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Drake S, Wang R, Healy L, Roberts SA, Murray CS, Simpson A, Fowler SJ. Diagnosing Asthma With and Without Aerosol-Generating Procedures. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4243-4251.e7. [PMID: 34303020 DOI: 10.1016/j.jaip.2021.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Asthma diagnostic guidelines require procedures with aerosol-generating potential (aerosol-generating procedures [AGPs]) to guide decision making. Restricted access to AGPs poses significant challenges in primary care and resource-poor countries, further amplified during the coronavirus disease 2019 pandemic. OBJECTIVE To establish an approach to asthma diagnosis that does not require AGPs. METHOD Symptomatic yet untreated (beyond as-required bronchodilator use) adults with clinician-suspected asthma and maximum 10 pack year smoking history were recruited. Clinical history, physical examination, spirometry with bronchodilator reversibility, home peak flow monitoring, and bronchial challenges were performed, and fractional exhaled nitric oxide and serum eosinophils measured. Tests were then repeated following treatment with inhaled corticosteroids before an asthma diagnosis was confirmed or refuted by an expert panel. RESULTS A total of 65 adults (mean age, 34.8 ± 12.2 years) were recruited. Five were excluded as "unclassifiable," because of borderline results or missing data. Of the remainder, 36 were diagnosed with asthma and 24 were not. Using data from non-AGPs only (wheeze on auscultation and blood eosinophilia) and home peak flow variability, a "rule-in" diagnostic model provided comparable discriminative ability to the application of established guidelines. Clinical suspicion of asthma together with at least 1 positive non-AGP test result provided a sensitivity of 55%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 60%. Application of this model reduced the need for spirometry-based tests by one-third. CONCLUSIONS The proposed diagnostic algorithm may be clinically useful in "ruling-in" asthma in adults when access to AGPs is limited. This algorithm is not suitable for those with low clinical probability, with a significant smoking history, or where alternative diagnoses are more likely. This pragmatic approach to asthma diagnosis merits prospective validation.
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Affiliation(s)
- Sarah Drake
- Faculty of Biology, Medicine and Health, School of Biological Sciences, Division of Infection, Immunity & Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Ran Wang
- Faculty of Biology, Medicine and Health, School of Biological Sciences, Division of Infection, Immunity & Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Laura Healy
- Faculty of Biology, Medicine and Health, School of Biological Sciences, Division of Infection, Immunity & Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Stephen A Roberts
- Centre for Biostatistics, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Clare S Murray
- Faculty of Biology, Medicine and Health, School of Biological Sciences, Division of Infection, Immunity & Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Angela Simpson
- Faculty of Biology, Medicine and Health, School of Biological Sciences, Division of Infection, Immunity & Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Stephen J Fowler
- Faculty of Biology, Medicine and Health, School of Biological Sciences, Division of Infection, Immunity & Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, United Kingdom.
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Bardsley G, Daley-Yates P, Baines A, Kempsford R, Williams M, Mallon T, Braithwaite I, Riddell K, Joshi S, Bareille P, Beasley R, Fingleton J. Anti-inflammatory duration of action of fluticasone furoate/vilanterol trifenatate in asthma: a cross-over randomised controlled trial. Respir Res 2018; 19:133. [PMID: 30001712 PMCID: PMC6044077 DOI: 10.1186/s12931-018-0836-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/27/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Fluticasone furoate/Vilanterol trifenatate (FF/VI) is an inhaled corticosteroid/long-acting beta-agonist combination with a prolonged bronchodilator duration of action. We characterised the time-course of onset and offset of airway anti-inflammatory action of FF/VI, as assessed by fraction of exhaled nitric oxide (FeNO), and compared this to the bronchodilator duration of action. METHODS A single-centre, randomised, double-blind, placebo-controlled, two-period, crossover study was undertaken in 28 steroid-naïve adults with asthma. Participants with an FEV1 ≥ 60% predicted, reversible airway disease, and FeNO > 40 ppb received FF/VI 100/25 mcg or placebo once daily for 14 days. FeNO and peak expiratory flow were measured twice-daily during treatment and during a 21-day washout period. FEV1 was measured for five days from treatment cessation. The primary outcome measure was FeNO change from baseline ratio for 21 days following treatment cessation. RESULTS In the 27 subjects who completed the study, median (range) baseline FeNO was 87 ppb (42-212). FF/VI 100/25 mcg reduced FeNO by day 3, ratio FF/VI versus placebo 0.72 (95% confidence interval 0.61-0.86) with the maximum reduction occurring at day 14, 0.32 (0.27-0.37). Following cessation of treatment FeNO remained suppressed for 18 days, ratio on day 18 0.77 (0.59-1.00), whereas improvements in FEV1 and peak flow were maintained for 3 to 4 days post-treatment. CONCLUSIONS The anti-inflammatory duration of action of FF/VI is consistent with the high glucocorticoid receptor affinity and long lung retention of fluticasone furoate. The anti-inflammatory effect of FF/VI was of greater duration than its bronchodilator effect in adults with mild asthma. Funding GlaxoSmithKline (201499). TRIAL REGISTRATION Prospectively registered on ClinicalTrials.gov registry number NCT02712047 .
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Affiliation(s)
- George Bardsley
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
| | - Peter Daley-Yates
- Respiratory Clinical Development, GlaxoSmithKline Research and Development, Stockley Park, Uxbridge, UK
| | - Amanda Baines
- Medicines Development Centre, GlaxoSmithKline Research and Development, Stevenage, UK
| | - Rodger Kempsford
- Medicines Development Centre, GlaxoSmithKline Research and Development, Stevenage, UK
| | - Mathew Williams
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
| | - Tony Mallon
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
| | - Irene Braithwaite
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
| | - Kylie Riddell
- GlaxoSmithKline Research and Development, 82 Hughes Ave, Ermington, NSW, 2115, Australia
| | | | - Philippe Bareille
- Medicines Development Centre, GlaxoSmithKline Research and Development, Stevenage, UK
| | - Richard Beasley
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
| | - James Fingleton
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand.
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Relationship of Inhaled Corticosteroid Adherence to Asthma Exacerbations in Patients with Moderate-to-Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1989-1998.e3. [PMID: 29627457 DOI: 10.1016/j.jaip.2018.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with asthma and elevated blood eosinophils are at increased risk of severe exacerbations. Management of these patients should consider nonadherence to inhaled corticosteroid (ICS) therapy as a factor for increased exacerbation risk. OBJECTIVE The objective of this study was to investigate whether poor adherence to ICS therapy explains the occurrence of asthma exacerbations in patients with elevated blood eosinophil levels. METHODS This historical cohort study identified patients within the Optimum Patient Care Research Database, aged 18 years or more, at Global Initiative for Asthma step 3 or 4, with 2 or more ICS prescriptions during the year before the clinical review. Patient characteristics and adherence (based on prescription refills and patient self-report) for ICS therapy were analyzed for those with elevated (>400 cells/μL) or normal (≤400 cells/μL) blood eosinophils. RESULTS We studied 7195 patients (66% female, mean age 60 years) with median eosinophil count of 200 cells/μL and found 81% to be not fully adherent to ICS therapy. A total of 1031 patients (14%) had elevated blood eosinophil counts (58% female, mean age 60 years), 83% of whom were not fully adherent to ICS. An increased proportion of adherent patients in the elevated blood eosinophil group had 2 or more exacerbations (14.0% vs 7.2%; P = .003) and uncontrolled asthma (73% vs 60.8%; P = .004) as compared with non-fully adherent patients. CONCLUSIONS Approximately 1 in 7 patients had elevated eosinophils. Adherence to ICS therapy was not associated with decreased exacerbations for these patients. Additional therapy should be considered for these patients, such as biologics, which have been previously shown to improve control in severe uncontrolled eosinophilic asthma.
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