Effect of intravenous immunoglobulin on steroid consumption in patients with severe asthma: a double-blind, placebo-controlled, randomized trial

Current Issues in the Management of IgG Subclass Deficiencies in Adults With Chronic Respiratory Diseases

Primary immunodeficiency diseases (PIDs) are uncommon in adults; however, immunoglobulin G subclass deficiency (IGGSCD) is often found in a subset of adult patients with chronic respiratory diseases. As quantitative laboratory tests are used to diagnose IGGSCD, the clinical significance of IGGSCD remains controversial. However, respiratory infection is a common presenting feature of IGGSCD, and respiratory complications are responsible for subsequent morbidities, such as severe asthma, bronchiectasis, chronic obstructive airway diseases, and mortality. This review summarizes the current epidemiological data for PIDs, focusing on IGGSCD in the adult population. In addition, the investigation, treatment, and management strategies are detailed, including distinct issues faced by patients with chronic airway disease and their physicians in the proper diagnosis and treatment of IGGSCD.

Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees

Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.

Antibody Deficiency, Chronic Lung Disease, and Comorbid Conditions: A Case-Based Approach

New emerging pulmonary phenotypes associated with antibody deficiency, such as neutrophilic asthma, frequent exacerbations of chronic obstructive pulmonary disease, and unexplained interstitial lung disease, particularly in younger adults, are discussed in this review through a case-based approach. Also discussed in similar fashion are antibody deficiency syndromes that lead to end-stage lung disease and the indications for lung transplantation in primary immunodeficiency disease. These challenging cases require timely and individualized strategies for genetic and immunologic diagnosis, decisions about therapeutic approaches, and long-term monitoring.

Utility of immunology, microbiology, and helminth investigations in clinical assessment of severe asthma

OBJECTIVE

Systematic assessment of patients with potential severe asthma is key to identification of treatable traits and optimal management. Assessment of antimicrobial immune function is part of that assessment at many centers although there is little evidence-base on its added value in clinical assessment of this patient group. As part of reviewing our local pathway, we have retrospectively reviewed these tests in 327 consecutive referrals to our severe asthma service, in an evaluation to describe the utility of these tests and allow refinement of the local guideline for patient assessment.

METHODS AND RESULTS

Serum immunoglobulin concentrations were in the normal range in most patients though 12 patients had serum IgG < 5.5 g/L and many had suboptimal anti-Haemophilus (127 of 249 patients tested) and anti-Pneumococcal (111 of 239) immune responses. As expected many patients had evidence of sensitization to Aspergillus although specific IgG was not confined to those with evidence of allergic sensitization/allergic bronchopulmonary aspergillosis (ABPA). Eighteen of 277 patients tested had serological evidence of Strongyloides infection. Bacteria and/or yeast were cultured from the sputum in 76 out of 110 patients productive of sputum, and the most common microbes cultured were Candida sp. (44 patients), Staphylococcus aureus (21 patients), Haemophilus influenzae (18 patients).

CONCLUSIONS

Many patients had evidence of infection, colonization, or sensitization to potential pathogens relevant to asthma. Strongyloides infection was evident in several patients, which may be a major issue when considering the risk of hyper-infection following immunosuppression and supports our local screening strategy.

Efficacy of immunoglobulin replacement therapy and azithromycin in severe asthma with antibody deficiency

BACKGROUND

Although antibody deficiency (AD) is a well-known cause of recurrent respiratory infections, there are few data on its impact in adults with asthma. The objective of the present study was to assess outcomes in adults with severe asthma and AD after treatment with either azithromycin or subcutaneous immunoglobulins (SCIg).

METHODS

We performed a 5-year, prospective, observational, two-centre study of adults with severe asthma and AD in France. Bronchiectasis was ruled out by high-resolution computed tomography. Patients were treated for one year with either azithromycin (250 mg every other day) or SCIg (0.4-0.6 g/kg/months, weekly). All patients were evaluated for exacerbations, asthma control and lung function at baseline and then one year after treatment initiation.

RESULTS

Thirty-nine patients with severe asthma were included in the study: 14 had been treated with azithromycin and 25 had been treated with SCIg. Before the initiation of treatment for AD, all patients had an Asthma Control Questionnaire (ACQ-7) score > 1.5 (mean ± SD: 2.71 ± 0.53) despite treatment at GINA step 4 or 5, and had a high exacerbation rate requiring oral corticosteroids and/or rescue antibiotics (∼7.2 ± 2.1/patient/year). One year after treatment initiation, we observed a significantly higher FEV1 (mean: 0.18 ± 0.22 L) and ACQ-7 score (1.26 ± 0.68), and a significantly lower exacerbation rate (1.63 ± 1.24/patient/year).

CONCLUSIONS

Treatment of AD dramatically improved asthma outcomes - suggesting that adults with severe asthma and recurrent respiratory infections should be screened and (if appropriate) treated for AD.

Inadequate assessment of adherence to maintenance medication leads to loss of power and increased costs in trials of severe asthma therapy: results from a systematic literature review and modelling study

Adherence to inhaled maintenance therapy in severe asthma is rarely adequately assessed, and its influence on trial outcomes is unknown. We systematically determined how adherence to maintenance therapy is assessed in clinical trials of "add-on" therapy for severe asthma. We model the improvement in trial power that could be achieved by accurately assessing adherence.A systematic search of six major databases identified randomised trials of add-on therapy for severe asthma. The relationship between measuring adherence and study outcomes was assessed. An estimate of potential improvements in statistical power and sample size was derived using digitally recorded adherence trial data.87 randomised controlled trials enrolling 22 173 participants were included. Adherence assessment was not reported in 67 trials (n=13 931, 63%). Studies that reported adherence used a range of self-report and subjective methods. None of the studies employed an objective assessment of adherence. Studies that reported adherence had a significantly reduced pooled variance in forced expiratory volume in 1 s (FEV₁) compared to those that did not assess adherence: s²=0.144 L² versus s²=0.168 L², p<0.0001. Power to detect clinically relevant changes in FEV₁ was significantly higher in trials that reported adherence assessment (mean power achieved 59% versus 49%). Modelling suggests that up to 50% of variance in FEV₁ outcomes is attributable to undetected variations in adherence. Controlling for such variations could potentially halve the required sample size.Few trials of add-on therapy monitor adherence to maintenance inhaled therapy, resulting in a greater variance in trial outcomes and inadequate power for determining efficacy.

Intravenous immunoglobulin: a biological corticosteroid-sparing agent in some autoimmune conditions

Intravenous immunoglobulin (IVIg) is increasingly used for the treatment of autoimmune and systemic inflammatory diseases. This compound is effective in a wide range of clinical conditions other than primary immunodeficiency, including autoimmune diseases, inflammatory disorders, infections, organ transplantation, and possibly supportive therapy for cancer. Systemic corticosteroids remain the gold standard treatment for many autoimmune diseases, but their long-term use is associated with complications in diverse organs and systems. Osteoporosis, osteonecrosis, cardiovascular disease, infections, and cancer have been associated with this treatment. Therefore, physicians are occasionally forced to withdraw the treatment with steroids. Biological agents may represent a good alternative, but in addition to being very expensive, these agents may have serious side effects. This review aimed to cover the major advances in the use of IVIg as a steroid-sparing agent in some relevant autoimmune diseases.

Effects of Immunoglobulin Replacement on Asthma Exacerbation in Adult Asthmatics with IgG Subclass Deficiency

Purpose

Recurrent respiratory tract infection is a common manifestation of primary immunodeficiency disease, and respiratory viruses or bacteria are important triggers of asthma exacerbations. Asthma often coexists with humoral immunodeficiency in adults, and some asthmatics with immunoglobulin (Ig) G subclass deficiency (IgGSCD) suffer from recurrent exacerbations. Although some studies suggest a benefit from Ig replacement, others have failed to support its use. This study aimed to assess the effect of Ig replacement on asthma exacerbation caused by respiratory infection as well as the asthma control status of adult asthmatics with IgGSCD.

Methods

This is a multi-center, open-label study of adult asthmatics with IgGSCD. All patients received monthly intravenous immunoglobulin (IVIG) for 6 months and were evaluated regarding asthma exacerbation related to infection, asthma control status, quality of life, and lung function before and after IVIG infusion.

Results

A total of 30 patients were enrolled, and 24 completed the study. Most of the patients had a moderate degree of asthma severity with partly (52%) or uncontrolled (41%) status at baseline. IVIG significantly reduced the proportion of patients with asthma exacerbations, lowered the number of respiratory infections, and improved asthma control status, compared to the baseline values (P<0.001). The mean asthma-specific quality of life and asthma control test scores were improved significantly (P=0.009 and P=0.053, respectively); however, there were no significant changes in lung function.

Conclusions

IVIG reduced the frequency of asthma exacerbations and improved asthma control status in adult asthmatics with IgGSCD, suggesting that IVIG could be an effective treatment option in this population.

Update on the use of immunoglobulin in human disease: A review of evidence

Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.

Immunoglobulin G Subclass Deficiencies in Adult Patients with Chronic Airway Diseases

Immunoglobulin G subclass deficiency (IgGSCD) is a relatively common primary immunodeficiency disease (PI) in adults. The biological significance of IgGSCD in patients with chronic airway diseases is controversial. We conducted a retrospective study to characterize the clinical features of IgGSCD in this population. This study examined the medical charts from 59 adult patients with IgGSCD who had bronchial asthma or chronic obstructive pulmonary disease (COPD) from January 2007 to December 2012. Subjects were classified according to the 10 warning signs developed by the Jeffrey Modell Foundation (JMF) and divided into two patient groups: group I (n = 17) met ≥ two JMF criteria, whereas group II (n = 42) met none. IgG3 deficiency was the most common subclass deficiency (88.1%), followed by IgG4 (15.3%). The most common infectious complication was pneumonia, followed by recurrent bronchitis, and rhinosinusitis. The numbers of infections, hospitalizations, and exacerbations of asthma or COPD per year were significantly higher in group I than in group II (P < 0.001, P = 0.012, and P < 0.001, respectively). The follow-up mean forced expiratory volume (FEV1) level in group I was significantly lower than it was at baseline despite treatment of asthma or COPD (P = 0.036). In conclusion, IgGSCD is an important PI in the subset of patients with chronic airway diseases who had recurrent upper and lower respiratory infections as they presented with exacerbation-prone phenotypes, decline in lung function, and subsequently poor prognosis.

Treatment of severe asthma: entering the era of targeted therapy

INTRODUCTION

It is estimated that 5 - 10% of asthma patients suffer from severe asthma. Severe asthma is associated with increased morbidity and mortality. These patients are not controlled with currently available treatments and therefore additional treatment options are needed. Asthma is a heterogeneous disease, and different asthma patient groups probably have different underlying pathophysiology. Novel therapies with, for example, monoclonal antibodies that target certain immunological pathways have become available. These novel treatments are not effective in all patients but only in certain phenotypes.

AREAS COVERED

This review covers the current evidence and novel developments in treatment with monoclonal antibodies in different asthma phenotypes. This includes monoclonal antibodies against IgE, against interleukin (IL)-5 and antibodies targeting IL-13 pathways. Although there is a certain overlap between patient groups benefiting from these treatments, a more detailed identification of responder profiles for these therapies is needed for personalized therapy.

EXPERT OPINION

In recent years, novel monoclonal antibodies have been developed, which are a promising addition to existing therapy in the treatment of severe asthma with eosinophilic inflammation and Th2-driven disease. We expect that several of the new antibodies will become available for clinical practice. In addition, it must be acknowledged that so far no effective strategies are available for patients with non-eosinophilic asthma and further research and development is necessary for this patient group.

The protective role of immunoglobulins in fungal infections and inflammation

Increased incidence of fungal infections in the immunocompromised individuals and fungi-mediated allergy and inflammatory conditions in immunocompetent individuals is a cause of concern. Consequently, there is a need for efficient therapeutic alternatives to treat fungal infections and inflammation. Several studies have demonstrated that antibodies or immunoglobulins have a role in restricting the fungal burden and their clearance. However, based on the data from monoclonal antibodies, it is now evident that the efficacy of antibodies in fungal infections is dependent on epitope specificity, abundance of protective antibodies, and their isotype. Antibodies confer protection against fungal infections by multiple mechanisms that include direct neutralization of fungi and their antigens, inhibition of growth of fungi, modification of gene expression, signaling and lipid metabolism, causing iron starvation, inhibition of polysaccharide release, and biofilm formation. Antibodies promote opsonization of fungi and their phagocytosis, complement activation, and antibody-dependent cell toxicity. Passive administration of specific protective monoclonal antibodies could also prove to be beneficial in drug resistance cases, to reduce the dosage and associated toxic symptoms of anti-fungal drugs. The longer half-life of the antibodies and flexibilities to modify their structure/forms are additional advantages. The clinical data obtained with two monoclonal antibodies should incite interests in translating pre-clinical success into the clinics. The anti-inflammatory and immunoregulatory role of antibodies in fungal inflammation could be exploited by intravenous immunoglobulin or IVIg.

Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital

BACKGROUND

Inhaled anticholinergics given in addition to β2-agonists are effective in reducing hospital admissions in children presenting to the emergency department with a moderate to severe asthma exacerbation. It seems logical to assume a similar beneficial effect in children hospitalised for an acute asthma exacerbation.

OBJECTIVES

To assess the efficacy and safety of anticholinergics added to β2-agonists as inhaled or nebulised therapy in children hospitalised for an acute asthma exacerbation. To investigate the characteristics of patients or therapy, if any, that would influence the magnitude of response attributable to the addition of anticholinergics.

SEARCH METHODS

We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO and through handsearching of respiratory journals and meeting abstracts. The search is current to November 2013.

SELECTION CRITERIA

Randomised trials comparing the combination of inhaled or nebulised anticholinergics and short-acting β2-agonists versus short-acting β2-agonists alone in children one to 18 years of age hospitalised for an acute asthma exacerbation were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of trials and extracted data; disagreement was resolved by consensus or with the input of a third review author, when needed. Primary outcomes were duration of hospital stay and serious adverse events. Secondary outcomes included admission and duration of stay in the intensive care unit (ICU), ventilation assistance, time to short-acting β2-agonists spaced at four hours or longer, supplemental asthma therapy, duration of supplemental oxygen, change from baseline in asthma severity, relapse after discharge, adverse health effects and withdrawals.

MAIN RESULTS

Seven randomised trials were included, four of which reported usable data on 472 children with asthma one to 18 years of age who were admitted to paediatric wards. No trials included patients admitted to the ICU. The anticholinergic used, ipratropium bromide 250 μg, was given every one to eight hours over a period from four hours to the entire length of the hospital stay. Two of four trials (50%) contributing data were deemed of high methodological quality. The addition of anticholinergics to β2-agonists showed no evidence of effect on the duration of hospital admission (mean difference (MD) -0.28 hours, 95% confidence interval (CI) -5.07 to 4.52, 3 studies, 327 participants, moderate quality evidence) and no serious or non-serious adverse events were reported in any included trials. As a result of the similarity of trials, we could not explore the influence of age, admission site, intensity of anticholinergic treatment and co-interventions on primary outcomes. No statistically significant group difference was noted in other secondary outcomes, including the need for supplemental asthma therapy, time to short-acting β2-agonists spaced at four hours or longer, asthma clinical scores, lung function and overall withdrawals for any reason.

AUTHORS' CONCLUSIONS

In children hospitalised for an acute asthma exacerbation, no evidence of benefit for length of hospital stay and other markers of response to therapy was noted when nebulised anticholinergics were added to short-acting β2-agonists. No adverse health effects were reported, yet the small number of trials combined with inadequate reporting prevent firm reassurance regarding the safety of anticholinergics. In the absence of trials conducted in ICUs, no conclusion can be drawn regarding children with impending respiratory failure. These findings support current national and international recommendations indicating that healthcare practitioners should refrain from using anticholinergics in children hospitalised for acute asthma.

Anti-inflammatory activity of sublingual immunoglobulin (SLIG) in a murine model of allergen-driven airway inflammation

AIM

Intravenous immunoglobulin (IVIG) displays anti-inflammatory activities in many diseases. Subcutaneous administration of anti-IgE in humans provides benefit in severe persistent allergic asthma. Given the well established efficacy of sublingual allergen immunotherapy in respiratory type I allergies, we investigated the therapeutic potential of sublingual immunoglobulin (SLIG), most particularly anti-IgE SLIG, in a murine model of allergen-driven airway inflammation.

METHODS

BALB/c mice sensitized with ovalbumin (OVA) were treated sublingually with rat monoclonal IgG1 or IgG2a, either directed to mouse IgE or with no reported specificity. Airway hyperresponsiveness (AHR) was assessed by whole body plethysmography, and eosinophil infiltrates were characterized in bronchial alveolar lavages (BAL). OVA-specific antibody and T cell responses were analyzed in sera and saliva or lung and draining lymph nodes, by ELISA or CBA measurement of cytokine production, respectively.

RESULTS

AHR and BAL eosinophil infiltrates were substantially decreased in mice treated sublingually with particulate OVA (positive control), as well as in animals receiving various rat IgG1, irrespective of their specificity for murine IgE. In contrast, no improvement was observed in mice treated with PBS (negative control) or various rat IgG2a. SLIG anti-inflammatory activity is not related to a downregulation of Th2, Th17 or an induction of Foxp3(+) CD4(+) regulatory T cell responses. Mass spectrometry analysis of glycan moieties, such as sialic acid, suggests that the differential efficacy of rat IgG1 and IgG2a is not related to their capacity to interact with lectins borne by oral immune cells.

CONCLUSIONS

In a murine model of allergen-driven airway inflammation, SLIG exhibits an anti-inflammatory activity irrespective of the immunoglobulin specificity, and in the absence of allergen. As a noninvasive approach, SLIG deserves to be further studied as a treatment for other inflammatory diseases beyond allergic asthma.

Asthma translational medicine: report card

Over the last 30 years, scientific research into asthma has focused almost exclusively on one component of the disorder - airway inflammation - as being the key underlying feature. These studies have provided a remarkably detailed and comprehensive picture of the events following antigen challenge that lead to an influx of T cells and eosinophils in the airways. Indeed, in basic research, even the term "asthma" has become synonymous with a T helper 2 cell-mediated disorder. From this cascade of cellular activation processes and mediators that have been identified it has been possible to pinpoint critical junctures for therapeutic intervention, leading experimentalists to produce therapies that are very effective in decreasing airway inflammation in animal models. Many of these compounds have now completed early Phase 2 "proof-of-concept" clinical trials so the translational success of the basic research model can be evaluated. This commentary discusses clinical results from 39 compounds and biologics acting at 23 different targets, and while 6 of these drugs can be regarded as a qualified success, none benefit the bulk of asthma sufferers. Despite this disappointing rate of success, the same immune paradigm and basic research models, with a few embellishments to incorporate newly identified cells and mediators, continue to drive target identification and drug discovery efforts. It is time to re-evaluate the focus of these efforts.

The inhibitory effects of intravenous administration of rabbit immunoglobulin G on airway inflammation are dependent upon Fcγ receptor IIb on CD11c(+) dendritic cells in a murine model

Immunoglobulins (Igs) play important immunomodulatory effects on allergic asthma. Among these, IgG has been reported to regulate allergic inflammation in previous studies about immunotherapy and intravenous immunoglobulin therapy. In this study, to examine the immunomodulatory mechanisms of IgG and FcRs we evaluated the effects of intravenous (i.v.) rabbit IgG administration (IVIgG) on allergic airway inflammation and lung antigen-presenting cells (APCs) in a murine model of ovalbumin (OVA) sensitization and challenge. In OVA-challenged mice, IVIgG attenuated airway eosinophilia, airway hyperresponsiveness and goblet cell hyperplasia and also inhibited the local T helper type (Th) 2 cytokine levels. Additionally, IVIgG attenuated the proliferation of OVA-specific CD4(+) T cells transplanted into OVA-challenged mice. Ex vivo co-culture with OVA-specific CD4(+) cells and lung CD11c(+) APCs from mice with IVIgG revealed the attenuated transcription level of Th2 cytokines, suggesting an inhibitory effect of IVIgG on CD11c(+) APCs to induce Th2 response. Next, to analyse the effects on Fcγ receptor IIb and dendritic cells (DCs), asthmatic features in Fcγ receptor IIb-deficient mice were analysed. IVIgG failed to attenuate airway eosinophilia, airway inflammation and goblet cell hyperplasia. However, the lacking effects of IVIgG on airway eosinophilia in Fcγ receptor IIb deficiency were restored by i.v. transplantation of wild-type bone marrow-derived CD11c(+) DCs. These results demonstrate that IVIgG attenuates asthmatic features and the function of lung CD11c(+) DCs via Fcγ receptor IIb in allergic airway inflammation. Targeting Fc portions of IgG and Fcγ receptor IIb on CD11c(+) DCs in allergic asthma is a promising therapeutic strategy.

[Diagnosis and treatment guidelines for difficult-to-control asthma in children]

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.

Managing patients with chronic severe asthma: rise to the challenge

Most asthmatic patients with moderate to severe disease can be satisfactorily managed with a combination of inhaled corticosteroids and beta(2)-agonists. However, there are perhaps 10% of the asthmatic population with persistent symptoms, impaired quality of life and excessive health-care utilization, despite this management regime. These patients often require frequent and even occasionally regular oral corticosteroid use. Chronic, severe asthma is a heterogeneous disease with distinct sub-phenotypes. A systematic diagnostic work-up may help to identify these distinct sub-phenotypes and this may help guide treatment and may even provide information about prognosis. Optimal treatment of chronic severe asthma should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent is dictated by the severity of disease and includes conventional, immunosuppressive/immunomodulating and biologic therapies. Unfortunately, current asthma management guidelines offer little contribution to the care of the challenging patient with chronic severe asthma. This review article aims at summarizing the evidence regarding various therapeutic modalities for chronic severe asthma and also aims to provide a practical approach to diagnosis and management for the benefit of those who have a specific interest in this problematic condition.

Use of inhaled and oral corticosteroids and the long-term risk of cataract

OBJECTIVE

Longitudinal associations between inhaled and oral corticosteroid use and 10-year incident cataract were examined.

DESIGN

Population-based cohort study.

PARTICIPANTS

The Blue Mountains Eye Study examined 3654 Australians aged 49 years or older (1992-1994); 2335 were re-examined after 5 years and 1952 were re-examined after 10 years (75.1%, 75.6% of survivors, respectively).

METHODS

Questionnaires were used to assess inhaled and oral corticosteroid use at baseline. Past users were participants who had used these medications for at least 1 month in the past but were not using them at baseline. Current users were those who were using these medications at baseline and had been doing so for at least 1 month. Ever users combined past and current users.

MAIN OUTCOME MEASURES

Lens photographs were obtained at each examination and graded for nuclear, cortical, and posterior subcapsular (PSC) cataracts following the Wisconsin Cataract Grading System. Participants without a specific subtype of cataract in either eye at baseline were considered to be at risk of that type of cataract developing over the 10-year follow-up. Incidence of each cataract subtype in this report refers to person-specific, first-eye incidence.

RESULTS

At baseline, 103 participants were current and 120 past users of inhaled corticosteroids, and 31 were current and 147 were past users of oral corticosteroids. Current users had a greater risk of developing PSC cataract after adjustment for age and gender (inhaled: odds ratio [OR] 2.50, 95% confidence interval [CI] 1.33-4.69; oral: OR 4.11; 95% CI 1.67-10.08) and nuclear cataract (inhaled: OR 2.04, 95% CI 1.21-3.43; oral: OR 3.45, 95% CI 1.26-9.43) but not cortical cataract. Interaction between inhaled and oral corticosteroid use was significant for PSC (P = 0.01) and nuclear (P = 0.02) cataract incidence. In subgroup analyses, only individuals who used both inhaled and oral steroids were at increased risk of PSC cataract (after adjusting for age, sex, smoking, hypertension, diabetes, and education levels; OR 4.76, 95% CI 2.59-8.74), comparing ever users of both with users of neither.

CONCLUSIONS

High long-term risks of PSC and nuclear cataract development were found for users of combined inhaled and oral corticosteroids.

The future of asthma therapy: integrating clinical and experimental studies

Asthma is one of the most common, and now most heavily investigated, of modern diseases. Research along two fronts, involving experimental models of asthma and human clinical trials, proceeds in parallel, often with investigators unaware of their counterpart's findings. Here, we review the unique immunological insights into asthma pathogenesis and therapy that may be gained from comparison of human clinical trial results and analogous experimental studies. The pitfalls and benefits of animal models of asthma are discussed, and we briefly review ongoing asthma clinical studies that are based on immunological principals. Finally, we use new insights from human and animal studies to construct a refined immunopathologic disease model that may be of use in designing future experimental and therapeutic studies.

Oral corticosteroid-dependent asthma: a 30-year review

OBJECTIVE

To identify novel aspects of the pathogenesis, therapeutic options, and prophylaxis measures of corticosteroid-dependent asthma.

DATA SOURCES

PubMed searches were undertaken of studies published between 1966 and 2006 on the pathogenesis of and corticosteroid-sparing therapies for corticosteroid-dependent asthma. Identified review articles were surveyed for additional and earlier citations. Recent American Academy of Asthma, Allergy, and Immunology meeting abstracts were also searched to identify other recently published and unpublished studies.

STUDY SELECTION

Inclusion of studies in the review was decided by simple agreement of both reviewers, who independently read the "Methods" and "Discussion" sections of articles identified using the search strategy. Quality assessment was performed by the 2 reviewers.

RESULTS

High-dose inhaled corticosteroids are the first-line option for corticosteroid-dependent asthmatic patients with clear efficacy. Omalizumab is effective in reducing oral corticosteroid requirements in allergic asthma. Methotrexate, gold, and cyclosporine have corticosteroid-sparing effects clinically that must be weighed against a serious adverse effect profile. Nebulized diuretics and lidocaine, with a low adverse effect profile, offer promising results but require further study. Clarithromycin and telithromycin seem to have an independent mechanism of inflammatory modulation, but their effect on corticosteroid-dependent asthma remains to be seen. Etanercept offers only early clinical evidence of a role in corticosteroid-dependent asthma.

CONCLUSIONS

With no clear consensus on corticosteroid-sparing treatment in corticosteroid-dependent asthmatic patients, systemic glucocorticoids remain the foremost therapy, with adverse effects that require monitoring and prophylaxis.

An overview of chronic severe asthma

Most asthmatic patients with moderate to severe disease can be satisfactorily managed with a combination of inhaled corticosteroids and beta(2)-agonists. However, there are a few with persistent symptoms, impaired quality of life and excessive health-care utilization, despite this management regimen. These patients often require frequent and even occasionally regular oral corticosteroid use. Chronic, severe asthma is a heterogeneous disease and a systematic diagnostic work-up may help to guide treatment and may even provide information about prognosis. Optimal treatment of chronic severe asthma (CSA) should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent is dictated by the severity of disease and includes conventional, immunosuppressive/immunomodulating and biologic therapies. Unfortunately, current asthma management guidelines offer little contribution to the care of the challenging patient with CSA. In this review, a diagnostic and therapeutic overview of CSA is provided for the benefit of those who have a specific interest in this problematic condition.

The mechanisms, diagnosis, and management of severe asthma in adults

There has been a recent increase in the prevalence of asthma worldwide; however, the 5-10% of patients with severe disease account for a substantial proportion of the health costs. Although most asthma cases can be satisfactorily managed with a combination of anti-inflammatory drugs and bronchodilators, patients who remain symptomatic despite maximum combination treatment represent a heterogeneous group consisting of those who are under-treated or non-adherent with their prescribed medication. After excluding under-treatment and poor compliance, corticosteroid refractory asthma can be identified as a subphenotype characterised by a heightened neutrophilic airway inflammatory response in the presence or absence of eosinophils, with evidence of increased tissue injury and remodelling. Although a wide range of environmental factors such as allergens, smoking, air pollution, infection, hormones, and specific drugs can contribute to this phenotype, other features associated with changes in the airway inflammatory response should be taken into account. Aberrant communication between an injured airway epithelium and underlying mesenchyme contributes to disease chronicity and refractoriness to corticosteroids. The importance of identifying underlying causative factors and the recent introduction of novel therapeutic approaches, including the targeting of immunoglobulin E and tumour necrosis factor alpha with biological agents, emphasise the need for careful phenotyping of patients with severe disease to target improved management of the individual patient's needs.

Structural changes in airway diseases: characteristics, mechanisms, consequences, and pharmacologic modulation

In airway diseases such as asthma and COPD, specific structural changes may be observed, very likely secondary to an underlying inflammatory process. Although it is still controversial, airway remodeling may contribute to the development of these diseases and to their clinical expression and outcome. Airway remodeling has been described in asthma in various degrees of severity, and correlations have been found between such features as increase in subepithelial collagen or proteoglycan deposits and airway responsiveness. Although the clinical significance of airway remodeling remains a matter of debate, it has been suggested as a potential target for treatments aimed at reducing asthma severity, improving its control, and possibly preventing its development. To date, drugs used to treat airway diseases have a little influence on airway structural changes. More research should be done to identify key changes, valuable treatments, and proper interventional timing to counteract these changes. The potential of novel therapeutic agents to reverse or prevent airway remodeling is an exciting avenue and warrants further evaluation.

Subtle immunodeficiency in severe asthma: IgA and IgG2 correlate with lung function and symptoms

BACKGROUND

Atopy, increased serum IgE and eosinophilic airway inflammation are common in asthma and may indicate aberrant immune responses, but the cause(s) are unknown. It was hypothesized that differences in serum immunoglobulins, immunoglobulin free light chains (FLC) and secretory IgA (sIgA) would exist between subjects with asthma of varying severity and normal subjects, and the levels would correlate with lung function, symptoms and airway inflammation.

METHODS

Serum IgG, IgA, IgE and IgM, IgG subclasses and FLC, and bronchoalveolar lavage sIgA were evaluated from 15 normal subjects, 9 mild and 22 severe asthmatics with similar atopic status. Asthma symptoms were obtained by questionnaire, and airway inflammation was assessed by immunostaining for five inflammatory cell types.

RESULTS

Immunoglobulin levels in all groups were generally within the normal range. However, IgA and IgG were lower in severe asthmatics than normal subjects (overall p = 0.006 and 0.02, respectively). IgA, but not IgG, correlated with lung function and asthma symptoms (r-values >0.58; p-values <0.009). Although similar among the groups, higher sIgA and IgG(2) also positively correlated with lung function and negatively with asthma symptoms (r-values >0.63; p-values <0.009). IgA and IgG/IgG(1) positively correlated with tissue mast cells.

CONCLUSIONS

Subtle alterations in IgA- and IgG(2)-mediated responses in asthma may be disease-related. As their levels are generally normal, it is possible that the quality/repertoire of immune protection provided by these isotypes, perhaps against carbohydrate epitopes, may be altered in asthma.

Asthma refractory to glucocorticoids: the role of newer immunosuppressants

Asthma is orchestrated by cytokine products of activated T cells. Glucocorticoids are thought to ameliorate asthma at least partly through T cell inhibition. Consequently, other T cell immunomodulatory agents have been assessed for asthma therapy. Since these agents may have serious unwanted effects, attention has been focused on patients with severe asthma refractory to maximal topical, and additional systemic glucocorticoid therapy. Although gold salts show a modest but significant glucocorticoid-sparing effect in severe asthma, lung function is not improved and not all patients respond. The minimum duration of a valid trial of therapy is probably 6 months. Unwanted effects include dermatitis, hepatic dysfunction, proteinuria and interstitial pneumonitis. Meta-analysis of trials of methotrexate in oral glucocorticoid-dependent asthma have confirmed that concomitant weekly methotrexate for a minimum of 3 to 6 months enables significant (approximately 20%) overall reduction in oral glucocorticoid requirements, although only approximately 60% of patients show a significant response. There is little effect on lung function. Blood count and liver function must be monitored. Opportunistic infection is rare but potentially fatal. Cyclosporine, administered for at least 3 months, is effective in only a proportion of patients with oral glucocorticoid-dependent asthma, where it may improve disease severity and/or enable oral glucocorticoid dosage reductions. Regular monitoring of renal function, blood pressure and blood concentrations of cyclosporine is required. The evidence that intravenous immunoglobulin (Ig) is of any benefit in patients with glucocorticoid-dependent asthma is at present equivocal. The therapy is expensive and associated with a high incidence of unwanted effects (fever, aseptic meningitis, urticaria). The macrolides tacrolimus (FK506) and sirolimus (rapamycin) have end effects similar to those of cyclosporine. Brequinar sodium, mycophenolate mofetil and leflunomide are inhibitors of de novo synthesis of pyrimidines and purines, to which T cells are particularly sensitive. Such drugs may in theory be beneficial for therapy of patients with oral glucocorticoid-dependent asthma. Humanized anti-CD4, anti-IgE and anti-interleukin (IL)-5 monoclonal antibodies, and other cytokine inhibitors such as soluble IL-4 receptor have entered early trials. The worth of current immunomodulatory drugs is limited since: (i) not all patients respond, and response cannot be predicted a priori; (ii) the high incidence of unwanted effects makes it difficult to assess overall benefit/risk ratios; (iii) there is increased risk of opportunistic infection and (theoretically) neoplasia; (iv) there are many relative and absolute contraindications to therapy; and (v) there is lack of knowledge about the long-term effects, beneficial or otherwise, of therapy.

Modulating Effects of Intravenous Immunoglobulins on Serum Cytokine Levels in Patients with Primary Hypogammaglobulinemia

BACKGROUND

Intravenous immunoglobulins (IVIG) have usually been administered for replacement therapy of humoral immunodeficiencies, but their use in treating other disorders with an immune pathogenesis is increasing. The exact mechanism of action by which IVIG are of benefit in such diseases is complex and only partly understood. One of the proposed mechanisms of action is the modulation of cytokine release.

METHODS

We selected 29 patients with primary hypogammaglobulinemia (common variable immunodeficiency), receiving long-term substitutive therapy with IVIG, and 14 healthy blood donors as a control group. Blood samples were then taken before and 1 hour after finishing the IVIG infusion. Only one blood sample was obtained from the healthy controls. The cytokines studied were interleukin (IL)-1 beta, IL-1 receptor antagonist (IL-1Ra), IL-2, IL-6, IL-8, tumor necrosis factor (TNF)-alpha, and interferon (IFN)-gamma.

RESULTS

Patients with primary hypogammaglobulinemia showed significantly higher serum levels of IL-6, IL-8, IL-1Ra, and TNF alpha than healthy controls. IVIG infusion significantly increased serum concentration levels of IL-6, IL-8, IL-1Ra, and TNF alpha. No significant variation was observed in serum levels of IL-beta, IFN gamma, or IL-2 after IVIG infusion. Age, IVIG commercial preparation, and IVIG dose did not influence cytokine serum levels. Moreover, a significant correlation was observed between serum level variations of IL-1Ra and TNF alpha, as well as an associative trend between maximum changes in IL-6 and IL-8 concentrations.

CONCLUSIONS

IVIG administration significantly alters the serum pattern of selected cytokines, which might explain, at least in part, the mechanism of action of IVIG in autoimmune or inflammatory disorders.

Effets immunomodulateurs des immunoglobulines intraveineuses

Intravenous immunoglobulins (IVIg) are therapeutic preparations of normal human IgG obtained from pools of more than 1000 healthy blood donors. They are currently used in the treatment of a wide range of auto-immune diseases, whether associated with auto-antibodies or auto-reactive T lymphocytes, as well as in the treatment of systemic inflammatory diseases. Several mechanisms of action have been identified during the last 20 years, including: (i) modulation of Fc receptors expression on leukocytes and endothelial cells; (ii) interaction with complement proteins; (iii) modulation of cytokines and chemokines synthesis and release; (iv) modulation of cell proliferation and apoptosis; (v) remyelinisation; (vi) neutralisation of circulating autoantibodies; (vii) selection of repertoires of B and T lymphocytes; (viii) interaction with other cell-surface molecules on lymphocytes and monocytes; (ix) corticosteroid sparing. These mechanisms of action are multiple and often intricate. However, they are still little known and further investigations are warranted.

Intravenous immunoglobulin for cystic fibrosis lung disease: a case series of 16 children

BACKGROUND AND OBJECTIVE

Some children with severe cystic fibrosis (CF) lung disease develop chest tightness, recurrent dry cough, and intractable wheeze, often accompanied by deteriorating lung function and failure to expectorate sputum. In an attempt to reduce the use of regular oral corticosteroids, we treated a group of such children with monthly courses of intravenous immunoglobulin (IVIG).

METHODS

This is a retrospective case note review of 16 children, aged 3-16 years (median 13.0 years) who received 1-66 (median 7.5) courses of monthly IVIG, at a dose of 1 g/kg on two successive days for the first dose, followed by 1 g/kg monthly as a 12 hour infusion, with corticosteroid and antihistamine cover.

RESULTS

FEV1 improved from a median (95% confidence interval (CI)) of 50% (39 to 61%) to 54% (48 to 66%), with a median (95% CI) difference of +7.5% (-1.5 to 14.5%; NS). FVC improved from 65% (60 to 77%) to 83% (70 to 89%), with a difference of +13% (4 to 22%, p = 0.01). The total daily dose/kg body weight of oral prednisolone was reduced from 0.6 (0.3 to 1.0) to 0 (0 to 0.1) mg/kg/day, with a reduction of -0.6 (-1.0 to -0.1, p = 0.006) mg/kg/day. The total daily dose of inhaled corticosteroid (budesonide equivalent) was a median (range) of 2000 microg (800-6000 microg), which was reduced to 1500 microg (0-3200 microg). The median (95% CI) difference was -400 microg (-1600 to 0 microg), p<0.05. IVIG was well tolerated and the regimen acceptable to all but one of the children. The following transient adverse reactions were seen in only one patient each: headache, fever, hypotension, aseptic meningitis, and chest tightness.

CONCLUSION

We suggest that an n = 1 trial of IVIG in carefully selected patients with severe obstructive CF lung disease is worth considering, as for some it may lead to significant benefit.

Role of intravenous immunoglobulin in severe steroid-dependent asthma

BACKGROUND

Subgroups of asthma patients have extremely severe respiratory symptoms that require chronic use of steroids for disease control. These patients are at risk of significant side-effects from chronic exposure to high doses of oral steroids. Intravenous immunoglobulin (IVIG) has immunomodulatory properties as shown by its use in some immune disorders. A few trials have suggested a possible benefit in individuals with severe asthma.

AIMS

To evaluate the role of IVIG as an adjunctive therapy in steroid-dependent asthma, monitoring the outcomes of lung function and measured reduction in oral steroid requirement.

METHOD

Seven patients with severe steroid-dependent asthma were given IVIG at a dose of 1 g/kg each month for 6 months. Baseline pulmonary function tests and immunoglobulin levels were obtained. At the end of 6 months, the end-points observed were lung function and the degree of reduction in the dose of oral steroids. The number of hospital admissions during the 12 months following commencement of IVIG was compared with the preceding 12 months.

RESULTS

There was a significant reduction in daily prednisolone dose from 56 +/- 31 mg to 39 +/- 35 mg (P=0.04, Wilcoxon rank sum test) and a decrease in the number of hospital admissions from 5.9 +/- 2.9 to 3.6 +/- 3.5 (P=0.04). No significant improvement occurred in lung function.

CONCLUSION

IVIG provides a potentially important adjunctive therapy in severe steroid-dependent asthma, reducing steroid requirement and decreasing hospital admissions, but not improving lung function.

Treatment of severe small airways disease in children with cystic fibrosis: alternatives to corticosteroids

A group of patients with cystic fibrosis (CF) have severe small airways disease characterized by wheeze, chest tightness and limited sputum production, often with deteriorating lung function. Suggested mechanisms include mucosal edema secondary to infection and inflammation, smooth muscle contraction caused by inflammatory mediators, and collapse of bronchiectatic airways. While treatment with long-term oral corticosteroids may result in symptomatic improvement, adverse effects often make them intolerable. Inhaled corticosteroids are used in many centers despite the lack of conclusive evidence of their efficacy. Therapeutic alternatives to corticosteroids are aimed at reversing bronchoconstriction and reducing inflammation. Many patients with CF are treated with short- and long-term inhaled bronchodilators, but data to support their use are inconclusive. Other attempted routes of administration for short-acting bronchodilators include the subcutaneous and intravenous routes, but clinical data are again lacking. Sodium cromoglycate (cromolyn sodium) has been studied, with little evidence of benefit. Theophyllines have also been studied, both intravenously and orally, with some effect, but are not often used in clinical practice. Nonsteroidal anti-inflammatory therapies include ibuprofen, macrolide antibiotics, intravenous immunoglobulin, cyclosporine, and leukotriene antagonists. Ibuprofen has been shown to be useful in patients with mild CF disease, but concerns about potential adverse effects have limited its use. The results of various macrolide studies are awaited, but to date there are no long-term studies published. While there is great interest in the potential of intravenous immunoglobulin, cyclosporine and leukotriene antagonists, the evidence for their effectiveness comes from anecdotal reports, thus there is currently insufficient data to support their use. Since this is a small group of patients, it is unlikely that sufficient numbers will ever be recruited for these studies; thus it is probable that drugs will be tried on an individual patient basis. The order in which they are attempted is unclear, but it would be sensible to try the least invasive medication with the least adverse effects first, moving on to more potent, but more toxic drugs if that treatment fails.

Refractory asthma

Treating patients with refractory asthma remains an ongoing challenge. Although most patients respond to large doses of systemic corticosteroid, the adverse effects associated with such a treatment limit its general use. Clinicians treating patients with refractory asthma must consider tapering systemic corticosteroid at every opportunity. Recent advances in the understanding of the pathogenesis of refractory asthma and corticosteroid resistance have fueled further study in the mechanisms of these processes and have prompted consideration of new treatment approaches. Unfortunately, most alternative approaches require more rigorous evidence to support their regular use.

Omalizumab and the immune system: an overview of preclinical and clinical data

OBJECTIVE

This review discusses the role of immunoglobulin (Ig)E in allergic disease, inhibition of IgE with omalizumab, and the consequences of IgE inhibition (both clinically and in terms of the effect on the immune system).

DATA SOURCES

Relevant publications obtained from a literature review.

STUDY SELECTION

Relevant publications on IgE, allergic disease, and anti-IgE were critically evaluated.

RESULTS

IgE plays a key role in allergic diseases such as allergic asthma and allergic rhinitis. Its role in healthy individuals is less well defined. Treatment of allergic asthma and rhinitis with omalizumab, a humanized monoclonal anti-IgE antibody, causes a marked reduction in circulating free IgE levels. This has been shown to reduce symptoms and decrease the need for other medication in patients with these allergic diseases. Anti-IgE treatment with omalizumab did not cause any of the complications that might, in theory, be expected to result from reduction in circulating free IgE, such as adverse effects upon the immune system or other body systems.

CONCLUSIONS

The limited clinical data currently available suggest that this novel method of treatment for allergic asthma and rhinitis seems to be both effective and well tolerated in clinical use.

Respiratory outcomes in high-risk children 7 to 10 years after prophylaxis with respiratory syncytial virus immune globulin

PURPOSE

Respiratory syncytial virus infections have been implicated in the development of asthma. We evaluated the long-term effects of respiratory syncytial virus immune globulin, an effective prophylactic agent for the prevention of these infections in children, on respiratory and allergic outcomes in children at high risk of chronic airway disease.

SUBJECTS AND METHODS

Thirteen children at high risk of respiratory disease (mean [+/-SD] age, 8.6 +/- 1.1 years) were evaluated using pulmonary function and allergy skin testing 7 to 10 years after they had received prophylaxis with respiratory syncytial virus immune globulin. For comparison, 26 high-risk control children (mean age, 8.5 +/- 0.9 years) were also evaluated. Health outcomes data were collected from all subjects. The children were matched for age and gestational age. There were more boys, and a lesser frequency of a lower respiratory tract infection with respiratory syncytial virus (P <0.001) in the group that had been treated prophylactically than in the controls. The ratio of the forced expiratory volume in 1 second to forced vital capacity was significantly better in children who had received immune globulin (median, 0.88; interquartile range, 0.81 to 0.91) than in the controls (median, 0.76; interquartile range, 0.67 to 0.86; P = 0.02). Children were also less atopic (2 of 13) in the respiratory syncytial virus immune globulin group than in the control group (13 of 26, P <0.04) and were less likely to have missed school (P = 0.006) or have had an asthma attack (P = 0.03).

CONCLUSION

The results suggest that prophylaxis of respiratory syncytial virus infections in infancy may have long-term effects on respiratory and immunologic parameters relevant to the development of asthma. Larger-scale studies are needed.

IVIG-pools: regulatory gifts--transiting from harmony toward harmonious immunoglobulins: why? and why not?

Based on 'initial conditions' which depend on each donors' exposure to a unique environment, a pooled intravenous immunoglobulin (IVIG) product transfers its immunoglobulin molecule repertoire, unchanged, to the altered host. The relay function of the cell-bound receptors, especially that of the inhibitory Fc(gamma)RIIB, may then allow sufficient amplification to make regulatory activity possible. To the clinician, IVIG may be considered a tool to promote reversal of the dysregulation causing autoimmune disease. Generically, IVIG may be seen as a promoter allowing a progression from harm by an inflammatory/fibrotic reaction, then down-regulating toward restitutio ad integrum. By modifying natural processes, IVIG may play minor roles in promoting defense against spontaneous bleeding and, perhaps, stimulating remyelination. The wide spectrum of IVIG specificities, by reflecting evolutionary epitope selection, may not further destabilize cell/molecule disarray in the affected host. Benefit to the patient by IVIG treatment cannot be predicted nor can potentially severe or even fatal accidents entirely be excluded. Important aspects of IVIG treatment still await clarification including dosage, timing and the isotype form. In the foreseeable future it does not seem that biotechnological advances will match the physiologic harmony of IVIG, leaving antibody characteristics aside.

High-dose intravenous immunoglobulins: An approach to treat severe immune-mediated and autoimmune diseases of the skin

Adjuvant high-dose intravenous immunoglobulins (IVIgs) are being used increasingly in a range of immune-mediated and autoimmune diseases. Although numerous immunomodulatory mechanisms have been suggested, the exact mechanisms of action are poorly understood. The efficacy of IVIg in certain diseases has been proven in clinical trials, insofar as IVIg is approved as the therapy of choice for Kawasaki syndrome or idiopathic thrombocytopenic purpura. IVIg treatment has been shown to be safe, without the many drug-related adverse effects, including systemic immunosuppression, that are related to corticosteroids and other immunosuppressive agents. Current dermatologic uses of IVIg are increasing, which calls for adequately controlled clinical trials. This review focuses on experiences with IVIg therapy for skin diseases and discusses current opinion concerning its potential immunomodulating mechanisms.

Children with difficult asthma: a practical approach

Many open studies investigating the effects of innovative treatments for steroid-dependent asthma demonstrate some benefit. This is also true of the majority of placebo arms in placebo-controlled trials. This suggests that children with difficult asthma benefit from the high level of input that is typically provided in clinical trials, with or without additional medication. Such intensive management of patients, with the emphasis on establishing the diagnosis, improving adherence, and identifying provoking factors, is the key to optimizing asthma control for these children. For patients with genuinely severe asthma, despite high doses of conventional treatment, a greater understanding of the pathological basis of persistent symptoms is needed. Identification of different pathological subtypes of severe asthma should allow for more rational prescribing of asthma therapy, as well as the design of further trials of potential steroid-sparing treatments.

A study of 20 SLE patients with intravenous immunoglobulin--clinical and serologic response

OBJECTIVE

To test the clinical response of systemic lupus erythematosus (SLE) patients to intravenous immunoglobulins (IVIg), and whether the clinical response of IVIg treatment in SLE is accompanied by modification of SLE-associated autoantibodies/antibodies (Abs) and complement levels.

METHODS

Twenty SLE patients were treated with high-dose (2 g/kg) IVIg monthly, in a 5-d schedule. Each patient received between 1-8 treatment courses. They were evaluated for the clinical response, Systemic Lupus Activity Measure (SLAM) score before and after IVIg, levels of antinuclear antibody (ANA), dsDNA (double-stranded DNA), SS-A or SS-B, ENA (extractable nuclear antigens), C3 and C4 levels before and after the treatment, and before and after each treatment course.

RESULTS

A beneficial clinical response following IVIg treatment was noted in 17 out of 20 patients (85%). Few clinical manifestations responded more to treatment: arthritis, fever, thrombocytopenia, and neuropsychiatric lupus. In 9 patients evaluated before and after IVIg, mean SLAM score decreased from 19. 3+/-4.7 to 4+/-2.9 (P<0.0001). There was a tendency towards abnormal levels of complement and Abs before IVIg courses among the treatment responders compared with the non-responders, and similarly the former tended to have normalization of their abnormal levels more than the latter. These differences were found statistically significant only with respect to C4 and SS-A or SS-B levels before IVIg courses.

CONCLUSION

IVIg has a high response rate among SLE patients. A combination of clinical manifestations, Abs and complement levels may aid in the future in predicting who among SLE patients will benefit more from IVIg treatment.