exacerbation. As-needed budesonide/formoterol as an anti-inflammatory reliever reduces the risk of severe exacerbations. However, supporting mechanistic evidence has not yet been described, specifically the temporal dynamics of parameters including airway inflammation, over time and during asthma worsening. The STIFLE study aims to characterise daily variability in airway inflammation, symptoms, lung function and reliever use in people with asthma. This phase IV, open-label, parallel-group, multicentre, exploratory study will enrol 60-80 adult patients with asthma receiving low- or medium-dose inhaled corticosteroids/long-acting β2-agonists (EudraCT identifier number 2018-003467-64). Participants will be randomised 1:1 to either as-needed budesonide/formoterol dry-powder inhaler or salbutamol reliever for 24 weeks, in addition to their maintenance therapy. Daily data will be captured for fractional exhaled nitric oxide, spirometry, asthma symptoms and medication use using devices connected to a smartphone via the STIFLE application. STIFLE will thereby enable not only characterisation of the variability of airway inflammation and clinical outcomes in relation to asthma worsening, but also elucidate the effect of as-needed budesonide/formoterol on airway inflammation against a background of daily maintenance therapy.
Collapse
Affiliation(s)
- Tim Harrison
- Nottingham NIHR Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | | | | | | | | | | | | |
Collapse
|
4
|
Karvonen T, Lehtimäki L. Flow-independent nitric oxide parameters in asthma: a systematic review and meta-analysis. J Breath Res 2019; 13:044001. [PMID: 31239409 DOI: 10.1088/1752-7163/ab2c99] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Fractional exhaled nitric oxide (FENO) has been proposed as a non-invasive marker of inflammation in the lungs. Measuring FENO at several flow rates enables the calculation of flow independent NO-parameters that describe the NO-exchange dynamics of the lungs more precisely. The purpose of this study was to compare the NO-parameters between asthmatics and healthy subjects in a systematic review and meta-analysis. METHODS A systematic search was performed in Ovid Medline, Web of Science, Scopus and Cochrane Library databases. All studies with asthmatic and healthy control groups with at least one NO-parameter calculated were included. RESULTS From 1137 identified studies, 33 were included in the meta-analysis. All NO-parameters (alveolar NO concentration (CANO), bronchial flux of NO (JawNO), bronchial mucosal NO concentration (CawNO) and bronchial wall NO diffusion capacity (DawNO)) were found increased in glucocorticoid-treated and glucocorticoid-naïve asthma. JawNO and CANO were most notably increased in both study groups. Elevation of DawNO and CawNO seemed less prominent in both asthma groups. DISCUSSION We found that all the NO-parameters are elevated in asthma as compared to healthy subjects. However, results were highly heterogenous and the evidence on CawNO and DawNO is still quite feeble due to only few studies reporting them. To gain more knowledge on the NO-parameters in asthma, nonlinear methods and standardized study protocols should be used in future studies.
Collapse
Affiliation(s)
- Tuomas Karvonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | |
Collapse
|
5
|
Further Studies of Unsuspected Emphysema in Nonsmoking Patients With Asthma With Persistent Expiratory Airflow Obstruction. Chest 2017; 153:618-629. [PMID: 29197547 DOI: 10.1016/j.chest.2017.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 10/02/2017] [Accepted: 11/06/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Previously, we and other investigators have described reversible loss of lung elastic recoil in patients with acute and persistent, moderate-to-severe, chronic, treated asthma who never smoked, and its adverse effect on maximal expiratory airflow. In four consecutive autopsies, we reported the pathophysiologic mechanism(s) has been unsuspected mild, diffuse, middle and upper lobe centrilobular emphysema. METHODS We performed prospective studies (5 to 22 years) in 25 patients (12 female) with chronic asthma, age 55 ± 15 years, who never smoked, with persistent moderate-to-severe expiratory obstruction. Studies included measuring blood eosinophils, IgE, total exhaled nitric oxide (NO), central airway NO flux, peripheral airway/alveolar NO concentration, impulse oscillometry, heliox curves, lung elastic recoil, and high-resolution thin-section (1 mm) lung CT imaging at full inspiration with voxel quantification. RESULTS In 25 patients with stable asthma with varying type 2 phenotype, after 270 μg of aerosolized albuterol sulfate had been administered with a metered dose inhaler with space chamber, FVC was 3.1 ± 1.0 L (83% ± 13% predicted) (mean ± SD), FEV1 was 1.8 ± 0.6 L (59% ± 11%), the FEV1/FVC ratio was 59% ± 10%, and the ratio of single-breath diffusing capacity of the lung for carbon monoxide to alveolar volume was 4.8 ± 1.1 mL/min/mm Hg/L (120% ± 26%). All 25 patients with asthma had loss of static lung elastic recoil pressure, which contributed equally to decreased intrinsic airway conductance in limiting expiratory airflow. Lung CT scanning detected none or mild emphysema. In all four autopsied asthmatic lungs previously reported and one unreported explanted lung, microscopy revealed unsuspected mild, diffuse centrilobular emphysema in the upper and middle lung fields, and asthma-related remodeling in airways. In eight cases, during asthma remission, there were increases in measured static lung elastic recoil pressure-calculated intrinsic airway conductance, and measured maximal expiratory airflow at effort-independent lung volumes. CONCLUSIONS As documented now in five cases, unsuspected microscopic mild centrilobular emphysema is the sentinel cause of loss of lung elastic recoil. This contributes significantly to expiratory airflow obstruction in never-smoking patients with asthma, with normal diffusing capacity and near-normal lung CT scan results. TRIAL REGISTRY Protocol No. 20070934 and Study No. 1090472, Western Institutional Review Board, Olympia, WA; ClinicalTrials.gov; No. NCT00576069; URL: www.clinicaltrials.gov.
Collapse
|
6
|
Shrestha SK, Shrestha S, Sharma L, Pant S, Neopane A. Comparison of fractional exhaled nitric oxide levels in chronic obstructive pulmonary disease, bronchial asthma and healthy subjects of Nepal. J Breath Res 2017; 11:047101. [PMID: 28686173 DOI: 10.1088/1752-7163/aa7e63] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Fractional exhaled nitric oxide levels in exhaled breath can indicate ongoing eosinophilic airway inflammation, specifically in asthma. But its utility is being explored for central airway inflammations, including chronic obstructive pulmonary disease. Normal levels of fractional exhaled nitric oxide (FENO50) have been defined in different studies but not in Nepal. This study compares FENO50 levels in normal subjects, asthma and chronic obstructive pulmonary disease. METHODS Single breath estimation of FENO50 was measured by a handheld electrochemical sensor-based device in normal non-smoking adults (n = 106), clinically controlled asthma (n = 106) and stable chronic obstructive pulmonary disease (n = 106). RESULTS The geometric mean for FENO50 was 14 parts per billion (ppb) with a median of 16 ppb, first quartile at 11 ppb and third quartile at 20 ppb in normal non-smoking adults. The values were 31 ppb (geometric mean), 34 ppb (median), 17 ppb (first quartile) and 79 ppb (third quartile) in clinically controlled asthma. Similarly the values were 10 ppb (geometric mean), 11 ppb (median), 6 ppb (first quartile) and 17 ppb (third quartile) in stable chronic obstructive airway disease. The log-transformed data showed significantly higher FENO50 levels in the asthma group compared with the normal (p < 0.001) and chronic obstructive airway disease (p < 0.001). However, levels were similar between healthy and chronic obstructive airway disease groups (p = 0.08). CONCLUSIONS FENO50 levels were higher in bronchial asthma (despite disease control) than in normal non-smoking adults and subjects with stable chronic obstructive pulmonary disease. Levels of FENO50 were similar between the chronic obstructive airway disease and normal groups.
Collapse
Affiliation(s)
- Sanjeet Krishna Shrestha
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | | | | | | | | |
Collapse
|
7
|
Mason P, Scarpa MC, Guarnieri G, Giordano G, Baraldi E, Maestrelli P. Exhaled nitric oxide dynamics in asthmatic reactions induced by diisocyanates. Clin Exp Allergy 2016; 46:1531-1539. [PMID: 27533788 DOI: 10.1111/cea.12798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 07/01/2016] [Accepted: 07/05/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Isocyanate-induced asthmatic reactions are associated with delayed increase in fractional exhaled nitric oxide measured at expiratory flow of 50 mL/s (FeNO50), a biomarker of airway inflammation. The time course of FeNO increase is compatible with the activation of NO synthase, but the origin of NO production in the lung is undetermined. OBJECTIVE The aim of this study was to define the dynamics of airway and alveolar NO during specific inhalation challenge (SIC) with isocyanates and the role of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of NO synthase. METHODS Spirometry, exhaled NO parameters (FeNO50, bronchial wall NO concentration, NO airway diffusing capacity, NO flux to luminal space, alveolar NO) and ADMA levels in exhaled breath condensate were measured before and at intervals up to 24 h after exposure to isocyanates. The results were compared between 17 SIC-positive and eight SIC-negative subjects. RESULTS A significant FeNO50 increase in SIC-positive subjects was detected 24 h after exposure and was associated with the augmented NO flux from airway wall to the lumen, whereas airway NO diffusion and alveolar NO were not affected. The changes in NO dynamics were specific for the subjects who developed an asthmatic reaction, but were independent from the pattern and magnitude of bronchoconstriction. There was no evidence that exhaled NO is modulated by the changes in ADMA concentration. CONCLUSIONS AND CLINICAL RELEVANCE Because isocyanate-induced increase in FeNO50 was almost exclusively determined by the increase in NO flux, the use of FeNO50 appears adequate to monitor the exhaled NO dynamics during SIC. FeNO50 measurement may provide additional information to spirometry, because bronchoconstriction and airway inflammatory responses are dissociated.
Collapse
Affiliation(s)
- P Mason
- Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - M C Scarpa
- Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - G Guarnieri
- Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - G Giordano
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - E Baraldi
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - P Maestrelli
- Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| |
Collapse
|
8
|
Affirmation of the adoration of the vagi and role of tiotropium in asthmatic patients. J Allergy Clin Immunol 2016; 138:1011-1013. [PMID: 27527265 DOI: 10.1016/j.jaci.2016.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/01/2016] [Accepted: 06/16/2016] [Indexed: 11/20/2022]
|
9
|
Al-Numani D, Colucci P, Ducharme MP. Rethinking bioequivalence and equivalence requirements of orally inhaled drug products. Asian J Pharm Sci 2015. [DOI: 10.1016/j.ajps.2015.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
|
10
|
Gelb AF, Yamamoto A, Verbeken EK, Nadel JA. Unraveling the Pathophysiology of the Asthma-COPD Overlap Syndrome: Unsuspected Mild Centrilobular Emphysema Is Responsible for Loss of Lung Elastic Recoil in Never Smokers With Asthma With Persistent Expiratory Airflow Limitation. Chest 2015; 148:313-320. [PMID: 25950858 DOI: 10.1378/chest.14-2483] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Investigators believe most patients with asthma have reversible airflow obstruction with treatment, despite airway remodeling and hyperresponsiveness. There are smokers with chronic expiratory airflow obstruction despite treatment who have features of both asthma and COPD. Some investigators refer to this conundrum as the asthma-COPD overlap syndrome (ACOS). Furthermore, a subset of treated nonsmokers with moderate to severe asthma have persistent expiratory airflow limitation, despite partial reversibility. This residuum has been assumed to be due to large and especially small airway remodeling. Alternatively, we and others have described reversible loss of lung elastic recoil in acute and persistent loss in patients with moderate to severe chronic asthma who never smoked and its adverse effect on maximal expiratory airflow. The mechanism(s) responsible for loss of lung elastic recoil and persistent expiratory airflow limitation in nonsmokers with chronic asthma consistent with ACOS remain unknown in the absence of structure-function studies. Recently we reported a new pathophysiologic observation in 10 treated never smokers with asthma with persistent expiratory airflow obstruction, despite partial reversibility: All 10 patients with asthma had a significant decrease in lung elastic recoil, and unsuspected, microscopic mild centrilobular emphysema was noted in all three autopsies obtained although it was not easily identified on lung CT scan. These sentinel pathophysiologic observations need to be confirmed to further unravel the epiphenomenon of ACOS. The proinflammatory and proteolytic mechanism(s) leading to lung tissue breakdown need to be further investigated.
Collapse
Affiliation(s)
- Arthur F Gelb
- Pulmonary Division, Department of Medicine, Lakewood Regional Medical Center, Lakewood, CA; Geffen School of Medicine at UCLA Medical Center, Los Angeles, CA.
| | - Alfred Yamamoto
- Department of Pathology, Lakewood Regional Medical Center, Lakewood, CA
| | - Eric K Verbeken
- Department of Pathology, Katholieke Univeritair Ziekenhuis Gasthuisberg, Leuven, Belgium
| | - Jay A Nadel
- Department of Medicine, University of California, San Francisco Medical Center, San Francisco, CA; Department of Physiology, University of California, San Francisco Medical Center, San Francisco, CA; Department of Radiology, University of California, San Francisco Medical Center, San Francisco, CA
| |
Collapse
|
11
|
Hakimeh D, Tripodi S. Recent advances on diagnosis and management of childhood asthma and food allergies. Ital J Pediatr 2013; 39:80. [PMID: 24373684 PMCID: PMC3891976 DOI: 10.1186/1824-7288-39-80] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 12/16/2013] [Indexed: 11/10/2022] Open
Abstract
The epidemic of childhood allergic disorders has been associated to the decline of infectious disease. However, exposure to many triggers (airborne viruses, tobacco smoke, pollution, indoor allergens, etc.) contribute to the disease. Breast feeding practices, nutrition, dietary and obesity also play a multifaceted role in shaping the observed worldwide trends of childhood allergies. Guidelines for treatment are available, but their implementation is suboptimal. Then developed countries are slowing learning integrating the development of suitable guidelines with implementation plans. Awareness, psychosocial and family factors strongly influence asthma and food allergy control. Moreover, monitoring tools are necessary to facilitate self-management. By taking into consideration these and many other pragmatic aspects, national public health programs to control the allergic epidemic have been successful in reducing its impact and trace the need for future research in the area.
Collapse
Affiliation(s)
| | - Salvatore Tripodi
- Department of Paediatrics and Allergology Unit, Sandro Pertini Hospital, Via dei Monti Tiburtini, 389, 00157 Rome, Italy.
| |
Collapse
|
12
|
Gelb AF, Singh DH, Moridzadeh R, Fraser C, Tran D, Verbanck S, George SC. Age-stratified comparison of large and peripheral airway/alveolar nitric oxide levels in children and young adults. J Allergy Clin Immunol 2013; 132:1222-4. [PMID: 23932460 DOI: 10.1016/j.jaci.2013.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 05/28/2013] [Accepted: 05/31/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Arthur F Gelb
- Pulmonary Division, Department of Medicine, Lakewood Regional Medical Center, Lakewood, Calif, and Geffen School of Medicine at University of California, Los Angeles Medical Center (AFG), Los Angeles, Calif.
| | | | | | | | | | | | | |
Collapse
|
13
|
Papaporfyriou A, Tseliou E, Loukides S, Kostikas K, Bakakos P. Noninvasive evaluation of airway inflammation in patients with severe asthma. Ann Allergy Asthma Immunol 2013; 110:316-21. [PMID: 23622000 DOI: 10.1016/j.anai.2012.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 12/26/2012] [Accepted: 12/30/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Anastasia Papaporfyriou
- Second Respiratory Medicine Department, University of Athens Medical School, Attiko Hospital, Athens, Greece
| | | | | | | | | |
Collapse
|
14
|
Columbo M, Wong B, Panettieri RA, Rohr AS. Asthma in the elderly: the role of exhaled nitric oxide measurements. Respir Med 2013; 107:785-7. [PMID: 23481173 DOI: 10.1016/j.rmed.2013.01.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 01/16/2013] [Accepted: 01/27/2013] [Indexed: 10/27/2022]
Abstract
Asthma in the elderly is poorly understood because only a small minority of asthma studies have investigated this patients group. Fractional exhaled nitric oxide (FENO) has been extensively studied in children and adults with asthma, but little is known about FENO in elderly asthmatics. We studied the role of serial measurements of FENO in elderly subjects with asthma. Thirty stable asthmatics 65 years old and older were followed for one year with evaluations at baseline and every three months. We looked for associations between FENO and subjects' demographics, comorbidities, asthma treatment, spirometric values and asthma control test (ACT) scores. FENO was not elevated in our study subjects throughout the study period (mean < 30 ppb). FENO significantly increased and FEV1% decreased between first and last study visit, while ACT scores and steroid dose remained unchanged. No significant correlation was found between FENO and FEV1/FVC, other spirometric values, inhaled steroid dose or ACT scores at any time point. No associations of FENO were found with age, sex, body mass index (BMI), atopic status, disease duration, presence of rhinitis or gastroesophageal reflux disease (GERD), or other medications used. Moderate asthma exacerbations did not consistently cause an increase of FENO. In stable elderly asthmatic patients, FENO was not elevated and did not correlate with subjects' demographics, comorbidities, treatment, symptoms or spirometric values. Routine measurements of FENO may not be clinically valuable in elderly asthmatics.
Collapse
Affiliation(s)
- Michele Columbo
- Asthma, Allergy and Immunology Specialists, 875 County Line Road, Bryn Mawr, PA 19010, USA.
| | | | | | | |
Collapse
|
15
|
Abstract
Last year's "Advances in pediatric asthma: moving forward" concluded the following: "Now is also the time to utilize information recorded in electronic medical records to develop innovative disease management plans that will track asthma over time and enable timely decisions on interventions in order to maintain control that can lead to disease remission and prevention." This year's summary will focus on recent advances in pediatric asthma on modifying disease activity, preventing asthma exacerbations, managing severe asthma, and risk factors for predicting and managing early asthma, as indicated in Journal of Allergy and Clinical Immunology publications in 2012. Recent reports continue to shed light on methods to improve asthma management through steps to assess disease activity, tools to standardize outcome measures in asthma, genetic markers that predict risk for asthma and appropriate treatment, and interventions that alter the early presentation of asthma to prevent progression. We are well on our way to creating a pathway around wellness in asthma care and also to use new tools to predict the risk for asthma and take steps to not only prevent asthma exacerbations but also to prevent the early manifestations of the disease and thus prevent its evolution to severe asthma.
Collapse
Affiliation(s)
- Stanley J Szefler
- Division of Pediatric Clinical Pharmacology, Department of Pediatrics, National Jewish Health, Denver, CO 80206, USA.
| |
Collapse
|
16
|
Ingram JL, Kraft M. IL-13 in asthma and allergic disease: asthma phenotypes and targeted therapies. J Allergy Clin Immunol 2012; 130:829-42; quiz 843-4. [PMID: 22951057 DOI: 10.1016/j.jaci.2012.06.034] [Citation(s) in RCA: 195] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 06/25/2012] [Accepted: 06/29/2012] [Indexed: 02/07/2023]
Abstract
Decades of research in animal models have provided abundant evidence to show that IL-13 is a key T(H)2 cytokine that directs many of the important features of airway inflammation and remodeling in patients with allergic asthma. Several promising focused therapies for asthma that target the IL-13/IL-4/signal transducer and activator of transcription 6 pathway are in development, including anti-IL-13 mAbs and IL-4 receptor antagonists. The efficacy of these new potential asthma therapies depends on the responsiveness of patients. However, an understanding of how IL-13-directed therapies might benefit asthmatic patients is confounded by the complex heterogeneity of the disease. Recent efforts to classify subphenotypes of asthma have focused on sputum cellular inflammation profiles, as well as cluster analyses of clinical variables and molecular and genetic signatures. Researchers and clinicians can now evaluate biomarkers of T(H)2-driven airway inflammation in asthmatic patients, such as serum IgE levels, sputum eosinophil counts, fraction of exhaled nitric oxide levels, and serum periostin levels, to aid decision making in clinical trials and drug development and to identify subsets of patients who might benefit from therapies. Although it is unlikely that these therapies will benefit all asthmatic patients with this heterogeneous disease, advances in understanding asthma subphenotypes in relation to clinical variables and T(H)2 cytokine responses offer the opportunity to improve the efficacy and safety of proposed therapies for asthma.
Collapse
Affiliation(s)
- Jennifer L Ingram
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, NC 27710, USA.
| | | |
Collapse
|