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Papadopoulos NG, Bacharier LB, Jackson DJ, Deschildre A, Phipatanakul W, Szefler SJ, Gall R, Ledanois O, Jacob-Nara JA, Sacks H. Type 2 Inflammation and Asthma in Children: A Narrative Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2310-2324. [PMID: 38878861 DOI: 10.1016/j.jaip.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 07/22/2024]
Abstract
Increased understanding of the underlying pathophysiology has highlighted the heterogeneity of asthma and identified that most children with asthma have type 2 inflammation with elevated biomarkers, such as blood eosinophils and/or fractional exhaled nitric oxide. Although in the past most of these children may have been categorized as having allergic asthma, identifying the type 2 inflammatory phenotype provides a mechanism to explain both allergic and non-allergic triggers in pediatric patients with asthma. Most children achieve control with low to medium doses of inhaled corticosteroids. However, in a small but significant proportion of children, asthma remains uncontrolled despite maximum conventional treatment, with an increased risk of severe exacerbations. In this review, we focus on the role of type 2 inflammation and allergic processes in children with asthma, together with evidence of the efficacy of available treatment options for those who experience severe symptoms.
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Affiliation(s)
- Nikolaos G Papadopoulos
- Allergy and Clinical Immunology Unit, Second Pediatric Clinic, University of Athens, Athens, Greece; Lydia Becker Institute of Immunity and Inflammation, The University of Manchester, Manchester, United Kingdom.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tenn
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Antoine Deschildre
- University Lille, CHU Lille, Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, Lille, France
| | - Wanda Phipatanakul
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Department of Allergy and Immunology, Boston Children's Hospital, Boston, Mass
| | - Stanley J Szefler
- Section of Pediatric Pulmonary and Sleep Medicine, Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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2
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Lejeune S, Hullo E, Bierme P, Baravalle M, Schweitzer C, Giovannini-Chami L. [From difficult-to-treat asthma to severe asthma: Step 5]. Rev Mal Respir 2024:S0761-8425(24)00245-6. [PMID: 39191540 DOI: 10.1016/j.rmr.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Affiliation(s)
- S Lejeune
- Service de pneumologie et d'allergologie pédiatrique, hôpital Jeanne de Flandre, université de Lille, CHU de Lille, 59000 Lille, France.
| | - E Hullo
- Service de pneumologie pédiatrique, hôpital Couple-Enfant, CHU de Grenoble, Grenoble, France
| | - P Bierme
- Service de pneumologie et d'allergologie pédiatrique, CHU de Lyon, Lyon, France
| | - M Baravalle
- Service de pneumologie pédiatrique, AP-HM, Marseille, France
| | - C Schweitzer
- Service de médecine infantile et explorations fonctionnelles pédiatriques, hôpital d'enfants, DeVAH EA 3450, CHRU de Nancy, faculté de médecine de Nancy, université de Lorraine, Vandœuvre-Lès-Nancy, France
| | - L Giovannini-Chami
- Service de pneumologie et d'allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU-Lenval, université Côte d'Azur, Nice, France
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Liu T, Woodruff PG, Zhou X. Advances in non-type 2 severe asthma: from molecular insights to novel treatment strategies. Eur Respir J 2024; 64:2300826. [PMID: 38697650 PMCID: PMC11325267 DOI: 10.1183/13993003.00826-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 04/18/2024] [Indexed: 05/05/2024]
Abstract
Asthma is a prevalent pulmonary disease that affects more than 300 million people worldwide and imposes a substantial economic burden. While medication can effectively control symptoms in some patients, severe asthma attacks, driven by airway inflammation induced by environmental and infectious exposures, continue to be a major cause of asthma-related mortality. Heterogeneous phenotypes of asthma include type 2 (T2) and non-T2 asthma. Non-T2 asthma is often observed in patients with severe and/or steroid-resistant asthma. This review covers the molecular mechanisms, clinical phenotypes, causes and promising treatments of non-T2 severe asthma. Specifically, we discuss the signalling pathways for non-T2 asthma including the activation of inflammasomes, interferon responses and interleukin-17 pathways, and their contributions to the subtypes, progression and severity of non-T2 asthma. Understanding the molecular mechanisms and genetic determinants underlying non-T2 asthma could form the basis for precision medicine in severe asthma treatment.
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Affiliation(s)
- Tao Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Department of Biochemistry and Molecular Biology, School of Medicine, Southeast University, Nanjing, China
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Prescott G Woodruff
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Xiaobo Zhou
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Xu Z, Forno E, Sun Y, Manni ML, Han YY, Kim S, Yue M, Vonk JM, Kersten ETM, Acosta-Perez E, Canino G, Koppelman GH, Chen W, Celedón JC. Nasal epithelial gene expression and total IgE in children and adolescents with asthma. J Allergy Clin Immunol 2024; 153:122-131. [PMID: 37742934 PMCID: PMC10842443 DOI: 10.1016/j.jaci.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/15/2023] [Accepted: 09/07/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Little is known about nasal epithelial gene expression and total IgE in youth. OBJECTIVE We aimed to identify genes whose nasal epithelial expression differs by total IgE in youth, and group them into modules that could be mapped to airway epithelial cell types. METHODS We conducted a transcriptome-wide association study of total IgE in 469 Puerto Ricans aged 9 to 20 years who participated in the Epigenetic Variation and Childhood Asthma in Puerto Ricans study, separately in all subjects and in those with asthma. We then attempted to replicate top findings for each analysis using data from 3 cohorts. Genes with a Benjamini-Hochberg-adjusted P value of less than .05 in the Epigenetic Variation and Childhood Asthma in Puerto Ricans study and a P value of less than .05 in the same direction of association in 1 or more replication cohort were considered differentially expressed genes (DEGs). DEGs for total IgE in subjects with asthma were further dissected into gene modules using coexpression analysis, and such modules were mapped to specific cell types in airway epithelia using public single-cell RNA-sequencing data. RESULTS A higher number of DEGs for total IgE were identified in subjects with asthma (n = 1179 DEGs) than in all subjects (n = 631 DEGs). In subjects with asthma, DEGs were mapped to 11 gene modules. The top module for positive correlation with total IgE was mapped to myoepithelial and mucus secretory cells in lower airway epithelia and was regulated by IL-4, IL5, IL-13, and IL-33. Within this module, hub genes included CDH26, FETUB, NTRK2, CCBL1, CST1, and CST2. Furthermore, an enrichment analysis showed overrepresentation of genes in signaling pathways for synaptogenesis, IL-13, and ferroptosis, supporting interactions between interleukin- and acetylcholine-induced responses. CONCLUSIONS Our findings for nasal epithelial gene expression support neuroimmune coregulation of total IgE in youth with asthma.
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Affiliation(s)
- Zhongli Xu
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa; School of Medicine, Tsinghua University, Beijing, China
| | - Erick Forno
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Yidan Sun
- Department of Pediatric Pulmonology and Pediatric Allergy, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands; GRIAC Research Institute, University Medical Center Groningen, Groningen, The Netherlands
| | - Michelle L Manni
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Yueh Ying Han
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Soyeon Kim
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Molin Yue
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Judith M Vonk
- GRIAC Research Institute, University Medical Center Groningen, Groningen, The Netherlands; Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elin T M Kersten
- Department of Pediatric Pulmonology and Pediatric Allergy, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands; GRIAC Research Institute, University Medical Center Groningen, Groningen, The Netherlands
| | - Edna Acosta-Perez
- Behavioral Sciences Research Institute of Puerto Rico, University of Puerto Rico, San Juan, Puerto Rico
| | - Glorisa Canino
- Behavioral Sciences Research Institute of Puerto Rico, University of Puerto Rico, San Juan, Puerto Rico; Department of Pediatrics, Medical Science Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Gerard H Koppelman
- Department of Pediatric Pulmonology and Pediatric Allergy, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands; GRIAC Research Institute, University Medical Center Groningen, Groningen, The Netherlands
| | - Wei Chen
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Juan C Celedón
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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Fainardi V, Caffarelli C, Deolmi M, Zambelli G, Palazzolo E, Scavone S, Bergamini BM, Bertelli L, Biserna L, Bottau P, Corinaldesi E, De Paulis N, Di Palmo E, Dondi A, Gallucci M, Guidi B, Lombardi F, Magistrali MS, Marastoni E, Pastorelli S, Piccorossi A, Poloni M, Tagliati S, Vaienti F, Gregori G, Sacchetti R, Antodaro F, Bergomi A, Reggiani L, De Fanti A, Marchetti F, Grandinetti R, Mussi N, Ricci G, Esposito S. Maintenance Therapy for Children and Adolescents with Asthma: Guidelines and Recommendations from the Emilia-Romagna Asthma (ERA) Study Group. J Clin Med 2023; 12:5467. [PMID: 37685533 PMCID: PMC10487522 DOI: 10.3390/jcm12175467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
Asthma is the most frequent chronic disease of childhood, affecting up to 20% of children worldwide. The main guidelines on asthma maintenance therapy in pediatrics suggest different approaches and describe different stages of asthma to determine the most appropriate treatment. This project aims to summarize the most recent evidence regarding maintenance therapy for asthma in children and adolescents. A multidisciplinary panel of experts was asked clinical questions regarding the treatment of children and adolescents with asthma. Overall, 10 clinical questions were addressed, and the search strategy included accessing electronic databases and a manual search of gray literature published in the last 25 years. After data extraction and narrative synthesis of results, recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Results showed that the choice of medication depends on the severity of the child's asthma, phenotype, age, preference, and individual factors. In addition to medications, the identification of comorbidities and modifiable factors is crucial to obtaining good control. Asthma in children is heterogeneous, and its evolution varies over time. Since most recommendations for asthma management in childhood are extrapolated from clinical studies performed in adults, more clinical trials specifically designed for young children should be conducted.
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Affiliation(s)
- Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
| | - Michela Deolmi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
| | - Giulia Zambelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
| | - Elisabetta Palazzolo
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
| | - Sara Scavone
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
| | - Barbara Maria Bergamini
- Paediatric Unit, Department of Medical and Surgical Sciences of Mothers, Children and Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy;
| | - Luca Bertelli
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.B.); (E.D.P.); (A.D.); (M.G.); (G.R.)
| | - Loretta Biserna
- Paediatrics and Neonatology Unit, Ravenna Hospital, Azienda Unità Sanitaria Locale (AUSL) Romagna, 48121 Ravenna, Italy; (L.B.); (F.M.)
| | - Paolo Bottau
- Paediatrics Unit, Imola Hospital, 40026 Imola, Italy;
| | | | - Nicoletta De Paulis
- Paediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy; (N.D.P.)
| | - Emanuela Di Palmo
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.B.); (E.D.P.); (A.D.); (M.G.); (G.R.)
| | - Arianna Dondi
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.B.); (E.D.P.); (A.D.); (M.G.); (G.R.)
| | - Marcella Gallucci
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.B.); (E.D.P.); (A.D.); (M.G.); (G.R.)
| | - Battista Guidi
- Hospital and Territorial Paediatrics Unit, 41026 Pavullo, Italy;
| | | | - Maria Sole Magistrali
- Paediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy; (N.D.P.)
| | - Elisabetta Marastoni
- Paediatrics Unit, Santa Maria Nuova Hospital, Azienda Unità Sanitaria Locale (AUSL)-Scientific Institute for Research and Healthcare (IRCCS) of Reggio Emilia, 42123 Reggio Emilia, Italy (A.D.F.)
| | | | - Alessandra Piccorossi
- Paediatrics and Paediatric Intensive Care Unit, Cesena Hospital, Azienda Unità Sanitaria Locale (AUSL) Romagna, 47521 Cesena, Italy
| | - Maurizio Poloni
- Paediatrics Unit, Rimini Hospital, Azienda Unità Sanitaria Locale (AUSL) Romagna, 47921 Rimini, Italy;
| | | | - Francesca Vaienti
- Paediatrics Unit, G.B. Morgagni Pierantoni Hospital, Azienda Unità Sanitaria Locale (AUSL) Romagna, 47121 Forlì, Italy;
| | - Giuseppe Gregori
- Primary Care Pediatricians, Azienda Unità Sanitaria Locale (AUSL) Piacenza, 29121 Piacenza, Italy; (G.G.); (R.S.)
| | - Roberto Sacchetti
- Primary Care Pediatricians, Azienda Unità Sanitaria Locale (AUSL) Piacenza, 29121 Piacenza, Italy; (G.G.); (R.S.)
| | - Francesco Antodaro
- Primary Care Pediatricians, Azienda Unità Sanitaria Locale (AUSL) Modena, 41125 Modena, Italy; (F.A.)
| | - Andrea Bergomi
- Primary Care Pediatricians, Azienda Unità Sanitaria Locale (AUSL) Modena, 41125 Modena, Italy; (F.A.)
| | - Lamberto Reggiani
- Primary Care Pediatricians, Azienda Unità Sanitaria Locale (AUSL) Imola, 40026 Imola, Italy
| | - Alessandro De Fanti
- Paediatrics Unit, Santa Maria Nuova Hospital, Azienda Unità Sanitaria Locale (AUSL)-Scientific Institute for Research and Healthcare (IRCCS) of Reggio Emilia, 42123 Reggio Emilia, Italy (A.D.F.)
| | - Federico Marchetti
- Paediatrics and Neonatology Unit, Ravenna Hospital, Azienda Unità Sanitaria Locale (AUSL) Romagna, 48121 Ravenna, Italy; (L.B.); (F.M.)
| | - Roberto Grandinetti
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
| | - Nicole Mussi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
| | - Giampaolo Ricci
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.B.); (E.D.P.); (A.D.); (M.G.); (G.R.)
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.F.); (C.C.); (M.D.); (G.Z.); (E.P.); (S.S.); (R.G.); (N.M.)
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Arslan B, Çetin GP, Yilmaz İ. The Role of Long-Acting Antimuscarinic Agents in the Treatment of Asthma. J Aerosol Med Pulm Drug Deliv 2023; 36:189-209. [PMID: 37428619 DOI: 10.1089/jamp.2022.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
The journey of using anticholinergics in the treatment of asthma started with anticholinergic-containing plants such as Datura stramonium and Atropa belladonna, followed by ipratropium bromide and continued with tiotropium, glycopyrronium, and umeclidinium. Although antimuscarinics were used in the maintenance treatment of asthma over a century ago, after a long time (since 2014), it has been recommended to be used as an add-on long-acting antimuscarinic agent (LAMA) therapy in the maintenance treatment of asthma. The airway tone controlled by the vagus nerve is increased in asthma. Allergens, toxins, or viruses cause airway inflammation and inflammation-related epithelial damage, increased sensory nerve stimulation, ganglionic and postganglionic acetylcholine (ACh) release by inflammatory mediators, intensification of ACh signaling at M1 and M3 muscarinic ACh receptors (mAChRs), and dysfunction of M2 mAChR. Optimal anticholinergic drug for asthma should effectively block M3 and M1 receptors, but have minimal effect on M2 receptors. Tiotropium, umeclidinium, and glycopyrronium are anticholinergic agents with this feature. Tiotropium has been used in a separate inhaler as an add-on treatment to inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA), and glycopyrronium and umeclidinium have been used in a single inhaler as a combination of ICS/LABA/LAMA in asthma in recent years. Guidelines recommend this regimen as an optimization step for patients with severe asthma before initiating any biologic or systemic corticosteroid therapy. In this review, the history of antimuscarinic agents, their effectiveness and safety in line with randomized controlled trials, and real-life studies in asthma treatment will be discussed according to the current data.
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Affiliation(s)
- Bahar Arslan
- Division of Immunology and Allergy, Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
| | - Gülden Paçacı Çetin
- Division of Immunology and Allergy, Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
| | - İnsu Yilmaz
- Division of Immunology and Allergy, Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
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8
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Salehian S, Fleming L, Saglani S, Custovic A. Phenotype and endotype based treatment of preschool wheeze. Expert Rev Respir Med 2023; 17:853-864. [PMID: 37873657 DOI: 10.1080/17476348.2023.2271832] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Preschool wheeze (PSW) is a significant public health issue, with a high presentation rate to emergency departments, recurrent symptoms, and severe exacerbations. A heterogenous condition, PSW comprises several phenotypes that may relate to a range of pathobiological mechanisms. However, treating PSW remains largely generalized to inhaled corticosteroids and a short acting beta agonist, guided by symptom-based labels that often do not reflect underlying pathways of disease. AREAS COVERED We review the observable features and characteristics used to ascribe phenotypes in children with PSW and available pathobiological evidence to identify possible endotypes. These are considered in the context of treatment options and future research directions. The role of machine learning (ML) and modern analytical techniques to identify patterns of disease that distinguish phenotypes is also explored. EXPERT OPINION Distinct clusters (phenotypes) of severe PSW are characterized by different underlying mechanisms, some shared and some unique. ML-based methodologies applied to clinical, biomarker, and environmental data can help design tools to differentiate children with PSW that continues into adulthood, from those in whom wheezing resolves, identifying mechanisms underpinning persistence and resolution. This may help identify novel therapeutic targets, inform mechanistic studies, and serve as a foundation for stratification in future interventional therapeutic trials.
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Affiliation(s)
- Sormeh Salehian
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Adnan Custovic
- NIHR Imperial Biomedical Research Centre (BRC), London, UK
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9
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Anderson WC, Banzon TM, Chawes B, Papadopoulos NG, Phipatanakul W, Szefler SJ. Factors to Consider in Prescribing Asthma Biologic Therapies to Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:693-701. [PMID: 36646381 DOI: 10.1016/j.jaip.2022.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023]
Abstract
The increasing availability of biologics, both by expanding age indications and by development of new therapies, provides additional options to treat children and adolescents with severe asthma. However, the evidence for these biologics in these populations is limited compared with that for adult studies. As such, before initiation of therapy, possible alternative therapies that can also provide asthma control, confirmation of the diagnosis of asthma, management of comorbidities, and assessment of adherence should be explored. The choice of a biologic should be a shared decision-making process between providers and families, balancing biologic efficacy, goals of care, administration, and ability to treat multiple conditions. Response to treatment should be periodically evaluated not only to ensure an ineffective treatment is not continued but also to consider when to potentially discontinue therapy should it be beneficial. The utilization of biologics in children and adolescents with severe asthma also leads to unanswered questions on their role in disease remission and long-term outcomes.
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Affiliation(s)
- William C Anderson
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Tina M Banzon
- Division of Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Wanda Phipatanakul
- Division of Asthma, Allergy, Dermatology, Rheumatology, Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Stanley J Szefler
- Section of Pediatric Pulmonary and Sleep Medicine, Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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Chen Y, Huang A, Tan G, Liu H. Antagonism of m3 Alleviates Type 2 Inflammation in Allergic Rhinitis Mice. Am J Rhinol Allergy 2022; 37:264-272. [PMID: 36343939 DOI: 10.1177/19458924221137977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Type 2 immune cells play a pivotal role in allergic rhinitis (AR). Increasing evidence shows that inhibition of cholinergic nerve activity decreases the severity of airway diseases including asthma and AR. However, the role of the cholinergic receptor muscarinic 3 (m3) in type 2 inflammation in AR is unknown. Objective We aimed to investigate the effect of m3 on the type 2 immune response, including both T helper 2 (Th2)-mediated and type 2 innate lymphocyte (ILC2)-mediated inflammation, in AR. Methods Peripheral blood mononuclear cells (PBMCs) from human were cultured in vitro. Treatment with the m3 antagonist 1,1-dimethyl-4-diphenylacetoxypiperidinium iodide (4-DAMP) was used. The percentages of Th2 and ILC2 cells in PBMCs were evaluated by flow cytometry. AR mouse models were established by house dust mite (HDM) sensitization, and treated with tiotropium intranasally. The expression of Th2 cytokines, ILC2 cytokines and related factors in the nasal mucosa was assessed by immunohistochemistry and quantitative real-time polymerase chain reaction. Serum HDM-specific immunoglobulin E (sIgE) level was detected by enzyme-linked immunosorbent assay. Results Both Th2 and ILC2 percentages in PBMCs were decreased after 4-DAMP treatment. Similarly, the levels of Th2 cytokines (interleukin 4 [IL-4] and IL-13) and ILC2 cytokines and related factors (IL-25, IL-33, GATA3 and RORα) were significantly decreased in the nasal mucosa of AR mice after tiotropium treatment. Furthermore, tiotropium treatment decreased the nasal symptom score, the serum sIgE level and eosinophil infiltration in AR mice. In addition, tiotropium decreased phospholipase Cγ1 (PLCγ1), PLCγ2, nuclear factor of activated T cell 1 (NFATc1), and NFATc2 mRNA levels in AR mice. Conclusion Antagonism of m3 alleviated type 2 inflammation in the nasal mucosa of AR mice.
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Affiliation(s)
- Yu Chen
- Department of Otorhinolaryngology—Head Neck Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Aijie Huang
- Department of Otorhinolaryngology—Head Neck Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Guolin Tan
- Department of Otorhinolaryngology—Head Neck Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Honghui Liu
- Department of Otorhinolaryngology—Head Neck Surgery, Third Xiangya Hospital, Central South University, Changsha, China
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11
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Alizadeh Bahmani AH, Abdel-Aziz MI, Maitland-van der Zee AH, Vijverberg SJH. Recent advances in the treatment of childhood asthma: a clinical pharmacology perspective. Expert Rev Clin Pharmacol 2022; 15:1165-1176. [PMID: 36196626 DOI: 10.1080/17512433.2022.2131537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Childhood asthma is a complex heterogenous inflammatory disease that can pose a large burden on patients and their caregivers. There is a strong need to adapt asthma treatment to the individual patient taking into account underlying inflammatory profiles, moving from a 'one size fits all' approach toward a much-needed personalized approach. AREAS COVERED This review article aims to provide an overview of recent advances in the management and treatment of pediatric asthma, including novel insights on the molecular heterogeneity of childhood asthma, the emergence of biologicals to treat severe asthma, and innovative e-health and home monitoring techniques to make asthma management more convenient and accessible. EXPERT OPINION Molecular technologies have provided new treatment leads. E-health and home monitoring technologies have helped to gain more insights into disease dynamics and improve adherence to treatment while bringing health care to the patient. However, uncontrolled childhood asthma is still a major unmet clinical need and precision-medicine approaches are still scarce in clinical practice. Advanced omics methods may help researchers or clinicians to more accurately phenotype and treat subtypes of childhood asthma and gain more insight into the complexity of the disease.
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Affiliation(s)
| | - Mahmoud I Abdel-Aziz
- Amsterdam UMC Location University of Amsterdam, Department of Pulmonary Medicine, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Anke H Maitland-van der Zee
- Amsterdam UMC Location University of Amsterdam, Department of Pulmonary Medicine, Amsterdam, The Netherlands.,Amsterdam UMC Location University of Amsterdam, Department of Paediatric Pulmonology, Amsterdam, The Netherlands
| | - Susanne J H Vijverberg
- Amsterdam UMC Location University of Amsterdam, Department of Pulmonary Medicine, Amsterdam, The Netherlands.,Amsterdam UMC Location University of Amsterdam, Department of Paediatric Pulmonology, Amsterdam, The Netherlands
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12
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Kotaniemi-Syrjänen A, Klemola T, Koponen P, Jauhola O, Aito H, Malmström K, Malmberg LP, Rahiala E, Sarna S, Pelkonen AS, Mäkelä MJ. Intermittent Tiotropium Bromide for Episodic Wheezing: A Randomized Trial. Pediatrics 2022; 150:188736. [PMID: 35942814 DOI: 10.1542/peds.2021-055860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Options to treat and prevent episodic wheezing in children are scarce. Our objective was to assess the efficacy of intermittent tiotropium bromide treatment in early childhood episodic wheezing. METHODS This 48-week, randomized, open-label, controlled, parallel-group trial was conducted at 4 hospitals in Finland. Children aged 6 to 35 months with 2 to 4 physician-confirmed episodes of wheeze and/or shortness of breath were considered eligible. Study participants were randomly allocated to receive 1 of 3 treatments: once-daily tiotropium bromide 5 µg for 7 to 14 days during respiratory tract infections and as-needed albuterol sulfate 0.2 mg (n = 27), twice-daily fluticasone propionate 125 µg for 7 to 14 days during respiratory tract infections and as-needed albuterol sulfate 0.2 mg (n = 25), or as-needed albuterol sulfate 0.2 mg alone (n = 28). The primary outcome was efficacy, assessed as intention-to-treat by comparing the proportion of episode-free days (the days lacking symptoms or treatments) between the treatment groups. RESULTS The proportion of episode-free days was higher in those receiving intermittent tiotropium bromide (median 97% [interquartile range, 93% to 99%]) than in those receiving intermittent fluticasone propionate (87% [78% to 93%], P = .002), or with as-needed albuterol sulfate alone (88% [79% to 95%], P = .003). Adjustment with allergic sensitization, the baseline number of physician-confirmed episodes of wheeze and/or shortness of breath, or short-course glucocorticoid treatment in the 2 weeks before the enrollment, did not affect the result. Intervention-related adverse events were not seen. CONCLUSIONS Intermittent tiotropium bromide treatment may be an effective alternative to current therapies for episodic wheezing. Before implementation of use, further research on safety and efficacy is indicated.
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Affiliation(s)
- Anne Kotaniemi-Syrjänen
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | - Kristiina Malmström
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L Pekka Malmberg
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Anna S Pelkonen
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika J Mäkelä
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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13
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Buendía JA, Patiño DG. Tiotropium for children and adolescents with severe asthma. J Asthma 2022; 60:1009-1015. [PMID: 36047659 DOI: 10.1080/02770903.2022.2120403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
IntroductionAn important proportion of asthma patients remain uncontrolled despite using inhaled corticosteroids and long-acting beta-agonists. Some add-on therapies, such as tiotropium bromide have been recommended for this subgroup of patients. The purpose of this study was to assess the cost-effectiveness of tiotropium as add-on therapies to ICS + LABA for children and adolescents with uncontrolled allergic asthma.MethodsA probabilistic Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with severe asthma in Colombia. Total costs and QALYS of two interventions including standard therapy (ICS + LABA), and add-on therapy with tiotropium, were calculated over a time horizon from 6 to 18 years. Probability sensitivity analyses were conducted.ResultsFor a patient with severe asthma, our markov model showed that compared to standard therapy, add-on therapy with tiotropium was associated with higher treatment costs and QALY . The incremental cost-effectiveness ratio estimated was US$2,017 in the probabilistic model after Monte-Carlo simulation. Our base-case results were robust to variations in all assumptions and parameters. The incremental net monetary benefit of US$327 with a 95% credible interval of US$396 to US425.ConclusionAdd-on therapy with tiotropium was cost-effective when added to usual care in children and adolescents with severe asthma who remained uncontrolled despite treatment with medium or high-dose ICS/LABA. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.
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Affiliation(s)
- Jefferson Antonio Buendía
- Research group in Pharmacology and Toxicology" INFARTO". Department of Pharmacology and Toxicology. University of Antioquia, Medellín, Colombia
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14
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Abstract
Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.
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15
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Neutrophils and Asthma. Diagnostics (Basel) 2022; 12:diagnostics12051175. [PMID: 35626330 PMCID: PMC9140072 DOI: 10.3390/diagnostics12051175] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
Although eosinophilic inflammation is characteristic of asthma pathogenesis, neutrophilic inflammation is also marked, and eosinophils and neutrophils can coexist in some cases. Based on the proportion of sputum cell differentiation, asthma is classified into eosinophilic asthma, neutrophilic asthma, neutrophilic and eosinophilic asthma, and paucigranulocytic asthma. Classification by bronchoalveolar lavage is also performed. Eosinophilic asthma accounts for most severe asthma cases, but neutrophilic asthma or a mixture of the two types can also present a severe phenotype. Biomarkers for the diagnosis of neutrophilic asthma include sputum neutrophils, blood neutrophils, chitinase-3-like protein, and hydrogen sulfide in sputum and serum. Thymic stromal lymphoprotein (TSLP)/T-helper 17 pathways, bacterial colonization/microbiome, neutrophil extracellular traps, and activation of nucleotide-binding oligomerization domain-like receptor family, pyrin domain-containing 3 pathways are involved in the pathophysiology of neutrophilic asthma and coexistence of obesity, gastroesophageal reflux disease, and habitual cigarette smoking have been associated with its pathogenesis. Thus, targeting neutrophilic asthma is important. Smoking cessation, neutrophil-targeting treatments, and biologics have been tested as treatments for severe asthma, but most clinical studies have not focused on neutrophilic asthma. Phosphodiesterase inhibitors, anti-TSLP antibodies, azithromycin, and anti-cholinergic agents are promising drugs for neutrophilic asthma. However, clinical research targeting neutrophilic inflammation is required to elucidate the optimal treatment.
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16
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Deschildre A, Abou-Taam R, Drummond D, Giovannini-Chami L, Labouret G, Lejeune S, Lezmi G, Lecam MT, Marguet C, Petat H, Taillé C, Wanin S, Corvol H, Epaud R. [Update of the 2021 Recommendations for the management of and follow-up of adolescent asthmatic patients (over 12 years) under the guidance of the French Society of Pulmonology and the Paediatric Society of Pulmonology and Allergology. Long version]. Rev Mal Respir 2022; 39:e1-e31. [PMID: 35148929 DOI: 10.1016/j.rmr.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022]
Affiliation(s)
- A Deschildre
- Université Lille, CHU Lille, service de pneumologie et allergologie pédiatriques, hôpital Jeanne de Flandre, 59000 Lille, France; Centre d'infection et d'immunité de Lille, Inserm U1019, CNRS UMR9017, équipe OpinFIELD: Infections opportunistes, Immunité, Environnement et Maladies Pulmonaires, Institut Pasteur de Lille, 59019 Lille cedex, France.
| | - R Abou-Taam
- Service de pneumologie et allergologie pédiatriques, hôpital Necker-enfants malades, APHP, université de Paris, Paris, France
| | - D Drummond
- Service de pneumologie et allergologie pédiatriques, hôpital Necker-enfants malades, APHP, université de Paris, Paris, France
| | - L Giovannini-Chami
- Service de Pneumo-Allergologie pédiatrique, Hôpitaux pédiatriques de Nice CHU-Lenval, 57, avenue de la Californie, 06200 Nice, France
| | - G Labouret
- Service de Pneumo-allergologie pédiatrique, Hôpital des Enfants, CHU Toulouse, 31000 Toulouse, France
| | - S Lejeune
- Université Lille, CHU Lille, service de pneumologie et allergologie pédiatriques, hôpital Jeanne de Flandre, 59000 Lille, France; Centre d'infection et d'immunité de Lille, Inserm U1019, CNRS UMR9017, équipe OpinFIELD: Infections opportunistes, Immunité, Environnement et Maladies Pulmonaires, Institut Pasteur de Lille, 59019 Lille cedex, France
| | - G Lezmi
- Service de pneumologie et allergologie pédiatriques, hôpital Necker-enfants malades, APHP, université de Paris, Paris, France
| | - M T Lecam
- Service de pathologies professionnelles et de l'environnement. Centre Hospitalier Inter Communal de Créteil, 94000 Créteil, France
| | - C Marguet
- Université de Normandie, UNIROUEN, EA 2456, CHU Rouen, maladies respiratoires et allergiques, CRCM, département de Pédiatrie, et de Médecine de l'adolescent, 76000 Rouen, France; Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie Université, UNICAEN,UNIROUEN, EA2656, 14033 Caen, France
| | - H Petat
- Université de Normandie, UNIROUEN, EA 2456, CHU Rouen, maladies respiratoires et allergiques, CRCM, département de Pédiatrie, et de Médecine de l'adolescent, 76000 Rouen, France; Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie Université, UNICAEN,UNIROUEN, EA2656, 14033 Caen, France
| | - C Taillé
- Groupe Hospitalier Universitaire AP-HP Nord-Université de Paris, hôpital Bichat, Service de Pneumologie et Centre de Référence constitutif des maladies pulmonaires rares ; Inserm UMR1152, Paris, France
| | - S Wanin
- Service d'allergologie pédiatrique, hôpital universitaire Armand Trousseau, 75012 Paris, France; Unité Transversale d'éducation thérapeutique Sorbonne Université, Paris, France
| | - H Corvol
- Service de pneumologie pédiatrique, Sorbonne Université, Centre de Recherche Saint-Antoine, Inserm UMRS938, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Trousseau, Paris, France
| | - R Epaud
- Centre hospitalier intercommunal de Créteil, service de pédiatrie générale, 94000 Créteil, France; Université Paris Est Créteil, Inserm, IMRB, 94010 Créteil, France; FHU SENEC, Créteil, France
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Chipps BE, Murphy KR, Oppenheimer J. 2020 NAEPP Guidelines Update and GINA 2021-Asthma Care Differences, Overlap, and Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:S19-S30. [PMID: 34718214 DOI: 10.1016/j.jaip.2021.10.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/29/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022]
Abstract
The 2020 National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (NAEPP [2020 Focused Asthma Update]) guidelines and the Global Initiative for Asthma (GINA) 2021 strategy report are compared in this Rostrum article. The methodologies of each publication are described. Subsequently, 4 different selected pharmacological recommendations are compared in the 2 documents: step 1 for children 0 to 4 years of age with viral-induced wheezing, step 2 in ages 12 years and older with the intermittent use of inhaled corticosteroid, steps 3 and 4 with single-inhaler maintenance and reliever therapy with inhaled corticosteroids-formoterol (SMART), and steps 3, 4, and 5 with add-on long-acting muscarinic antagonist therapy. Nonpharmacological recommendations are also considered and contrasted, including for exhaled nitric oxide, environmental control, immunotherapy, and bronchial thermoplasty. Similarities and differences in these 2 documents are highlighted, and recommendations are made about harmonizing the approaches where possible.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif.
| | - Kevin R Murphy
- Boys Town National Research Hospital, Section of Adult and Pediatric Allergy and Pediatric Pulmonary, Boystown, Neb
| | - John Oppenheimer
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ
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18
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Murphy RC, Pavord ID, Alam R, Altman MC. Management Strategies to Reduce Exacerbations in non-T2 Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2588-2597. [PMID: 34246435 DOI: 10.1016/j.jaip.2021.04.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/19/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Abstract
There have been considerable advances in our understanding of asthmatic airway inflammation, resulting in a paradigm shift of classifying individuals on the basis of either the presence or the absence of type 2 (T2) inflammatory markers. Several novel monoclonal antibody therapies targeting T2 cytokines have demonstrated significant clinical effects including reductions in acute exacerbations and improvements in asthma-related quality of life and lung function for individuals with T2-high asthma. However, there have been fewer advancements in developing therapies for those without evidence of T2 airway inflammation (so-called non-T2 asthma). Here, we review the heterogeneity of molecular mechanisms responsible for initiation and regulation of non-T2 inflammation and discuss both current and potential future therapeutic options for individuals with non-T2 asthma.
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Affiliation(s)
- Ryan C Murphy
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Wash; Center for Lung Biology, Department of Medicine, University of Washington, Seattle, Wash.
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rafeul Alam
- Division of Allergy and Immunology, Department of Medicine, National Jewish Health and University of Colorado, Denver, Colo
| | - Matthew C Altman
- Center for Lung Biology, Department of Medicine, University of Washington, Seattle, Wash; Division of Allergy and Immunology, University of Washington, Seattle, Wash
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Sunther M, Marchon K, Gupta A. Tiotropium in the management of paediatric and adolescent asthma: Systematic review. Paediatr Respir Rev 2021; 38:58-62. [PMID: 33243704 DOI: 10.1016/j.prrv.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 01/25/2023]
Abstract
Tiotropium bromide is a long-acting muscarinic antagonist (LAMA) and is the only LAMA licensed for management for patients' ≥6 years old with severe asthma who have experienced one or more severe asthma exacerbations in the preceding year. Recent clinical trials have demonstrated that once-daily tiotropium is safe and efficacious in 6-17 year-olds with symptomatic asthma despite treatment with inhaled corticosteroids (ICSs), with or without additional controllers. In this paper, we review the evidence of the safety and efficacy of tiotropium add-on maintenance treatment in children and adolescents with symptomatic moderate and severe asthma.
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Affiliation(s)
- Meera Sunther
- Department of Respiratory Paediatrics, King's College Hospital, London, UK
| | - Keisha Marchon
- Department of Respiratory Paediatrics, King's College Hospital, London, UK
| | - Atul Gupta
- Department of Respiratory Paediatrics, King's College Hospital, London, UK; Institute for Women's and Children's Health, King's College London, London, UK.
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20
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Calzetta L, Coppola A, Ritondo BL, Matino M, Chetta A, Rogliani P. The Impact of Muscarinic Receptor Antagonists on Airway Inflammation: A Systematic Review. Int J Chron Obstruct Pulmon Dis 2021; 16:257-279. [PMID: 33603353 PMCID: PMC7886086 DOI: 10.2147/copd.s285867] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/30/2020] [Indexed: 12/16/2022] Open
Abstract
Long-acting muscarinic receptor antagonists (LAMAs) are the cornerstone for the treatment of chronic obstructive pulmonary disease (COPD); furthermore, tiotropium is approved as add-on therapy in severe asthmatic patients. Accumulating evidence suggests that LAMAs may modulate airway contractility and airway hyperresponsiveness not only by blocking muscarinic acetylcholine receptors (mAchRs) expressed on airway smooth muscle but also via anti-inflammatory mechanisms by blocking mAchRs expressed on inflammatory cells, submucosal glands, and epithelial cells. The aim of this systematic review, performed according to the PRISMA-P guidelines, was to provide a synthesis of the literature on the anti-inflammatory impact of muscarinic receptor antagonists in the airways. Most of the current evidence originates from studies on tiotropium, that demonstrated a reduction in synthesis and release of cytokines and chemokines, as well as the number of total and differential inflammatory cells, induced by different pro-inflammatory stimuli. Conversely, few data are currently available for aclidinium and glycopyrronium, whereas no studies on the potential anti-inflammatory effect of umeclidinium have been reported. Overall, a large body of evidence supports the beneficial impact of tiotropium against airway inflammation. Further well-designed randomized controlled trials are needed to better elucidate the anti-inflammatory mechanisms leading to the protective effect of LAMAs against exacerbations via identifying suitable biomarkers.
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Affiliation(s)
- Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Angelo Coppola
- Division of Respiratory Medicine, University Hospital "Policlinico Tor Vergata", Rome, Italy
| | - Beatrice Ludovica Ritondo
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Matteo Matino
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Alfredo Chetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Paola Rogliani
- Division of Respiratory Medicine, University Hospital "Policlinico Tor Vergata", Rome, Italy.,Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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21
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Comparing LAMA with LABA and LTRA as add-on therapies in primary care asthma management. NPJ Prim Care Respir Med 2020; 30:50. [PMID: 33177503 PMCID: PMC7658210 DOI: 10.1038/s41533-020-00205-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023] Open
Abstract
The Global Initiative for Asthma recommends a stepwise approach to adjust asthma treatment to the needs of individual patients; inhaled corticosteroids (ICS) remain the core pharmacological treatment. However, many patients remain poorly controlled, and evidence-based algorithms to decide on the best order and rationale for add-on therapies are lacking. We explore the challenges of asthma management in primary care and review outcomes from randomised controlled trials and meta-analyses comparing the long-acting muscarinic antagonist (LAMA) tiotropium with long-acting β2-agonists (LABAs) or leukotriene receptor antagonists (LTRAs) as add-on to ICS in patients with asthma. In adults, LAMAs and LABAs provide a greater improvement in lung function than LTRAs as add-on to ICS. In children, results were positive and comparable between therapies, but data are scarce. This information could aid decision-making in primary care, supporting the use of add-on therapy to ICS to help improve lung function, control asthma symptoms and prevent exacerbations.
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Álvarez-Gutiérrez FJ, Blanco-Aparicio M, Plaza V, Cisneros C, García-Rivero JL, Padilla A, Pérez-de Llano L, Perpiñá M, Soto-Campos G. Documento de consenso de asma grave en adultos. Actualización 2020. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Teague WG. Tiotropium: An Effective Bronchodilator in Severe Asthma Independent of Type 2 Inflammation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:2296-2297. [PMID: 31495432 DOI: 10.1016/j.jaip.2019.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 05/08/2019] [Indexed: 01/23/2023]
Affiliation(s)
- W Gerald Teague
- Division of Respiratory Medicine, Allergy, Immunology, and Sleep, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va; Child Health Research Center, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va.
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Matera MG, Belardo C, Rinaldi M, Rinaldi B, Cazzola M. New perspectives on the role of muscarinic antagonists in asthma therapy. Expert Rev Respir Med 2020; 14:817-824. [PMID: 32316778 DOI: 10.1080/17476348.2020.1758069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION There is increasing evidence that tiotropium, a long-acting muscarinic agent (LAMA), is useful in the presence of severe-uncontrolled asthma despite the optimization of therapy with inhaled corticosteroids (ICSs) and long-acting β2 agonists (LABAs) as recommended by the current guidelines. Furthermore, in recent years there have been several preclinical and clinical studies on the pharmacological and therapeutic impact of other LAMAs in asthma. AREAS COVERED We have conducted an extensive search on muscarinic antagonists in asthma therapy throughout several sources and discuss what has emerged in the last 3 years (January 2017-March 2020). EXPERT OPINION New evidence indicates that the effectiveness of adding a LAMA, at least tiotropium, is independent of the degree of the type 2 inflammation and age of patient. Therefore, tiotropium can be administered without the need for patient phenotyping. Umeclidinium and glycopyrronium also appear effective in asthma. Initial treatment with LAMA+ICS for those with mild asthma may be an equally effective therapeutic option as LABA+ICS but this hypothesis should be confirmed by statistically powered trials.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Carmela Belardo
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Michele Rinaldi
- Multidisciplinary Department of Medical-Surgical and Dental Specialities, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Barbara Rinaldi
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome, Italy
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Schatz M, Sicherer SH, Khan DA, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2019 Highlights. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:912-936. [PMID: 31980411 DOI: 10.1016/j.jaip.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
This article provides highlights of the clinically impactful original studies and reviews published in The Journal of Allergy and Clinical Immunology: In Practice in 2019 on the subjects of anaphylaxis, asthma, dermatitis, drug allergy, food allergy, immunodeficiency, immunotherapy, rhinitis/sinusitis, and urticaria/angioedema/mast cell disorders. Within each topic, practical aspects of diagnosis and management are emphasized. Treatments discussed include lifestyle modifications, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We designed this review to help readers consolidate and use this extensive and practical knowledge for the benefit of their patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
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Cazzola M, Puxeddu E, Matera MG, Rogliani P. A potential role of triple therapy for asthma patients. Expert Rev Respir Med 2019; 13:1079-1085. [PMID: 31422716 DOI: 10.1080/17476348.2019.1657408] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: The use of LAMAs in asthma is now supported by pharmacological and clinical evidence, whereas the effectiveness of therapy with ICS/LABA/LAMA fixed dose combinations in patients with asthma still remains to be determined. Areas covered: The pharmacological rationale that explains why it is possible to use triple therapy in asthma and the results of clinical studies that have explored the effects of this therapy in asthmatics is critically examined. A systematic search was conducted on 10 August 2019, and included six electronic databases: EMBASE, MEDLINE, Scopus, The Cochrane Library, Web of Science, and Google Scholar. Expert opinion: The real role of single inhaler triple therapy in asthma will be demonstrated when the various trials that are currently ongoing or are scheduled will be completed. We believe that it is appropriate to treat with triple therapy asthmatic patients who have smoked and remain symptomatic or suffer from frequent exacerbations despite initial inhaler therapy with ICS/LABA. However, we must establish when to step up or mainly step down triple therapy especially in patients who are well controlled, and what will be the cost of these combinations in the management of asthma.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
| | - Ermanno Puxeddu
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
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