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Pianigiani T, Luzzi S, Dilroba A, Meocci M, Salvadori E, Alderighi L, Bergantini L, d'Alessandro M, Sestini P, Bargagli E, Cameli P. Evaluation of multiple-flows exhaled nitric oxide and its clinical significance in severe asthmatic patients treated with biologics: a prospective real-life study. J Asthma 2024:1-10. [PMID: 38884564 DOI: 10.1080/02770903.2024.2370012] [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: 05/07/2024] [Accepted: 06/16/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Specific biomarkers, such as eosinophilia in peripheral blood or fractional exhaled nitric oxide (FeNO), can guide us in the choice of biologic therapy, allowing a more personalized approach. Although there are multiple evidences in the literature about the role of FeNO as a predictor of response to different biologic treatments, there are no data on the relationship between FeNO changes and clinical response to the four biologic drugs currently in use. OBJECTIVE To evaluate and to compare the expression of multiple-flows FeNO parameters in a cohort of patients with severe asthma (SA) before and during the treatment with biologics to evaluate the performance of these biomarkers in predicting the achievement of clinical remission. METHODS We prospectively enrolled 50 patients with severe asthma eligible for biologic therapy. Patients underwent clinical and functional monitoring at baseline (T0) and after 1, 6, and 12 months of treatment (T1, T6, T12), including multiple flows FeNO assessment. RESULTS A statistically significant reduction of FeNO50 values and J'awNO was observed only in benralizumab and dupilumab subgroups. Among biomarkers, the reduction of FeNO 50 values at T1 was associated with a higher probability of achieving clinical remission at T12 (p = 0.003), which was also confirmed by ROC curve analysis (AUC 0.758, p = 0.002; sensitivity 60% and specificity 74% for a reduction of 16 ppb). CONCLUSION These data confirm the potential of this biomarker in predicting clinical response to biologic treatment in patients with severe asthma in order to guide clinical decisions and evaluate a shift to other biologic therapy.
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Affiliation(s)
- Tommaso Pianigiani
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Simona Luzzi
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Akter Dilroba
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Martina Meocci
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Elisa Salvadori
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Lorenzo Alderighi
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Laura Bergantini
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Miriana d'Alessandro
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Piersante Sestini
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Dhar R, Talwar D, Christopher DJ, Dumra H, Koul PA, Chhajed PN, Chowdhury SR, Arjun P, Guleria R. Expert opinion on diagnosis and management of Severe Asthma in low and middle income countries (LMIC) with focus on India. J Asthma 2024:1-13. [PMID: 38767570 DOI: 10.1080/02770903.2024.2349614] [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: 01/28/2024] [Accepted: 04/25/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE In this document, 9 Indian experts have evaluated the factors specific to LMICs when it came to Severe Asthma (SA) diagnosis, evaluation, biologic selection, non-biologic treatment options, and follow-up. DATA SOURCES A search was performed using 50 keywords, focusing on the Indian/LMICs perspective, in PubMed, Cochrane Library, and Google Scholar. The key areas of the search were focused on diagnosis, phenoendotyping, non-biological therapies, selecting a biologic, assessment of treatment response, and management of exacerbation. STUDY SELECTIONS The initial search revealed 1826 articles, from these case reports, observational studies, cohort studies, non-English language papers, etc., were excluded and we short-listed 20 articles for each area. Five relevant articles were selected by the experts for review. RESULTS In LMICs, SA patients may be referred to the specialist for evaluation a little late for Phenoendotyping of SA. While biologic therapy is now a standard of care, pulmonologists in LMICs may not have access to all the investigations to phenoendotype SA patients like fractional exhaled nitric oxide (FeNO), skin prick test (SPT), etc., but phenotyping of SA patients can also be done with simple blood investigations, eosinophil count and serum immunoglobulin E (IgE). Choosing a biologic in the overlapping phenotype of SA and ACO patients is also a challenge in the LMICs. CONCLUSIONS Given the limitations of LMIC, it is important to select the right patient and explain the potential benefits of biological therapy. Non-biologic add-on therapies can be attempted in a resource-limited setting where biological therapy is not available/feasible for patients.
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Affiliation(s)
- Raja Dhar
- Department of Pulmonology, CK BIRLA Hospitals, Kolkata, India
| | | | | | - Harjit Dumra
- Sparsh Chest Disease Centre, Navrangpura, Ahmedabad, India
| | - Parvaiz A Koul
- Department of Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Prashant N Chhajed
- Department of Lung Care and Sleep Center, Institute of Pulmonology, Medical Research and Development, Fortis Hiranandani Hospital, Vashi, Mumbai, India
- Department of Respiratory Medicine, Dr. Balabhai Nanavati Hospital and Lilavati Hospital, Mumbai, Maharashtra, India
| | | | - Padmanabhan Arjun
- Department of Respiratory Medicine, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Berni Canani R, Caminati M, Carucci L, Eguiluz-Gracia I. Skin, gut, and lung barrier: Physiological interface and target of intervention for preventing and treating allergic diseases. Allergy 2024; 79:1485-1500. [PMID: 38439599 DOI: 10.1111/all.16092] [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: 09/05/2023] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/06/2024]
Abstract
The epithelial barriers of the skin, gut, and respiratory tract are critical interfaces between the environment and the host, and they orchestrate both homeostatic and pathogenic immune responses. The mechanisms underlying epithelial barrier dysfunction in allergic and inflammatory conditions, such as atopic dermatitis, food allergy, eosinophilic oesophagitis, allergic rhinitis, chronic rhinosinusitis, and asthma, are complex and influenced by the exposome, microbiome, individual genetics, and epigenetics. Here, we review the role of the epithelial barriers of the skin, digestive tract, and airways in maintaining homeostasis, how they influence the occurrence and progression of allergic and inflammatory conditions, how current treatments target the epithelium to improve symptoms of these disorders, and what the unmet needs are in the identification and treatment of epithelial disorders.
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Affiliation(s)
- Roberto Berni Canani
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Marco Caminati
- Allergy Unit and Asthma Centre, Verona Integrated University Hospital and Department of Medicine, University of Verona, Verona, Italy
| | - Laura Carucci
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Ibon Eguiluz-Gracia
- Allergy Unit, Hospital Regional Universitario de Malága, Malaga, Spain
- Allergy Group, Biomedical Research Institute of Malaga (IBIMA)-BIONAND Platform, RICORS Inflammatory Diseases, Malaga, Spain
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Reilly C, Raja A, Anilkumar P, Sullivan J, White L, Bahron A, Marsh J, Mansur AH. The clinical effectiveness of mepolizumab treatment in severe eosinophilic asthma; outcomes from four years cohort evaluation. J Asthma 2024; 61:561-573. [PMID: 38088937 DOI: 10.1080/02770903.2023.2294908] [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] [Received: 08/21/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Clinical trials and real world studies demonstrated benefit of mepolizumab treatment in severe asthma but data on its effectiveness beyond 2 years remain limited. Herein, we provide mepolizumab treatment evaluation up to 4 years. METHODS we studied all patients initiated on mepolizumab in our center from June 2017 to August 2018. Clinical outcomes data were retrieved from the local dendrite systems registry. Comparison analyses and logistic regression were conducted to explore longevity and predictors of response to mepolizumab treatment. RESULTS a total of 66 patients initiated on mepolizumab with a median follow-up of 45.8 (42.4,48.1) months were included in the study [mean age 50.3 years (range 18-79), females 50 (73%) ]. At 20.7 months of treatment, 42 patients (63.6%) had positive response, 13 (19.7%) negative response, and 11 (16.7%) discontinued due to other factors. At 45.8 months, 35 (53%) patients were still on mepolizumab, 21 (31.8%) switched to a different biologic, and 10 (15.2%) discontinued biologics. Two deaths were recorded during the study period.The median blood eosinophil was reduced from 0.43x109/L (0.27, 0.75) to 0.04 (0.0, 0.1) (p < 0.00001)]. The median annual exacerbations were reduced from 6.0 (4,8) to 1.0 (0.0,3.0) (p < 0.00001), and mOCS use was reduced from59% to 29%, p = 0.001. The mean asthma control questionnaire-6 (ACQ6) improved from 3.1 ± 1.7 to 2.1 ± 1.3 (p < 0.00001). CONCLUSIONS mepolizumab clinical benefit was sustained over 4 years. However, approximately half of the cohort discontinued the treatment prompting the need for further research into the treatment response longevity.
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Affiliation(s)
- Christopher Reilly
- Birmingham Regional Severe Asthma Service, Birmingham Heartland Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Anandavelu Raja
- Birmingham Regional Severe Asthma Service, Birmingham Heartland Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Pillai Anilkumar
- Birmingham Regional Severe Asthma Service, Birmingham Heartland Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Julie Sullivan
- Birmingham Regional Severe Asthma Service, Birmingham Heartland Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Lisa White
- Birmingham Regional Severe Asthma Service, Birmingham Heartland Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Ali Bahron
- Birmingham Regional Severe Asthma Service, Birmingham Heartland Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Julie Marsh
- Birmingham Regional Severe Asthma Service, Birmingham Heartland Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Adel H Mansur
- Birmingham Regional Severe Asthma Service, Birmingham Heartland Hospital, University Hospitals Birmingham, Birmingham, UK
- University of Birmingham, Birmingham, UK
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Oppenheimer J, Kerstjens HA, Boulet LP, Hanania NA, Kerwin E, Moore A, Nathan RA, Peachey G, Pizzichini E, Slade D, Zarankaite A, Pavord ID. Characterization of Moderate and Severe Asthma Exacerbations in the CAPTAIN Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00533-6. [PMID: 38777124 DOI: 10.1016/j.jaip.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 04/23/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Limited data exist on the relative impact of moderate and severe exacerbations on asthma control and impairment. OBJECTIVE To explore data from the CAPTAIN trial to evaluate the relationship between first moderate or severe exacerbation and changes in lung function, symptoms, physical activity limitation scores, and short-acting β2-agonist (SABA) usage to determine the clinical relevance of moderate events. METHODS CAPTAIN was a phase IIIA 24- to 52-week, multicenter, international, randomized controlled trial evaluating efficacy and safety of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) versus FF/VI in patients with uncontrolled asthma on inhaled corticosteroid/long-acting β2-agonist. Outcomes reported include first postrandomization exacerbation event by severity (wk 1-52), frequency and duration of moderate and severe exacerbations, and time course of changes over ± 14-day peri-exacerbation period for lung function, symptoms, limitations, and SABA use. RESULTS Of the intent-to-treat population (n = 2,436), 550 patients (23%) continued to 52 weeks. There were 529 moderate and 546 severe exacerbations. Lung function changes were similar, but symptom, physical activity limitation scores, and SABA use were higher, for severe versus moderate exacerbations. Lung function decline preceded increases in symptom, physical activity limitation scores, and SABA use, irrespective of exacerbation severity. Lung function variables, limitation scores, and SABA use returned to pre-exacerbation baseline after approximately 8 to 12 days for both exacerbation severities. CONCLUSIONS Whereas severe events were associated with greater impact on symptoms, physical activity limitations, and SABA use, onset and time to resolution were generally similar for moderate and severe events. Both exacerbation severities represent clinically important deteriorations comprising clinical and functional changes.
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Affiliation(s)
| | - Huib A Kerstjens
- Faculty of Medical Sciences, University of Groningen and University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
| | | | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Edward Kerwin
- Altitude Clinical Consulting and Clinical Research Institute, Medford, OR
| | - Alison Moore
- Global Medical Affairs, General Medicines, GSK, Brentford, Middlesex, UK
| | - Robert A Nathan
- Asthma & Allergy Associates, PC, and Research Center, Colorado Springs, Colo
| | - Guy Peachey
- Global Medical Affairs, General Medicines, GSK, Brentford, Middlesex, UK
| | - Emilio Pizzichini
- Global Medical Affairs, General Medicines, GSK, Brentford, Middlesex, UK; Department of Clinical Medicine, Federal University of Santa Catarina, Santa Catarina, Brazil
| | | | - Agne Zarankaite
- Global Medical Affairs, General Medicines, GSK, Brentford, Middlesex, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory National Institute for Health & Care Research Biomedical Research Centres, Oxford, UK.
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Marchi E, Hinks TSC, Richardson M, Khalfaoui L, Symon FA, Rajasekar P, Clifford R, Hargadon B, Austin CD, MacIsaac JL, Kobor MS, Siddiqui S, Mar JS, Arron JR, Choy DF, Bradding P. The effects of inhaled corticosteroids on healthy airways. Allergy 2024. [PMID: 38686450 DOI: 10.1111/all.16146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/27/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND The effects of inhaled corticosteroids (ICS) on healthy airways are poorly defined. OBJECTIVES To delineate the effects of ICS on gene expression in healthy airways, without confounding caused by changes in disease-related genes and disease-related alterations in ICS responsiveness. METHODS Randomized open-label bronchoscopy study of high-dose ICS therapy in 30 healthy adult volunteers randomized 2:1 to (i) fluticasone propionate 500 mcg bd daily or (ii) no treatment, for 4 weeks. Laboratory staff were blinded to allocation. Biopsies and brushings were analysed by immunohistochemistry, bulk RNA sequencing, DNA methylation array and metagenomics. RESULTS ICS induced small between-group differences in blood and lamina propria eosinophil numbers, but not in other immunopathological features, blood neutrophils, FeNO, FEV1, microbiome or DNA methylation. ICS treatment upregulated 72 genes in brushings and 53 genes in biopsies, and downregulated 82 genes in brushings and 416 genes in biopsies. The most downregulated genes in both tissues were canonical markers of type-2 inflammation (FCER1A, CPA3, IL33, CLEC10A, SERPINB10 and CCR5), T cell-mediated adaptive immunity (TARP, TRBC1, TRBC2, PTPN22, TRAC, CD2, CD8A, HLA-DQB2, CD96, PTPN7), B-cell immunity (CD20, immunoglobulin heavy and light chains) and innate immunity, including CD48, Hobit, RANTES, Langerin and GFI1. An IL-17-dependent gene signature was not upregulated by ICS. CONCLUSIONS In healthy airways, 4-week ICS exposure reduces gene expression related to both innate and adaptive immunity, and reduces markers of type-2 inflammation. This implies that homeostasis in health involves tonic type-2 signalling in the airway mucosa, which is exquisitely sensitive to ICS.
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Affiliation(s)
- Emanuele Marchi
- NIHR Oxford Respiratory BRC and Respiratory Medicine Unit, Experimental Medicine, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Timothy S C Hinks
- NIHR Oxford Respiratory BRC and Respiratory Medicine Unit, Experimental Medicine, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Matthew Richardson
- Department of Respiratory Sciences, University of Leicester, Leicester Respiratory NIHR BRC, Glenfield Hospital, Leicester, UK
| | - Latifa Khalfaoui
- Department of Respiratory Sciences, University of Leicester, Leicester Respiratory NIHR BRC, Glenfield Hospital, Leicester, UK
| | - Fiona A Symon
- Department of Respiratory Sciences, University of Leicester, Leicester Respiratory NIHR BRC, Glenfield Hospital, Leicester, UK
| | - Poojitha Rajasekar
- Centre for Respiratory Research, Translational Medical Sciences, School of Medicine, Nottingham NIHR Biomedical Research Centre, Biodiscovery Institute, University Park, University of Nottingham, Nottingham, UK
| | - Rachel Clifford
- Centre for Respiratory Research, Translational Medical Sciences, School of Medicine, Nottingham NIHR Biomedical Research Centre, Biodiscovery Institute, University Park, University of Nottingham, Nottingham, UK
| | - Beverley Hargadon
- Department of Respiratory Sciences, University of Leicester, Leicester Respiratory NIHR BRC, Glenfield Hospital, Leicester, UK
| | - Cary D Austin
- Genentech, Inc., South San Francisco, California, USA
| | - Julia L MacIsaac
- Edwin S.H. Leong Centre for Healthy Aging, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael S Kobor
- Edwin S.H. Leong Centre for Healthy Aging, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Salman Siddiqui
- Department of Respiratory Sciences, University of Leicester, Leicester Respiratory NIHR BRC, Glenfield Hospital, Leicester, UK
| | - Jordan S Mar
- Genentech, Inc., South San Francisco, California, USA
| | | | - David F Choy
- Genentech, Inc., South San Francisco, California, USA
| | - Peter Bradding
- Department of Respiratory Sciences, University of Leicester, Leicester Respiratory NIHR BRC, Glenfield Hospital, Leicester, UK
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Farinha I, Heaney LG. Barriers to clinical remission in severe asthma. Respir Res 2024; 25:178. [PMID: 38658975 PMCID: PMC11044532 DOI: 10.1186/s12931-024-02812-3] [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] [Received: 01/24/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
Severe asthma is associated with an increased risk for exacerbations, reduced lung function, fixed airflow obstruction, and substantial morbidity and mortality. The concept of remission in severe asthma as a new treatment goal has recently gained attention due to the growing use of monoclonal antibody therapies, which target specific pathologic pathways of inflammation. This review evaluates the current definitions of asthma remission and unveils some of the barriers for achieving this state in the severe asthma population. Although there is no unified definition, the concept of clinical remission in asthma should be based on a sustained period of symptom control, elimination of oral corticosteroid exposure and exacerbations, and stabilization of pulmonary function. The conjugation of these criteria seems a realistic treatment target in a minority of asthmatic patients. Some unmet needs in severe asthma may affect the achievement of clinical remission. Late intervention with targeted therapies in the severe asthma population may increase the risk of corticosteroid exposure and the development of irreversible structural airway changes. Moreover, airway infection is an important component in persistent exacerbations in patients on biologic therapies. Phenotyping exacerbations may be useful to guide therapy decisions and to avoid the liberal use of oral corticosteroids. Another challenge associated with the aim of clinical remission in severe asthma is the multifaceted interaction between the disease and its associated comorbidities. Behavioural factors should be evaluated in case of persistent symptoms despite optimised treatment, and assessing biomarkers and targeting treatable traits may allow for a more objective way of reaching remission. The concept of clinical remission will benefit from an international consensus to establish unifying criteria for its assessment, and it should be addressed in the future management guidelines.
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Affiliation(s)
- Inês Farinha
- Pulmonology Department, Coimbra Hospital and University Centre, Praceta Prof. Mota Pinto, Coimbra, 3004-561, Portugal
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.
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Bourdin A, Brusselle G, Couillard S, Fajt ML, Heaney LG, Israel E, McDowell PJ, Menzies-Gow A, Martin N, Mitchell PD, Petousi N, Quirce S, Schleich F, Pavord ID. Phenotyping of Severe Asthma in the Era of Broad-Acting Anti-Asthma Biologics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:809-823. [PMID: 38280454 DOI: 10.1016/j.jaip.2024.01.023] [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: 10/02/2023] [Revised: 12/20/2023] [Accepted: 01/01/2024] [Indexed: 01/29/2024]
Abstract
Severe asthma is associated with significant morbidity and mortality despite the maximal use of inhaled corticosteroids and additional controller medications, and has a high economic burden. Biologic therapies are recommended for the management of severe, uncontrolled asthma to help to prevent exacerbations and to improve symptoms and health-related quality of life. The effective management of severe asthma requires consideration of clinical heterogeneity that is driven by varying clinical and inflammatory phenotypes, which are reflective of distinct underlying disease mechanisms. Phenotyping patients using a combination of clinical characteristics such as the age of onset or comorbidities and biomarker profiles, including blood eosinophil counts and levels of fractional exhaled nitric oxide and serum total immunoglobulin E, is important for the differential diagnosis of asthma. In addition, phenotyping is beneficial for risk assessment, selection of treatment, and monitoring of the treatment response in patients with asthma. This review describes the clinical and inflammatory phenotypes of asthma, provides an overview of biomarkers routinely used in clinical practice and those that have recently been explored for phenotyping, and aims to assess the value of phenotyping in severe asthma management in the current era of biologics.
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Affiliation(s)
- Arnaud Bourdin
- PhyMedExp, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Simon Couillard
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Merritt L Fajt
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Elliot Israel
- Pulmonary and Critical Care Medicine, Allergy & Immunology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - P Jane McDowell
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Andrew Menzies-Gow
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom; Royal Brompton and Harefield Hospitals, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Neil Martin
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom; University of Leicester, Leicester, United Kingdom
| | | | - Nayia Petousi
- Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Florence Schleich
- Department of Respiratory Medicine, CHU Liege, GIGA I3 Lab, University of Liege, Liege, Belgium
| | - Ian D Pavord
- Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
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9
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Cameli P, Aliani M, Altieri E, Bracciale P, Brussino L, Caiaffa MF, Canonica GW, Caruso C, Centanni S, D’Amato M, De Michele F, Del Giacco S, Di Marco F, Pelaia G, Rogliani P, Romagnoli M, Schino P, Schroeder JW, Senna G, Vultaggio A, Benci M, Boarino S, Menzella F. Sustained Effectiveness of Benralizumab in Naïve and Biologics-Experienced Severe Eosinophilic Asthma Patients: Results from the ANANKE Study. J Asthma Allergy 2024; 17:273-290. [PMID: 38562251 PMCID: PMC10982664 DOI: 10.2147/jaa.s438981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/16/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose Severe eosinophilic asthma (SEA) patients often present overlapping inflammatory features rendering them eligible for multiple biologic therapies; switching biologic treatment is a strategy adopted to optimize asthma control when patients show partial or no response to previous biologics. Patients and Methods ANANKE is a retrospective, multicenter Italian study (NCT04272463). Here, we outline the characteristics and long-term clinical outcomes in naïve-to-biologics and biologics-experienced patients treated with benralizumab for up to 96 weeks. Bio-experienced patients were split into omalizumab and mepolizumab subsets according to the type of biologic previously used. Results A total of 124 (76.5%) naïve and 38 (23.5%) bio-experienced patients were evaluated at index date; 13 patients (34.2%) switched from mepolizumab, 21 patients (55.3%) switched from omalizumab, and four patients (10.5%) received both biologics. The mepolizumab subset was characterized by the longest SEA duration (median of 4.6 years), the highest prevalence of chronic rhinosinusitis with nasal polyposis (CRSwNP) (76.5%), and the greatest oral corticosteroid (OCS) daily dosage (median of 25 mg prednisone equivalent). The omalizumab group showed the highest severe annual exacerbation rate (AER) (1.70). At 96 weeks, treatment with benralizumab reduced any and severe AER by more than 87% and 94%, respectively, across all groups. Lung function was overall preserved, with major improvements observed in the mepolizumab group, which also revealed a 100% drop of the median OCS dose. Asthma Control Test (ACT) score improved in the naïve group while its increment was more variable in bio-experienced patients; among these, a marked difference was noticed between omalizumab and mepolizumab subsets (median ACT score of 23.5 and 18, respectively). Conclusion Benralizumab promotes durable and profound clinical benefits in naïve and bio-experienced groups, indicating that a nearly complete depletion of eosinophils is highly beneficial in the control of SEA, independently of previous biologic use.
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Affiliation(s)
- Paolo Cameli
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Maria Aliani
- UO Pneumologia e Pneumologia Riabilitativa, ICS Maugeri, IRCCS Bari, Bari, Italy
| | - Elena Altieri
- Reparto di Pneumologia, P.O. Garbagnate Milanese, Garbagnate Milanese (MI), Italy
| | | | - Luisa Brussino
- Dipartimento di Scienze Mediche, Università degli Studi di Torino; SCDU Immunologia e Allergologia, AO Ordine Mauriziano Umberto I, Torino, Italy
| | - Maria Filomena Caiaffa
- Cattedra e Scuola di Allergologia e Immunologia Clinica, Dipartimento di Scienze Mediche, Università di Foggia, Foggia, Italy
| | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Personalized Medicine Center: Asthma and Allergology, Humanitas Research Hospital, Rozzano (MI), Italy
| | - Cristiano Caruso
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Stefano Centanni
- Respiratory Unit ASST Santi Paolo e Carlo, Department of Health Sciences Universita’ degli Studi di Milano, Milano, Italy
| | - Maria D’Amato
- UOSD Malattie Respiratorie “Federico II”, Ospedale Monaldi, AO Dei Colli, Napoli, Italy
| | - Fausto De Michele
- UOC Pneumologia e Fisiopatologia Respiratoria, AORN A. Cardarelli, Napoli, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università Degli Studi Di Milano, Pneumologia, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Girolamo Pelaia
- Dipartimento di Scienze della Salute, Università Magna Graecia, Catanzaro, Italy
| | - Paola Rogliani
- Division of Respiratory Medicine, University Hospital “Tor Vergata”, Roma, Italy
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome “Tor Vergata”, Roma, Italy
| | | | - Pietro Schino
- Fisiopatologia Respiratoria, Ospedale Generale Regionale, Ente Ecclesiastico “F. Miulli”, Acquaviva delle Fonti (BA), Italy
| | - Jan Walter Schroeder
- Allergy and Clinical Immunology, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Gianenrico Senna
- Allergy Unit and Asthma Center, Verona University Hospital, Verona, Italy
| | - Alessandra Vultaggio
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Firenze, Italy
| | - Marco Benci
- Medical Affairs R&I, AstraZeneca, Milano, Italy
| | | | - Francesco Menzella
- Pulmonology Unit, Ospedale “S. Valentino”, AULSS 2 Marca Trevigiana, Montebelluna (TV), Italy
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10
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Nanzer AM, Maynard-Paquette AC, Alam V, Green L, Thomson L, Lam J, Fernandes M, Roxas C, d'Ancona G, Hearn A, Gates J, Agarwal S, Kent BD, Fernando M, D'Cruz DP, Hopkins C, Ismail TF, Dhariwal J, Jackson DJ. Long-Term Effectiveness of Benralizumab in Eosinophilic Granulomatosis With Polyangiitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:724-732. [PMID: 38211889 DOI: 10.1016/j.jaip.2024.01.006] [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: 10/24/2023] [Revised: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystemic disease characterized by eosinophilic tissue inflammation. Benralizumab, an anti-IL-5 receptor (anti-IL-5R) monoclonal antibody, induces rapid depletion of eosinophils; its longer-term effect in EGPA is unknown. OBJECTIVE To assess the real-world effectiveness and clinical remission rates of anti-IL-5R therapy in EGPA. METHODS We performed a retrospective cohort analysis of patients with EGPA, who commenced treatment with benralizumab. Clinical remission, assessed at 1 year and 2 years after the initiation of benralizumab, was defined as an absence of active vasculitis (Birmingham Vasculitis Activity Score of 0) and an oral corticosteroid (OCS) dose of ≤4 mg/d of prednisolone. "Super-responders" were defined as patients in remission and free of any significant relapses (asthma or extrapulmonary) over the preceding 12 months. The corticosteroid-sparing capacity of benralizumab, patient-reported outcome measures, and characteristics associated with clinical remission and super-responder status were also analyzed. RESULTS A total of 70 patients completed at least 1 year of treatment with benralizumab, of whom 53 completed 2 years. Of 70 patients, 47 (67.1%) met the definition for clinical remission at 1 year, with a similar proportion in remission at 2 years. Excluding asthma-related relapses, 61 of 70 (87.1%) patients were relapse free at 1 year, and of the 53 who completed 2 years, 45 (84.9%) were relapse free. A total of 67.9% of patients no longer needed any OCS for disease control. No significant difference was seen between antineutrophilic cytoplasmic antibody (ANCA)-positive and ANCA-negative subgroups. CONCLUSIONS In this real-world setting of patients with EGPA, treatment with benralizumab was well tolerated and resulted in corticosteroid-free clinical remission for the majority of patients.
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Affiliation(s)
- Alexandra M Nanzer
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | | | - Vardah Alam
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Linda Green
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Louise Thomson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Jodie Lam
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Mariana Fernandes
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Cris Roxas
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Grainne d'Ancona
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Andrew Hearn
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Jessica Gates
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Sangita Agarwal
- Rheumatology Department, Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Brian D Kent
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Michelle Fernando
- Rheumatology Department, Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - David P D'Cruz
- Rheumatology Department, Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Claire Hopkins
- Department of Ear, Nose and Throat Surgery, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Tevfik F Ismail
- Department of Cardiology, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Jaideep Dhariwal
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom.
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11
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Kilpatrick K, Ambrose CS, Lindsley AW, Oppenheimer J. At-home asthma mortality unchanged despite declining mortality in other settings: US death certificate data (2000-2019). Ann Allergy Asthma Immunol 2024; 132:216-222. [PMID: 37848103 DOI: 10.1016/j.anai.2023.10.009] [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: 06/28/2023] [Revised: 09/15/2023] [Accepted: 10/09/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Asthma mortality rates in the United States have declined since 1999; however, asthma mortality by place of death has not been comprehensively evaluated. OBJECTIVE To evaluate temporal trends in asthma mortality rates and place of death in the United States. METHODS We conducted a population-based analysis using data from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research platform to evaluate deaths with asthma as the underlying cause (2000-2019) among US residents of all ages. Absolute numbers of asthma-related deaths were described by place of death. Counts were applied to US Census Bureau population counts to calculate mortality rates per 100,000 persons. RESULTS In the 20-year period evaluated, 67,695 asthma deaths were registered in the United States. An overall 32% decline in the asthma mortality rate was observed, from 1.43 to 0.98 per 100,000 persons from 2000 to 2019, respectively. Although asthma mortality rates declined in all medical facility locations, the at-home asthma mortality rate remained stable (0.32 and 0.34 per 100,000 persons in 2000 and 2019, respectively). Consequently, the proportion of at-home asthma deaths increased from 23% in 2000 to 2001 to 36% in 2018 to 2019. The distribution of place of death varied by age, sex, race, ethnicity, and geographic region. CONCLUSION Despite an overall decline in asthma mortality in the United States, at-home asthma mortality has remained unchanged. In recent years, more than one-third of asthma deaths have occurred at home. These findings warrant further study and underscore the importance of increased efforts to identify and treat uncontrolled asthma across demographic groups.
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Affiliation(s)
- Karynsa Kilpatrick
- Center for Observational Research, Amgen Inc, Thousand Oaks, California.
| | - Christopher S Ambrose
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland
| | | | - John Oppenheimer
- Pulmonary and Allergy Associates, Atlantic Medical Group, Atlantic Health System, Morristown, New Jersey
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12
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Jackson DJ, Heaney LG, Humbert M, Kent BD, Shavit A, Hiljemark L, Olinger L, Cohen D, Menzies-Gow A, Korn S. Reduction of daily maintenance inhaled corticosteroids in patients with severe eosinophilic asthma treated with benralizumab (SHAMAL): a randomised, multicentre, open-label, phase 4 study. Lancet 2024; 403:271-281. [PMID: 38071986 DOI: 10.1016/s0140-6736(23)02284-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Stepwise intensification of inhaled corticosteroids (ICS) is routine for severe eosinophilic asthma, despite some poor responses to high-dose ICS. Dose reductions are recommended in patients responding to biologics, but little supporting safety evidence exists. METHODS SHAMAL was a phase 4, randomised, open-label, active-controlled study done at 22 study sites in four countries. Eligible participants were adults (aged ≥18 years) with severe eosinophilic asthma and a five-item Asthma Control Questionnaire score below 1·5 and who received at least three consecutive doses of benralizumab before screening. We randomly assigned patients (3:1) to taper their high-dose ICS to a medium-dose, low-dose, and as-needed dose (reduction group) or continue (reference group) their ICS-formoterol therapy for 32 weeks, followed by a 16-week maintenance period. The primary endpoint was the proportion of patients reducing their ICS-formoterol dose by week 32. The primary outcome was assessed in the reduction group, and safety analyses included all randomly assigned patients receiving study treatment. This study is registered at ClinicalTrials.gov, NCT04159519. FINDINGS Between Nov 12, 2019, and Feb 16, 2023, we screened and enrolled in the run-in period 208 patients. We randomly assigned 168 (81%) to the reduction (n=125 [74%]) and reference arms (n=43 [26%]). Overall, 110 (92%) patients reduced their ICS-formoterol dose: 18 (15%) to medium-dose, 20 (17%) to low-dose, and 72 (61%) to as-needed only. In 113 (96%) patients, reductions were maintained to week 48; 114 (91%) of patients in the reduction group had zero exacerbations during tapering. Rates of adverse events were similar between groups. 91 (73%) patients had adverse events in the reduction group and 35 (83%) in the reference group. 17 patients had serious adverse events in the study: 12 (10%) in the reduction group and five (12%) in the reference group. No deaths occurred during the study. INTERPRETATION These findings show that patients controlled on benralizumab can have meaningful reductions in ICS therapy while maintaining asthma control. FUNDING AstraZeneca.
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Affiliation(s)
- David J Jackson
- School of Immunology & Microbial Sciences, Guy's Hospital, King's College London, London, UK.
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Marc Humbert
- Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Brian D Kent
- St James's Hospital, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Anat Shavit
- BioPharmaceuticals Medical, Respiratory and Immunology, AstraZeneca, Cambridge, UK
| | | | - Lynda Olinger
- Late-Stage Development, Respiratory and Immunology, AstraZeneca, Cambridge, UK; Cytel, Waltham, MA, USA
| | - David Cohen
- BioPharmaceuticals Medical, Respiratory and Immunology, AstraZeneca, Gaithersburg, MD, USA
| | - Andrew Menzies-Gow
- BioPharmaceuticals Medical, Respiratory and Immunology, AstraZeneca, Cambridge, UK
| | - Stephanie Korn
- Thoraxklinik Heidelberg, Germany, IKF Pneumologie, Mainz, Germany
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13
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Shimizu Y, Sugimoto C, Wakao H. Potential of MAIT cells to modulate asthma. Allergol Int 2024; 73:40-47. [PMID: 37567833 DOI: 10.1016/j.alit.2023.07.006] [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] [Received: 05/24/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 08/13/2023] Open
Abstract
Despite recent advances in asthma treatments, the search for novel therapies remains necessary because there are still patients with recurrent asthma exacerbations and poor responses to the existing treatments. Since group 2 innate lymphoid cells (ILC2) play a pivotal role in asthma by triggering and exacerbating type 2 inflammation, controlling ILC2s function is key to combating severe asthma. Mucosal-associated invariant T (MAIT) cells are innate-like T cells abundant in humans and are activated both in a T cell receptor-dependent and -independent manner. MAIT cells are composed of MAIT1 and MAIT17 based on the expression of transcription factors T-bet and RORγt, respectively. MAIT cells play pivotal roles in host defense against pathogens and in tissue repair and are essential for the maintenance of immunity and hemostasis. Our recent studies revealed that MAIT cells inhibit both ILC2 proliferation and functions in a mouse model of airway inflammation. MAIT cells may alleviate airway inflammation in two ways, by promoting airway epithelial cell barrier repair and by repressing ILC2s. Therefore, reagents that promote MAIT cell-mediated suppression of ILC2 proliferation and function, or designer MAIT cells (genetically engineered to suppress ILC2s or promote repair of airway damage), may be effective therapeutic agents for severe asthma.
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Affiliation(s)
- Yasuo Shimizu
- Department of Pulmonary Medicine and Clinical Immunology, Dokkyo Medical University School of Medicine, Tochigi, Japan; Respiratory Endoscopy Center, Dokkyo Medical University Hospital, Tochigi, Japan; Regenerative Center, Dokkyo Medical University Hospital, Tochigi, Japan.
| | - Chie Sugimoto
- Center for the Frontier Medicine, Host Defense Division, Dokkyo Medical University, Tochigi, Japan
| | - Hiroshi Wakao
- Center for the Frontier Medicine, Host Defense Division, Dokkyo Medical University, Tochigi, Japan
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14
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Jesenak M, Diamant Z, Simon D, Tufvesson E, Seys SF, Mukherjee M, Lacy P, Vijverberg S, Slisz T, Sediva A, Simon HU, Striz I, Plevkova J, Schwarze J, Kosturiak R, Alexis NE, Untersmayr E, Vasakova MK, Knol E, Koenderman L. Eosinophils-from cradle to grave: An EAACI task force paper on new molecular insights and clinical functions of eosinophils and the clinical effects of targeted eosinophil depletion. Allergy 2023; 78:3077-3102. [PMID: 37702095 DOI: 10.1111/all.15884] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/14/2023]
Abstract
Over the past years, eosinophils have become a focus of scientific interest, especially in the context of their recently uncovered functions (e.g. antiviral, anti-inflammatory, regulatory). These versatile cells display both beneficial and detrimental activities under various physiological and pathological conditions. Eosinophils are involved in the pathogenesis of many diseases which can be classified into primary (clonal) and secondary (reactive) disorders and idiopathic (hyper)eosinophilic syndromes. Depending on the biological specimen, the eosinophil count in different body compartments may serve as a biomarker reflecting the underlying pathophysiology and/or activity of distinct diseases and as a therapy-driving (predictive) and monitoring tool. Personalized selection of an appropriate therapeutic strategy directly or indirectly targeting the increased number and/or activity of eosinophils should be based on the understanding of eosinophil homeostasis including their interactions with other immune and non-immune cells within different body compartments. Hence, restoring as well as maintaining homeostasis within an individual's eosinophil pool is a goal of both specific and non-specific eosinophil-targeting therapies. Despite the overall favourable safety profile of the currently available anti-eosinophil biologics, the effect of eosinophil depletion should be monitored from the perspective of possible unwanted consequences.
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Affiliation(s)
- Milos Jesenak
- Department of Clinical Immunology and Allergology, University Teaching Hospital in Martin, Martin, Slovak Republic
- Department of Paediatrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
- Department of Pulmonology and Phthisiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
| | - Zuzana Diamant
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
- Department Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ellen Tufvesson
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
| | - Sven F Seys
- Laboratory of Clinical Immunology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Manali Mukherjee
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- The Firestone Institute for Respiratory Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Paige Lacy
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Susanne Vijverberg
- Amsterdam UMC Location University of Amsterdam, Pulmonary Diseases, Amsterdam, The Netherlands
| | - Tomas Slisz
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, 2nd Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
- Institute of Biochemistry, Brandenburg Medical School, Neuruppin, Germany
| | - Ilja Striz
- Department of Clinical and Transplant Immunology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jana Plevkova
- Department of Pathophysiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Jurgen Schwarze
- Child Life and Health and Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Radovan Kosturiak
- Department of Paediatrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
- Outpatient Clinic for Clinical Immunology and Allergology, Nitra, Slovak Republic
| | - Neil E Alexis
- Center for Environmental Medicine, Asthma and Lung Biology, Department of Paediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Martina Koziar Vasakova
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Edward Knol
- Department Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department Dermatology/Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leo Koenderman
- Department Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department Pulmonary Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Celis-Preciado CA, Leclerc S, Duval M, Cliche DO, Larivée P, Lemaire-Paquette S, Lévesque S, Côté A, Lachapelle P, Couillard S. Phenotyping the Responses to Systemic Corticosteroids in the Management of Asthma Attacks (PRISMA): protocol for an observational and translational pilot study. BMJ Open Respir Res 2023; 10:e001932. [PMID: 37940357 PMCID: PMC10632890 DOI: 10.1136/bmjresp-2023-001932] [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: 07/04/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023] Open
Abstract
INTRODUCTION Asthma and its associated exacerbation are heterogeneous. Although severe asthma attacks are systematically prescribed corticosteroids and often antibiotics, little is known about the variability of response to these therapies. Blood eosinophils and fractional exhaled nitric oxide (FeNO) are type 2 inflammation biomarkers that have established mechanistic, prognostic and theragnostic values in chronic asthma, but their utility in acute asthma is unclear. We speculate that the clinical and biological response to those treatments varies according to inflammometry and microbiological test results. METHODS AND ANALYSIS An observational longitudinal pilot study with multimodal clinical and translational assessments will be performed on 50 physician-diagnosed ≥12-year-old asthmatics presenting with an asthma attack and 12 healthy controls, including blood eosinophil count (venous and point-of-care (POC) capillary blood), FeNO and testing for airway infection (sputum cultures and POC nasopharyngeal swabs). People with asthma will be assessed on day 0 and after a 7-day corticosteroid course, with home monitoring performed in between. The primary analysis will be the change in the forced expiratory volume in 1 s according to type 2 inflammatory status (blood eosinophils ≥0.15×109/L and/or FeNO ≥25 ppb) after treatment. Key secondary analyses will compare changes in symptom scores and the proportion of patients achieving a minimal clinically important difference. Exploratory analyses will assess the relationship between clinical, lung function, inflammatory and microbiome parameters; satisfaction plus reliability indices of POC tests; and sex-gender variability in treatment response. Ultimately, this pilot study will serve to plan a larger trial comparing the clinical and biological response to systemic corticosteroids according to inflammatory biomarkers, offering valuable guidance for more personalised therapeutic strategies in asthma attacks. ETHICS AND DISSEMINATION The protocol has been approved by the Research Ethics Committee of the CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada (#2023-4687). Results will be communicated in an international meeting and submitted to a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05870215).
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Affiliation(s)
- Carlos Andrés Celis-Preciado
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Internal Medicine-Pulmonary Unit, Faculty of Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Simon Leclerc
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Martine Duval
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Dominic O Cliche
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Pierre Larivée
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Samuel Lemaire-Paquette
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Simon Lévesque
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Laboratoire de Microbiologie, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Andréanne Côté
- Department of Medicine, Faculty of Medicine, Centre de Recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Philippe Lachapelle
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Simon Couillard
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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16
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Schleich F, Moermans C, Seidel L, Kempeneers C, Louis G, Rogister F, Tombu S, Pottier L, Poirrier AL, Ziant S, Henket M, Sanchez C, Paulus V, Guissard F, Donneau AF, Louis R. Benralizumab in severe eosinophilic asthma in real life: confirmed effectiveness and contrasted effect on sputum eosinophilia versus exhaled nitric oxide fraction - PROMISE. ERJ Open Res 2023; 9:00383-2023. [PMID: 38020567 PMCID: PMC10680030 DOI: 10.1183/23120541.00383-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
Background Randomised controlled trials have shown that benralizumab, an anti-interleukin-5 receptor monoclonal antibody, reduces exacerbations and oral corticosteroid dose and improves asthma control and lung function in severe eosinophilic asthma. The aim of this study was to confirm results of randomised controlled trials in real life in a population of 73 patients with severe eosinophilic asthma treated with benralizumab for at least 12 months. Methods Patients underwent careful monitoring of asthma exacerbations, exhaled nitric oxide fraction, lung function, asthma control and quality of life questionnaire responses and sputum induction, and gave a blood sample at baseline, after 6 months and then every year. Results We found significant reductions in exacerbations (by 92%, p<0.0001) and oral corticosteroid dose (by 83%, p<0.001) after 6 months that were maintained over time, with 78% of patients able to stop oral corticosteroid therapy. Patients improved their Asthma Control Test (ACT) score (from 11.7±5.1 to 16.9±5.35, p<0.0001), Asthma Control Questionnaire (ACQ) score (from 2.88±1.26 to 1.77±1.32, p<0.0001) and Asthma Quality of Life Questionnaire score (+1.04, p<0.0001) at 6 months and this was maintained during follow-up. Only 35% and 43% of patients reached asthma control according to an ACT score ≥20 and ACQ score <1.5, respectively. We observed stable post-bronchodilation lung function over time and a significant reduction in sputum eosinophil count, with 85% of patients exhibiting sputum eosinophil counts <3% after 6 months (p<0.01) with no effect on exhaled nitric oxide fraction. Conclusion In our real-life study, we confirm the results published in randomised controlled trials showing a sharp reduction in exacerbations and oral corticosteroid therapy, an improvement in asthma control and quality of life, and a dramatic reduction in sputum eosinophil count.
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Affiliation(s)
- Florence Schleich
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
| | - Catherine Moermans
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
| | | | - Céline Kempeneers
- Biostatistics and Research Method Center (B-STAT), University of Liege and CHU Liege, Liege, Belgium
| | - Gilles Louis
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
| | - Florence Rogister
- Division of Respirology, Department of Pediatrics, CHU Liege, Liege, Belgium
| | - Sophie Tombu
- Department of Ear, Nose and Throat, CHU Sart-Tilman, Liege, Belgium
| | - Laurence Pottier
- Department of Ear, Nose and Throat, CHU Sart-Tilman, Liege, Belgium
| | | | - Stéphanie Ziant
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
| | - Monique Henket
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
| | - Carole Sanchez
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
| | - Virginie Paulus
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
| | - Françoise Guissard
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
| | - Anne-Françoise Donneau
- Biostatistics and Research Method Center (B-STAT), University of Liege and CHU Liege, Liege, Belgium
| | - Renaud Louis
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium
- IGIGA Research Group, University of Liege, Liege, Belgium
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17
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Subsets of Eosinophils in Asthma, a Challenge for Precise Treatment. Int J Mol Sci 2023; 24:ijms24065716. [PMID: 36982789 PMCID: PMC10052006 DOI: 10.3390/ijms24065716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
The existence of eosinophils was documented histopathologically in the first half of the 19th century. However, the term “eosinophils” was first used by Paul Ehrlich in 1878. Since their discovery and description, their existence has been associated with asthma, allergies, and antihelminthic immunity. Eosinophils may also be responsible for various possible tissue pathologies in many eosinophil-associated diseases. Since the beginning of the 21st century, the understanding of the nature of this cell population has undergone a fundamental reassessment, and in 2010, J. J. Lee proposed the concept of “LIAR” (Local Immunity And/or Remodeling/Repair), underlining the extensive immunoregulatory functions of eosinophils in the context of health and disease. It soon became apparent that mature eosinophils (in line with previous morphological studies) are not structurally, functionally, or immunologically homogeneous cell populations. On the contrary, these cells form subtypes characterized by their further development, immunophenotype, sensitivity to growth factors, localization, role and fate in tissues, and contribution to the pathogenesis of various diseases, including asthma. The eosinophil subsets were recently characterized as resident (rEos) and inflammatory (iEos) eosinophils. During the last 20 years, the biological therapy of eosinophil diseases, including asthma, has been significantly revolutionized. Treatment management has been improved through the enhancement of treatment effectiveness and a decrease in the adverse events associated with the formerly ultimately used systemic corticosteroids. However, as we observed from real-life data, the global treatment efficacy is still far from optimal. A fundamental condition, “sine qua non”, for correct treatment management is a thorough evaluation of the inflammatory phenotype of the disease. We believe that a better understanding of eosinophils would lead to more precise diagnostics and classification of asthma subtypes, which could further improve treatment outcomes. The currently validated asthma biomarkers (eosinophil count, production of NO in exhaled breath, and IgE synthesis) are insufficient to unveil super-responders among all severe asthma patients and thus give only a blurred picture of the adepts for treatment. We propose an emerging approach consisting of a more precise characterization of pathogenic eosinophils in terms of the definition of their functional status or subset affiliation by flow cytometry. We believe that the effort to find new eosinophil-associated biomarkers and their rational use in treatment algorithms may ameliorate the response rate to biological therapy in patients with severe asthma.
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McDowell PJ, Busby J, Heaney LG. Asthma Exacerbations in Severe Asthma: Why Systemic Corticosteroids May not Always Be the Best Treatment Option. CURRENT TREATMENT OPTIONS IN ALLERGY 2023. [DOI: 10.1007/s40521-023-00330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Abstract
Purpose
Advances in the management of severe, eosinophilic asthma have improved, but asthma exacerbations continue to occur. This review aims to look at the evidence we have about why exacerbations may occur; their phenotype and why oral corticosteroids may not always be the best treatment option for all exacerbation of symptoms in individuals with severe asthma.
Recent findings
Studies dating back to the 1990s showed that asthma exacerbations across the spectrum of asthma severity were of different inflammatory endotypes. In addition, there is a wealth of evidence suggesting that eosinophilic inflammation is very responsive to corticosteroid therapy, but that non-eosinophilic inflammation is less so. Two recent UK-based studies have undertaken systematic phenotyping of exacerbations in severe asthma and have shown that there are a significant minority of exacerbation events with an increase in asthma symptoms, fall in lung function, but without evidence of raised T2 biomarkers.
Summary
The evidence to date would suggest that T2 biomarker low asthma exacerbations do not benefit from the administration of oral corticosteroids; in fact, the effect of the oral corticosteroids is harmful. However, there is a paucity of data to answer this question directly. Further research is needed to assess the evolution of non-T2 exacerbations not treated with OCS in a randomised, placebo-controlled, manner.
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Pianigiani T, Alderighi L, Meocci M, Messina M, Perea B, Luzzi S, Bergantini L, D’Alessandro M, Refini RM, Bargagli E, Cameli P. Exploring the Interaction between Fractional Exhaled Nitric Oxide and Biologic Treatment in Severe Asthma: A Systematic Review. Antioxidants (Basel) 2023; 12:antiox12020400. [PMID: 36829959 PMCID: PMC9952501 DOI: 10.3390/antiox12020400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a biomarker of airway inflammation associated with airway hyper-responsiveness and type-2 inflammation. Its role in the management of severe asthmatic patients undergoing biologic treatment, as well as FeNO dynamics during biologic treatment, is largely unexplored. PURPOSE The aim was to evaluate published data contributing to the following areas: (1) FeNO as a predictive biomarker of response to biologic treatment; (2) the influence of biologic treatment in FeNO values; (3) FeNO as a biomarker for the prediction of exacerbations in patients treated with biologics. METHODS The systematic search was conducted on the Medline database through the Pubmed search engine, including all studies from 2009 to the present. RESULTS Higher baseline values of FeNO are associated with better clinical control in patients treated with omalizumab, dupilumab, and tezepelumab. FeNO dynamics during biologic treatment highlights a clear reduction in FeNO values in patients treated with anti-IL4/13 and anti-IL13, as well as in patients treated with tezepelumab. During the treatment, FeNO may help to predict clinical worsening and to differentiate eosinophilic from non-eosinophilic exacerbations. CONCLUSIONS Higher baseline FeNO levels appear to be associated with a greater benefit in terms of clinical control and reduction of exacerbation rate, while FeNO dynamics during biologic treatment remains a largely unexplored issue since few studies have investigated it as a primary outcome. FeNO remains detectable during biologic treatment, but its potential utility as a biomarker of clinical control is still unclear and represents an interesting research area to be developed.
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20
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Hilvering B, Koenderman L. Quality over quantity; eosinophil activation status will deepen the insight into eosinophilic diseases. Respir Med 2023; 207:107094. [PMID: 36572067 DOI: 10.1016/j.rmed.2022.107094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/01/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Eosinophil associated diseases have gained much attention recently because of the introduction of specific eosinophil targeted therapies. These diseases range from acute parasitic infections to chronic inflammatory diseases such as eosinophilic asthma. In eosinophilic asthma an increased eosinophil cell count in peripheral blood is the gold standard for determination of the pheno-/endotype and severity of disease. Despite a broad consensus there is concern on validity of this simple measurement, because the eosinophil compartment is far from homogenous. Multiple tissues harbour non-activated cells under homeostatic conditions and other tissues, normally devoid of eosinophils, become infested with these cells under inflammatory conditions. It will, therefore, be clear that eosinophils become differentially (pre)-activated at different tissue sites in homeostatic and inflammatory conditions. This complexity should be investigated in detail as it is 1) far from clear what the long-term side effects are that are caused by application of eosinophil targeted therapies in a "one size fits all" concept and 2) real-world data of eosinophil targeted therapies in asthma shows a broad variety in the treatment response. This review will focus on complex mechanisms of eosinophil activation in vivo to create a better view on the dynamics of the eosinophil compartment in health and disease both to prevent collateral damage caused by aberrant activation of eosinophils ánd to improve effectiveness of eosinophil targeted treatments.
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Affiliation(s)
- B Hilvering
- Dept. Pulmonary Medicine, Amsterdam University Medical Center, the Netherlands.
| | - L Koenderman
- Dept. Respiratory Medicine and Center for Translational Immunology, University Medical Center Utrecht, the Netherlands
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21
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Cottin S, Doyen V, Pilette C. Upper airway disease diagnosis as a predictive biomarker of therapeutic response to biologics in severe asthma. Front Med (Lausanne) 2023; 10:1129300. [PMID: 37035303 PMCID: PMC10073432 DOI: 10.3389/fmed.2023.1129300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Asthma is a heterogeneous disease sharing airway instability but with different biology, risk factors, and response-to-therapy patterns. Biologics have revolutionized the one-size-fits-to-all approach to personalized medicine in severe asthma (SA), which relies on the identification of biomarkers that define distinct endotypes. Thus, blood eosinophils and, to some extent, exhaled nitric oxide (FeNO) can predict the response to approved anti-type 2 (T2) biologics (anti-IgE, anti-IL-5, and anti-IL-4R alpha), whereas age at onset and comorbidities such as anxiety/depression, obesity, reflux, and upper airway disease (UAD) also influence therapeutic responses in SA. In this article, focusing on the predictive value of biomarkers for the therapeutic response to biologics in SA, we first summarize the level of prediction achieved by T2 biomarkers (blood eosinophils, FeNO) and then review whether data support the predictive value of upper airway diagnosis on such outcomes. Post hoc analysis of most studies with T2 biologics suggests that chronic rhinosinusitis with nasal polyps (CRSwNP) and, to a lower extent, allergic rhinitis may help in predicting clinical response. Considering that T2 biologics are now also approved for the treatment of severe CRSwNP, diagnosis of upper airway disease is a key step in determining eligibility for such therapy.
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Affiliation(s)
- Sophie Cottin
- Department of Pulmonary Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Virginie Doyen
- Department of Pulmonary Medicine, Centre Hospitalier Universitaire UCL Namur, Université catholique de Louvain, Yvoir, Belgium
| | - Charles Pilette
- Department of Pulmonary Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Pole of Pulmonology, ENT and Dermatology, Institute of Experimental and Cliniqal Research, Université catholique de Louvain, Brussels, Belgium
- *Correspondence: Charles Pilette
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22
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Papi A, Corren J, Castro M, Domingo C, Rogers L, Chapman KR, Jackson DJ, Daizadeh N, Pandit-Abid N, Gall R, Jacob-Nara JA, Rowe PJ, Deniz Y, Ortiz B. Dupilumab reduced impact of severe exacerbations on lung function in patients with moderate-to-severe type 2 asthma. Allergy 2023; 78:233-243. [PMID: 35899469 PMCID: PMC10087924 DOI: 10.1111/all.15456] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 06/10/2022] [Accepted: 07/05/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Severe asthma exacerbations increase the risk of accelerated lung function decline. This analysis examined the effect of dupilumab on forced expiratory volume in 1 s (FEV1 ) in patients with moderate-to-severe asthma and elevated type 2 biomarkers from phase 3 LIBERTY ASTHMA QUEST (NCT02414854). METHODS Changes from baseline in pre- and post-bronchodilator (BD) FEV1 and 5-item Asthma Control Questionnaire (ACQ-5) scores were assessed in patients with elevated type 2 biomarkers at baseline (type 2-150/25: eosinophils ≥150 cells/μl and/or fractional exhaled nitric oxide [FeNO] ≥25 ppb; type 2-300/25: eosinophils ≥300 cells/μl and/or FeNO ≥25 ppb), stratified as exacerbators (≥1 severe exacerbation during the study) or non-exacerbators. RESULTS In exacerbators and non-exacerbators, dupilumab increased pre-BD FEV1 by Week 2 vs placebo; differences were maintained to Week 52 (type 2-150/25: LS mean difference (LSMD) vs placebo: 0.17 L (95% CI: 0.10-0.24) and 0.17 L (0.12-0.23); type 2-300/25: 0.22 L (0.13-0.30) and 0.21 L (0.15-0.28)), in exacerbators and non-exacerbators, respectively (p < .0001). Similar trends were seen for post-BD FEV1 . Dupilumab vs placebo also showed significantly greater improvements in post-BD FEV1 0-42 days after first severe exacerbation in type 2-150/25 (LSMD vs placebo: 0.13 L [0.06-0.20]; p = .006) and type 2-300/25 (0.14 L [0.06-0.22]; p = .001) patients. ACQ-5 improvements were greater with dupilumab vs placebo in both groups. CONCLUSION Dupilumab treatment led to improvements in lung function independent of exacerbations and appeared to reduce the impact of exacerbations on lung function in patients who experienced a severe exacerbation during the study.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine, University of Ferrara and Emergency Department, University Hospital, Ferrara, Italy
| | - Jonathan Corren
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Christian Domingo
- Pulmonary Service, Corporació Sanitària Parc Taulí, Autonomous University of Barcelona, Sabadell, Barcelona, Spain
| | - Linda Rogers
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Daniel J Jackson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | | | - Rebecca Gall
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | | | - Paul J Rowe
- Sanofi, Bridgewater Township, New Jersey, USA
| | - Yamo Deniz
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Benjamin Ortiz
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
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23
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Venegas Garrido C, Mukherjee M, Bhalla A, Nair P. Airway autoimmunity, asthma exacerbations, and response to biologics. Clin Exp Allergy 2022; 52:1365-1378. [PMID: 35993511 DOI: 10.1111/cea.14220] [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: 06/28/2022] [Accepted: 08/16/2022] [Indexed: 01/26/2023]
Abstract
Biologic therapies in asthma are indicated in severe disease, and they are directed against specific inflammatory modulators that contribute to pathogenesis and severity. Currently approved biologics target T2 cytokines (IgE, IL-5, IL-4/IL-13, and TLSP) and have demonstrated efficacy in clinical outcomes such as exacerbation rate and oral corticosteroid dose reductions, blood and airway eosinophil depletion, and lung function improvement. However, a proportion of these patients may show inadequate responses to biologics, with either initial lack of improvement or clinical and functional worsening after an optimal initial response. Exacerbations while on a biologic may be due to several reasons, including imprecise identification of the dominant effector pathway contributing to severity, additional inflammatory pathways that are not targeted by the biologic, inaccuracies of the biomarker used to guide therapy, inadequate dosing schedules, intercurrent airway infections, anti-drug neutralizing antibodies, and a novel phenomenon of autoimmune responses in the airways interfering with the effectiveness of the monoclonal antibodies. This review, illustrated using case scenarios, describes the underpinnings of airway autoimmune responses in driving exacerbations while patients are being treated with biologics, device a strategy to evaluate such exacerbations, an algorithm to switch between biologics, and perhaps to consider two biologics concurrently.
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Affiliation(s)
- Carmen Venegas Garrido
- Firestone Institute for Respiratory Health, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,Division of Respirology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Manali Mukherjee
- Firestone Institute for Respiratory Health, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,Division of Respirology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anurag Bhalla
- Division of Respirology, Department of Medicine, Western University, London, Ontario, Canada
| | - Parameswaran Nair
- Firestone Institute for Respiratory Health, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,Division of Respirology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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24
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Yang F, Busby J, Heaney LG, Pavord ID, Brightling CE, Borg K, McDowell JP, Diver SE, Shrimanker R, Bradding P, Shepherd M, Chaudhuri R. Corticosteroid Responsiveness Following Mepolizumab in Severe Eosinophilic Asthma-A Randomized, Placebo-Controlled Crossover Trial (MAPLE). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2925-2934.e12. [PMID: 35863669 DOI: 10.1016/j.jaip.2022.06.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mepolizumab inhibits IL-5 activity and reduces exacerbation frequency and maintenance oral corticosteroid (OCS) dosage in patients with severe eosinophilic asthma (SEA). Some patients remain dependent on OCS despite anti-IL-5 treatment, suggesting residual corticosteroid-responsive mechanisms. OBJECTIVE To determine the clinical and anti-inflammatory effects of OCS in patients with SEA on mepolizumab. METHODS We conducted a randomized, triple-blind, placebo-controlled crossover trial of prednisolone (0.5 mg/kg/d, maximum 40 mg/d, for 14 ± 2 days) in adults with SEA after 12 or more weeks of mepolizumab. We compared change in asthma symptoms, quality of life, lung function measured by spirometry and airwave oscillometry, fractional exhaled nitric oxide, and blood and sputum eosinophil cell count after prednisolone and placebo treatment. RESULTS A total of 27 patients completed the study. Prednisolone did not improve 5-item Asthma Control Questionnaire (mean difference in change for prednisolone vs placebo, -0.23; 95% CI, -0.58 to 0.11), mini-Asthma Quality of Life Questionnaire (0.03; 95% CI, -0.26 to 0.42), St. George's Respiratory Questionnaire (0.24; 95% CI, -3.20 to 3.69), or Visual Analogue Scale scores for overall asthma symptoms (0.11; 95% CI, -0.58 to 0.80). The mean difference for FEV1 in favor of prednisolone was 105 mL (95% CI, -4 to 213 mL); forced expiratory flow at 25% and 75% 484 mL/s (95% CI, 151 to 816 mL/s); fractional exhaled nitric oxide reduction 41% (95% CI, 25% to 54%); blood eosinophil count reduction 49% (95% CI, 31% to 62%); and percentage of sputum eosinophil reduction 71% (95% CI, 26% to 89%). CONCLUSIONS OCS improved small-airway obstruction and reduced biomarkers of type 2 inflammation but had no significant effect on symptoms or quality of life in patients with SEA receiving treatment with mepolizumab.
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Affiliation(s)
- Freda Yang
- University of Glasgow, Glasgow, United Kingdom.
| | - John Busby
- Queen's University Belfast, Belfast, United Kingdom
| | | | - Ian D Pavord
- NIHR Respiratory BRC, Nuffield Department of Medicine, Oxford, United Kingdom
| | - Chris E Brightling
- Institute for Lung Health, Leicester NIHR BRC, University of Leicester, Leicester, United Kingdom
| | - Katie Borg
- NIHR Respiratory BRC, Nuffield Department of Medicine, Oxford, United Kingdom
| | | | - Sarah E Diver
- Institute for Lung Health, Leicester NIHR BRC, University of Leicester, Leicester, United Kingdom
| | - Rahul Shrimanker
- Academic Respiratory Unit, University of Bristol, Bristol, United Kingdom
| | - Peter Bradding
- Institute for Lung Health, Leicester NIHR BRC, University of Leicester, Leicester, United Kingdom
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25
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Oguma A, Shimizu K, Kimura H, Tanabe N, Sato S, Yokota I, Takimoto-Sato M, Matsumoto-Sasaki M, Abe Y, Takei N, Goudarzi H, Suzuki M, Makita H, Hirai T, Nishimura M, Konno S. Differential role of mucus plugs in asthma: Effects of smoking and association with airway inflammation. Allergol Int 2022; 72:262-270. [PMID: 36402674 DOI: 10.1016/j.alit.2022.10.007] [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: 04/22/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The physiological importance of mucus plugs in computed tomography (CT) imaging is being increasingly recognized. However, whether airway inflammation and smoking affect the association between mucus plugs and clinical-physiological outcomes in asthma remains to be elucidated. The objective of this study is to examine how airway inflammation and/or smoking affect the correlation of CT-based mucus plug scores with exacerbation frequency and airflow limitation indices in asthma. METHODS A total of 168 patients with asthma who underwent chest CT and sputum evaluation were enrolled and classified in eosinophilic asthma (EA; n = 103) and non-eosinophilic asthma (NEA; n = 65) groups based on sputum eosinophil percentage (cut-off: 3%). The mucus plug score was defined as the number of lung segments with mucus plugs seen on CT. RESULTS More mucus plugs were detected on CT scans in the EA group than in the NEA group, regardless of smoking status. Mucus plug score and exacerbation frequency during one year after enrollment were significantly associated in the EA group but not in the NEA group after adjusting for demographics, blood eosinophil count, and fractional exhaled nitric oxide. Mucus plug score was associated with percentage of predicted forced expiratory volume in 1 s in non-smoking individuals in the EA and NEA group and in smoking individuals in the EA group but not in the NEA group after adjusting for demographics. CONCLUSIONS The association of mucus plug score with exacerbation frequency and reduced lung function may vary due to airway inflammatory profile and smoking status in asthma.
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Affiliation(s)
- Akira Oguma
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Kaoruko Shimizu
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan.
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoya Tanabe
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Susumu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Michiko Takimoto-Sato
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | | | - Yuki Abe
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Nozomu Takei
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Houman Goudarzi
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hironi Makita
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan
| | - Toyohiro Hirai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaharu Nishimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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26
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Diver S, Haldar K, McDowell PJ, Busby J, Mistry V, Micieli C, Brown V, Cox C, Yang F, Borg C, Shrimanker R, Ramsheh MY, Hardman T, Arron J, Bradding P, Cowan D, Mansur AH, Fowler SJ, Lordan J, Menzies-Gow A, Robinson D, Matthews J, Pavord ID, Chaudhuri R, Heaney LG, Barer MR, Brightling C. Relationship between inflammatory status and microbial composition in severe asthma and during exacerbation. Allergy 2022; 77:3362-3376. [PMID: 35778780 DOI: 10.1111/all.15425] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/24/2022] [Accepted: 05/30/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND In T2-mediated severe asthma, biologic therapies, such as mepolizumab, are increasingly used to control disease. Current biomarkers can indicate adequate suppression of T2 inflammation, but it is unclear whether they provide information about airway microbial composition. We investigated the relationships between current T2 biomarkers and microbial profiles, characteristics associated with a ProteobacteriaHIGH microbial profile and the effects of mepolizumab on airway ecology. METHODS Microbiota sequencing was performed on sputum samples obtained at stable and exacerbation state from 140 subjects with severe asthma participating in two clinical trials. Inflammatory subgroups were compared on the basis of biomarkers, including FeNO and sputum and blood eosinophils. ProteobacteriaHIGH subjects were identified by Proteobacteria to Firmicutes ratio ≥0.485. Where paired sputum from stable visits was available, we compared microbial composition at baseline and following ≥12 weeks of mepolizumab. RESULTS Microbial composition was not related to inflammatory subgroup based on sputum or blood eosinophils. FeNO ≥50 ppb when stable and at exacerbation indicated a group with less dispersed microbial profiles characterised by high alpha-diversity and low Proteobacteria. ProteobacteriaHIGH subjects were neutrophilic and had a longer time from asthma diagnosis than ProteobacteriaLOW subjects. In those studied, mepolizumab did not alter airway bacterial load or lead to increased Proteobacteria. CONCLUSION High FeNO could indicate a subgroup of severe asthma less likely to benefit from antimicrobial strategies at exacerbation or in the context of poor control. Where FeNO is <50 ppb, biomarkers of microbial composition are required to identify those likely to respond to microbiome-directed strategies. We found no evidence that mepolizumab alters airway microbial composition.
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Affiliation(s)
- Sarah Diver
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
| | - Koirobi Haldar
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
| | - Pamela Jane McDowell
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Belfast, UK
- Queen's University Belfast, Belfast, UK
| | - John Busby
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Belfast, UK
- Queen's University Belfast, Belfast, UK
| | - Vijay Mistry
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
| | - Claudia Micieli
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
| | - Vanessa Brown
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Belfast, UK
- Queen's University Belfast, Belfast, UK
| | - Ciara Cox
- Regional Virus Laboratory, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Freda Yang
- Division of Immunology, Infection and Inflammation, University of Glasgow, Glasgow, UK
| | - Catherine Borg
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rahul Shrimanker
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mohammadali Yavari Ramsheh
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
| | - Tim Hardman
- Niche Science & Technology Ltd., Unit 26, Falstaff House, Richmond, UK
| | - Joseph Arron
- Genentech Inc., South San Francisco, California, USA
| | - Peter Bradding
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
| | - Douglas Cowan
- NHS Greater Glasgow and Clyde, Stobhill Hospital, Glasgow, UK
| | - Adel Hasan Mansur
- University of Birmingham and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Jim Lordan
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - John Matthews
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
- 23andMe, Sunnyvale, California, USA
| | - Ian D Pavord
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rekha Chaudhuri
- Division of Immunology, Infection and Inflammation, University of Glasgow, Glasgow, UK
| | - Liam G Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Belfast, UK
- Queen's University Belfast, Belfast, UK
| | - Michael R Barer
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
| | - Christopher Brightling
- Department of Respiratory Sciences, Leicester NIHR BRC, Institute for Lung Health, University of Leicester, Leicester, UK
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Guida G, Bagnasco D, Carriero V, Bertolini F, Ricciardolo FLM, Nicola S, Brussino L, Nappi E, Paoletti G, Canonica GW, Heffler E. Critical evaluation of asthma biomarkers in clinical practice. Front Med (Lausanne) 2022; 9:969243. [PMID: 36300189 PMCID: PMC9588982 DOI: 10.3389/fmed.2022.969243] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
The advent of personalized medicine has revolutionized the whole approach to the management of asthma, representing the essential basis for future developments. The cornerstones of personalized medicine are the highest precision in diagnosis, individualized prediction of disease evolution, and patient-tailored treatment. To this aim, enormous efforts have been established to discover biomarkers able to predict patients' phenotypes according to clinical, functional, and bio-humoral traits. Biomarkers are objectively measured characteristics used as indicators of biological or pathogenic processes or clinical responses to specific therapeutic interventions. The diagnosis of type-2 asthma, prediction of response to type-2 targeted treatments, and evaluation of the risk of exacerbation and lung function impairment have been associated with biomarkers detectable either in peripheral blood or in airway samples. The surrogate nature of serum biomarkers, set up to be less invasive than sputum analysis or bronchial biopsies, has shown several limits concerning their clinical applicability. Routinely used biomarkers, like peripheral eosinophilia, total IgE, or exhaled nitric oxide, result, even when combined, to be not completely satisfactory in segregating different type-2 asthma phenotypes, particularly in the context of severe asthma where the choice among different biologics is compelling. Moreover, the type-2 low fraction of patients is not only an orphan of biological treatments but is at risk of being misdiagnosed due to the low negative predictive value of type-2 high biomarkers. Sputum inflammatory cell analysis, considered the highest specific biomarker in discriminating eosinophilic inflammation in asthma, and therefore elected as the gold standard in clinical trials and research models, demonstrated many limits in clinical applicability. Many factors may influence the measure of these biomarkers, such as corticosteroid intake, comorbidities, and environmental exposures or habits. Not least, biomarkers variability over time is a confounding factor leading to wrong clinical choices. In this narrative review, we try to explore many aspects concerning the role of routinely used biomarkers in asthma, applying a critical view over the "state of the art" and contemporarily offering an overview of the most recent evidence in this field.
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Affiliation(s)
- Giuseppe Guida
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Diego Bagnasco
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Vitina Carriero
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Francesca Bertolini
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Fabio Luigi Massimo Ricciardolo
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Stefania Nicola
- Allergy and Immunology, AO Mauriziano Hospital, University of Turin, Turin, Italy
| | - Luisa Brussino
- Allergy and Immunology, AO Mauriziano Hospital, University of Turin, Turin, Italy
| | - Emanuele Nappi
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giovanni Paoletti
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giorgio Walter Canonica
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Heffler
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Khalfaoui L, Symon FA, Couillard S, Hargadon B, Chaudhuri R, Bicknell S, Mansur AH, Shrimanker R, Hinks TC, Pavord ID, Fowler SJ, Brown V, McGarvey LP, Heaney LG, Austin CD, Howarth PH, Arron JR, Choy DF, Bradding P. Airway remodelling rather than cellular infiltration characterizes both type2 cytokine biomarker-high and -low severe asthma. Allergy 2022; 77:2974-2986. [PMID: 35579040 PMCID: PMC9790286 DOI: 10.1111/all.15376] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/31/2022] [Accepted: 04/19/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The most recognizable phenotype of severe asthma comprises people who are blood eosinophil and FeNO-high, driven by type 2 (T2) cytokine biology, which responds to targeted biological therapies. However, in many people with severe asthma, these T2 biomarkers are suppressed but poorly controlled asthma persists. The mechanisms driving asthma in the absence of T2 biology are poorly understood. OBJECTIVES To explore airway pathology in T2 biomarker-high and -low severe asthma. METHODS T2 biomarker-high severe asthma (T2-high, n = 17) was compared with biomarker-intermediate (T2-intermediate, n = 21) and biomarker-low (T2-low, n = 20) severe asthma and healthy controls (n = 28). Bronchoscopy samples were processed for immunohistochemistry, and sputum for cytokines, PGD2 and LTE4 measurements. RESULTS Tissue eosinophil, neutrophil and mast cell counts were similar across severe asthma phenotypes and not increased when compared to healthy controls. In contrast, the remodelling features of airway smooth muscle mass and MUC5AC expression were increased in all asthma groups compared with health, but similar across asthma subgroups. Submucosal glands were increased in T2-intermediate and T2-low asthma. In spite of similar tissue cellular inflammation, sputum IL-4, IL-5 and CCL26 were increased in T2-high versus T2-low asthma, and several further T2-associated cytokines, PGD2 and LTE4 , were increased in T2-high and T2-intermediate asthma compared with healthy controls. CONCLUSIONS Eosinophilic tissue inflammation within proximal airways is suppressed in T2 biomarker-high and T2-low severe asthma, but inflammatory and structural cell activation is present, with sputum T2-associated cytokines highest in T2 biomarker-high patients. Airway remodelling persists and may be important for residual disease expression beyond eosinophilic exacerbations. Registered at ClincialTrials.gov: NCT02883530.
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Affiliation(s)
- Latifa Khalfaoui
- Department of Respiratory Sciences, Leicester Respiratory NIHR BRC, Glenfield HospitalUniversity of LeicesterLeicesterUK
| | - Fiona A. Symon
- Department of Respiratory Sciences, Leicester Respiratory NIHR BRC, Glenfield HospitalUniversity of LeicesterLeicesterUK
| | - Simon Couillard
- NIHR Oxford Respiratory BRC, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Beverley Hargadon
- Department of Respiratory Sciences, Leicester Respiratory NIHR BRC, Glenfield HospitalUniversity of LeicesterLeicesterUK
| | - Rekha Chaudhuri
- Gartnavel General Hospital, Glasgow, and Institute of Infection, Immunity and InflammationUniversity of GlasgowGlasgowUK
| | - Steve Bicknell
- Gartnavel General Hospital, Glasgow, and Institute of Infection, Immunity and InflammationUniversity of GlasgowGlasgowUK
| | - Adel H. Mansur
- University of Birmingham and Heartlands HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Rahul Shrimanker
- NIHR Oxford Respiratory BRC, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Timothy S. C. Hinks
- NIHR Oxford Respiratory BRC, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Ian D. Pavord
- NIHR Oxford Respiratory BRC, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Stephen J. Fowler
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation TrustUniversity of ManchesterManchesterUK
| | - Vanessa Brown
- Wellcome‐Wolfson‐ Centre for Experimental MedicineQueen's University Belfast School of Medicine Dentistry and Biomedical SciencesBelfastUK
| | - Lorcan P. McGarvey
- Wellcome‐Wolfson‐ Centre for Experimental MedicineQueen's University Belfast School of Medicine Dentistry and Biomedical SciencesBelfastUK
| | - Liam G. Heaney
- Wellcome‐Wolfson‐ Centre for Experimental MedicineQueen's University Belfast School of Medicine Dentistry and Biomedical SciencesBelfastUK
| | | | - Peter H. Howarth
- School of Clinical and Experimental Sciences, NIHR Southampton Biomedical Research CentreUniversity of SouthamptonSouthamptonUK
| | | | | | - Peter Bradding
- Department of Respiratory Sciences, Leicester Respiratory NIHR BRC, Glenfield HospitalUniversity of LeicesterLeicesterUK
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29
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Brown MA, Jabeen M, Bharj G, Hinks TSC. Non-typeable Haemophilus influenzae airways infection: the next treatable trait in asthma? Eur Respir Rev 2022; 31:220008. [PMID: 36130784 PMCID: PMC9724834 DOI: 10.1183/16000617.0008-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 07/04/2022] [Indexed: 11/05/2022] Open
Abstract
Asthma is a complex, heterogeneous condition that affects over 350 million people globally. It is characterised by bronchial hyperreactivity and airways inflammation. A subset display marked airway neutrophilia, associated with worse lung function, higher morbidity and poor response to treatment. In these individuals, recent metagenomic studies have identified persistent bacterial infection, particularly with non-encapsulated strains of the Gram-negative bacterium Haemophilus influenzae. Here we review knowledge of non-typeable H. influenzae (NTHi) in the microbiology of asthma, the immune consequences of mucosal NTHi infection, various immune evasion mechanisms, and the clinical implications of NTHi infection for phenotyping and targeted therapies in neutrophilic asthma. Airway neutrophilia is associated with production of neutrophil chemokines and proinflammatory cytokines in the airways, including interleukin (IL)-1β, IL-6, IL-8, IL-12, IL-17A and tumour necrosis factor. NTHi adheres to and invades the lower respiratory tract epithelium, inducing the NLR family pyrin domain containing 3 (NLRP3) and absent in melanoma 2 (AIM2) inflammasomes. NTHi reduces expression of tight-junction proteins, impairing epithelial integrity, and can persist intracellularly. NTHi interacts with rhinoviruses synergistically via upregulation of intracellular cell adhesion molecule 1 and promotion of a neutrophilic environment, to which NTHi is adapted. We highlight the clinical relevance of this emerging pathogen and its relevance for the efficacy of long-term macrolide therapy in airways diseases, we identify important unanswered questions and we propose future directions for research.
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Affiliation(s)
- Mary Ashley Brown
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Experimental Medicine Division, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Maisha Jabeen
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Experimental Medicine Division, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Gurpreet Bharj
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Experimental Medicine Division, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
- Mammalian Genetics Unit, MRC Harwell Institute, Oxford, UK
| | - Timothy S C Hinks
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Experimental Medicine Division, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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30
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Mansur AH, Gonem S, Brown T, Burhan H, Chaudhuri R, Dodd JW, Pantin T, Gore R, Jackson D, Menzies-Gow A, Patel M, Pavord I, Pfeffer P, Siddiqui S, Busby J, Heaney LG. Biologic therapy practices in severe asthma; outcomes from the UK Severe Asthma Registry and survey of specialist opinion. Clin Exp Allergy 2022; 53:173-185. [PMID: 36057784 DOI: 10.1111/cea.14222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/05/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND several biological treatments have become available for management of severe asthma. There is a significant overlap in the indication of these treatments with lack of consensus on the first-line biologic choice and switching practice in event of treatment failure. AIMS to evaluate outcomes of biologic treatments through analysis of the UK Severe Asthma Registry (UKSAR), and survey of the UK severe asthma specialists' opinion. METHODS patients registered in the UKSAR database and treated with biologics for severe asthma in the period between January 2014 and August 2021, were studied to explore biologic treatments practice. This was complemented by survey of opinion of severe asthma specialists. RESULTS a total of 2,490 patients from 10 severe asthma centres were included in the study (mean age 51.3 years, 61.1% female, mean BMI 30.9kg/m2 ). Biologics use included mepolizumab 1,115 (44.8%), benralizumab 925 (37.1%), omalizumab 432 (17.3%), dupilumab 13 (0.5%), and reslizumab 5 (0.2%). Patients on omalizumab were younger and had earlier age of onset asthma than those prescribed mepolizumab or benralizumab. Patients prescribed mepolizumab and benralizumab had similar clinical characteristics. Those on benralizumab were more likely to continue treatment at approximately one year follow up (93.9%), than those on mepolizumab (80%), or omalizumab (69.6%). The first choice biologic differed between centres and changed over the study time period. Experts' opinion also diverged in terms of biologic initiation choice and switching practice. CONCLUSION We observed significant variation and divergence in the prescribing practices of biologics in severe asthma that necessitates further research and standardisation.
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Affiliation(s)
- Adel H Mansur
- Birmingham Regional Severe Asthma Service, Heartlands Hospital, University Hospitals Birmingham and University of Birmingham, UK
| | - Sherif Gonem
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Thomas Brown
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Hassan Burhan
- Dr Hassan Burhan, Liverpool University Hospitals NHS Foundation Trust and University of Liverpool
| | - Rekha Chaudhuri
- Gartnavel General Hospital, Glasgow and University of Glasgow, UK
| | - James W Dodd
- North Bristol Complex Airways Service, Southmead Hospital, North Bristol NHS Trust & Academic Respiratory Unit, Translational Health Sciences, Bristol Medical School, University of Britsol, UK
| | - Thomas Pantin
- Severe Asthma Service, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Robin Gore
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David Jackson
- Guy's Severe Asthma Centre, Guy's & St Thomas' NHS Trust; School of Immunology & Microbial Sciences, King's College London
| | | | - Mitesh Patel
- Mitesh Patel, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ian Pavord
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, Infection and Inflammation, University of Oxford, UK
| | - Paul Pfeffer
- Department of Respiratory Medicine, Barts Health NHS Trust, London, UK; and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Salman Siddiqui
- College of Life Sciences, Department of Respiratory Medicine, University of Leicester. Leicester NIHR Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Leicester, UK
| | - John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Liam G Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
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31
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Caruso C, Cameli P, Altieri E, Aliani M, Bracciale P, Brussino L, Caiaffa MF, Canonica GW, Centanni S, D’Amato M, Del Giacco S, De Michele F, Pastorello EA, Pelaia G, Rogliani P, Romagnoli M, Schino P, Caminati M, Vultaggio A, Zullo A, Rizzoli S, Boarino S, Vitiello G, Menzella F, Di Marco F. Switching from one biologic to benralizumab in patients with severe eosinophilic asthma: An ANANKE study post hoc analysis. Front Med (Lausanne) 2022; 9:950883. [PMID: 36117962 PMCID: PMC9478391 DOI: 10.3389/fmed.2022.950883] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSevere asthma is a heterogeneous inflammatory disease driven by eosinophilic inflammation in the majority of cases. Despite biologic therapy patients may still be sub-optimally controlled, and the choice of the best biologic is a matter of debate. Indeed, switching between biologics is common, but no official guidelines are available and real-world data are limited.Materials and methodsIn this post hoc analysis of the Italian, multi-center, observational, retrospective study, ANANKE. Patients with severe eosinophilic asthma treated with benralizumab were divided in two groups based on history of previous biologic therapy (biologic-experienced [suboptimal response] vs naïve). Baseline clinical and laboratory characteristics were collected in the 12 months prior to benralizumab treatment. Change over time in blood eosinophils, annualized exacerbation rate (AER), asthma control (ACT), lung function and oral corticosteroid (OCS) use following benralizumab initiation were collected in the two groups.ResultsA total of 147 biologic-naïve and 58 biologic-experienced (34 omalizumab, 19 mepolizumab, and 5 omalizumab-mepolizumab) patients were enrolled. Biologic-experienced patients were more likely to be atopic and have a higher AER despite more frequent OCS use. Similar reductions in AER (>90% in both groups), OCS use (≥49% reduction in dosage and ≥41% able to eliminate OCS), ACT improvement (≥7 points gained in 48 weeks) and lung function (≥300 mL of FEV1 improvement in 48 weeks) were observed after benralizumab introduction within the two groups. There were no registered discontinuations of benralizumab for safety reasons.ConclusionIn this post hoc analysis, patients who were switched to benralizumab because of suboptimal control with a previous biologic therapy were more likely to be atopic and more often treated with omalizumab. Benralizumab is effective in both naïve patients and those previously treated with a biologic.
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Affiliation(s)
- Cristiano Caruso
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
- *Correspondence: Cristiano Caruso,
| | - Paolo Cameli
- Respiratory Diseases and Lung Transplantation, Department of Medical and Surgical Sciences and Neurosciences, Siena University Hospital, Siena, Italy
| | - Elena Altieri
- Reparto di Pneumologia, P.O. Garbagnate Milanese, Garbagnate Milanese, MI, Italy
| | - Maria Aliani
- UO Pneumologia e Pneumologia Riabilitativa, ICS Maugeri, IRCCS Bari, Bari, Italy
| | | | - Luisa Brussino
- Dipartimento di Scienze Mediche, SSDDU Allergologia e Immunologia Clinica, Università degli Studi di Torino, AO Ordine Mauriziano Umberto I - Torino, Turin, Italy
| | - Maria Filomena Caiaffa
- Cattedra e Scuola di Allergologia e Immunologia Clinica, Dipartimento di Scienze Mediche, Università di Foggia, Foggia, Italy
| | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- Asthma and Allergy Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Maria D’Amato
- UOSD Malattie Respiratorie “Federico II,” Ospedale Monaldi, AO Dei Colli, Naples, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Fausto De Michele
- UOC Pneumologia e Fisiopatologia Respiratoria, AORN A. Cardarelli, Naples, Italy
| | | | - Girolamo Pelaia
- Dipartimento di Scienze della Salute, Università Magna Graecia, Catanzaro, Italy
| | - Paola Rogliani
- Division of Respiratory Medicine, University Hospital “Tor Vergata,” Rome, Italy
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome “Tor Vergata,” Rome, Italy
| | | | - Pietro Schino
- Fisiopatologia Respiratoria, Ospedale Generale Regionale, Ente Ecclesiastico “F. Miulli,” Acquaviva delle Fonti, BA, Italy
| | - Marco Caminati
- Department of Medicine, University of Verona, Verona, Italy
- Allergy Unit and Asthma Center, Verona University Hospital, Verona, Italy
| | | | - Alessandro Zullo
- Medineos Observational Research - An IQVIA Company, Modena, Italy
| | - Sara Rizzoli
- Medineos Observational Research - An IQVIA Company, Modena, Italy
| | | | | | - Francesco Menzella
- UOC Pneumologia, Ospedale “S. Valentino,” Montebelluna (TV) - AULSS 2 Marca Trevigiana, Treviso, Italy
| | - Fabiano Di Marco
- Department of Health Sciences and Pneumology, University of Milan, ASST Papa Giovanni XXIII, Bergamo, Italy
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32
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Hinks TSC. From spirometry to spatial omics in pursuit of asthma endotypes. Clin Transl Med 2022; 12:e878. [PMID: 36149782 PMCID: PMC9506425 DOI: 10.1002/ctm2.878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 04/25/2022] [Accepted: 04/28/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Timothy S C Hinks
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Nuffield Department of Medicine Experimental Medicine, University of Oxford, Oxford, UK
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33
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McDowell PJ, Busby J, Hanratty CE, Djukanovic R, Woodcock A, Walker S, Hardman TC, Arron JR, Choy DF, Bradding P, Brightling CE, Chaudhuri R, Cowan D, Mansur AH, Fowler SJ, Diver SE, Howarth P, Lordan J, Menzies-Gow A, Harrison T, Robinson DS, Holweg CTJ, Matthews JG, Pavord ID, Heaney LG. Exacerbation Profile and Risk Factors in a Type-2-Low Enriched Severe Asthma Cohort: A Clinical Trial to Assess Asthma Exacerbation Phenotypes. Am J Respir Crit Care Med 2022; 206:545-553. [PMID: 35549845 PMCID: PMC9716911 DOI: 10.1164/rccm.202201-0129oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The past 25 years have seen huge progress in understanding of the pathobiology of type-2 (T2) asthma, identification of measurable biomarkers, and the emergence of novel monoclonal antibody treatments. Although present in a minority of patients with severe asthma, very little is known about the mechanisms underlying T2-low asthma, making it a significant unmet need in asthma research. Objectives: The objective of this study was to explore the differences between study exacerbators and nonexacerbators, to describe physiological changes at exacerbation in those who are T2HIGH and T2LOW at the time of exacerbation, and to evaluate the stability of inflammatory phenotypes when stable and at exacerbation. Methods: Exacerbation assessment was a prespecified secondary analysis of data from a 48-week, multicenter, randomized controlled clinical study comparing the use of biomarkers and symptoms to adjust steroid treatment in a T2-low severe asthma-enriched cohort. Participants were phenotyped as T2LOW (fractional exhaled nitric oxide ⩽ 20 ppb and blood eosinophil count ⩽ 150 cells/µl) or T2HIGH (fractional exhaled nitric oxide > 20 or blood eosinophil count > 150) at study enrollment and at each exacerbation. Here, we report the findings of the exacerbation analyses, including comparison of exacerbators and nonexacerbators, the physiological changes at exacerbation in those who had evidence of T2 biology at exacerbation versus those that did not, and the stability of inflammatory phenotypes when stable and at exacerbation. Measurements and Main Results: Of the 301 participants, 60.8% (183) had one or more self-reported exacerbations (total of 390). Exacerbators were more likely to be female, have a higher body mass index, and have more exacerbations requiring oral corticosteroid and unscheduled primary care attendances for exacerbations. At enrollment, 23.6% (71) were T2LOW and 76.4% (230) T2HIGH. The T2LOW group had more asthma primary care attendances, were more likely to have a previous admission to HDU (high dependency unit)/ICU and to be receiving maintenance oral corticosteroids. At exacerbation, the T2LOW events were indistinguishable from T2HIGH exacerbations in terms of lung function (mean fall in T2LOW FEV1, 200 [400] ml vs. T2HIGH 200 [300] ml; P = 0.93) and symptom increase (ACQ5: T2LOW, 1.4 [0.8] vs. T2HIGH, 1.3 [0.8]; P = 0.72), with no increase in T2 biomarkers from stable to exacerbation state in the T2LOW exacerbations. The inflammatory phenotype within individual patients was dynamic; inflammatory phenotype at study entry did not have a significant association with exacerbation phenotype. Conclusions: Asthma exacerbations demonstrating a T2LOW phenotype were physiologically and symptomatically similar to T2HIGH exacerbations. T2LOW asthma was an unstable phenotype, suggesting that exacerbation phenotyping should occur at the time of exacerbation. The clinically significant exacerbations in participants without evidence of T2 biology at the time of exacerbation highlight the unmet and pressing need to further understand the mechanisms at play in non-T2 asthma. Clinical trial registered with www.clinicaltrials.gov (NCT02717689).
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Affiliation(s)
- P. Jane McDowell
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - John Busby
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - Catherine E. Hanratty
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, University of Southampton, National Institute for Health and Care Research (NIHR) Southampton Biomedical Research Center, Southampton, United Kingdom
| | - Ashley Woodcock
- Manchester Academic Health Science Center and NIHR Manchester Biomedical Research Center, Manchester University Hospitals National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Samantha Walker
- Asthma UK and British Lung Foundation Partnership, London, United Kingdom
| | | | | | | | - Peter Bradding
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Chris E. Brightling
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Rekha Chaudhuri
- Gartnavel General Hospital, Glasgow and University of Glasgow, Glasgow, United Kingdom
| | - Douglas Cowan
- NHS Greater Glasgow and Clyde, Stobhill Hospital, Glasgow, United Kingdom
| | - Adel H. Mansur
- University of Birmingham and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Stephen J. Fowler
- Manchester Academic Health Science Center and NIHR Manchester Biomedical Research Center, Manchester University Hospitals National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Sarah E. Diver
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Peter Howarth
- School of Clinical and Experimental Sciences, University of Southampton, National Institute for Health and Care Research (NIHR) Southampton Biomedical Research Center, Southampton, United Kingdom
| | - James Lordan
- the Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew Menzies-Gow
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, the University of Manchester, Royal Brompton and Harefield Hospitals, London, United Kingdom
| | - Timothy Harrison
- Nottingham Respiratory NIHR Biomedical Research Center, University of Nottingham, Nottingham, United Kingdom
| | | | | | | | - Ian D. Pavord
- Oxford Respiratory NIHR Biomedical Research Center, Nuffield Department of Medicine, the University of Oxford, Oxford, United Kingdom
| | - Liam G. Heaney
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
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Morita H, Matsumoto K, Saito H. Review of biologics in allergy and immunology. J Allergy Clin Immunol 2022; 150:766-777. [PMID: 36058723 DOI: 10.1016/j.jaci.2022.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 10/14/2022]
Abstract
Biologics or molecularly targeted drugs are often highly effective for the treatment of allergic diseases and other immunologic disorders, and they are relatively safe for short-term use as compared with conventional approaches such as the systemic use of corticosteroids. A number of studies published in 2021 consistently demonstrated their effectiveness and also revealed unanticipated findings. Among them, clinical trials for asthma and chronic obstructive pulmonary disease using biologics targeting thymic stromal lymphopoietin, IL-33, and IL-33 receptor demonstrated that these type 2 alarmin cytokines are also involved in non-type 2, noneosinophilic inflammation. Randomized controlled trials reporting the efficacies of 2 small-molecule oral drugs targeting Janus kinase-1 had a substantial impact on the management of atopic dermatitis. These drugs demonstrated superiority over dupilumab, which has previously demonstrated efficacy and is in wide use in clinical practice. As a concern, biologics are generally costly, and it should be noted that racial/ethnic minority populations may be less likely to receive biologics in the real world. Here, we have reviewed recent clinical trials and related topics dealing with the effects of biologics on allergic and immunologic diseases; in addition, we discuss how our understanding of the pathophysiology of these disorders has progressed.
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Affiliation(s)
- Hideaki Morita
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan; Allergy Center, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Kenji Matsumoto
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Hirohisa Saito
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan.
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Marcos MC, Cisneros Serrano C. What is the added value of FeNO as T2 biomarker? FRONTIERS IN ALLERGY 2022; 3:957106. [PMID: 36032508 PMCID: PMC9403133 DOI: 10.3389/falgy.2022.957106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022] Open
Abstract
There is increasing evidence about the role of nitric oxide in type 2 (T2) immune response. Fraction of exhaled nitric oxide (FeNO) is a product of airways inflammation and it is increased in patients with asthma. Since Gustaffson published the first article about this biomarker in the 1990s, interest has continued to grow. Compared with other T2 biomarkers such as blood eosinophil count, induced sputum, or serum periostin, FeNO has some remarkable advantages, including its not invasive nature, easy repeatability, and possibility to be performed even in patients with severe airway obstruction. It is considered as an indicator of T2 inflammation and, by the same token, a useful predictor for inhaled steroid response. It is difficult to determine the utility of nitric oxide (NO) for initial asthma diagnosis. In such a heterogenous disease, a single parameter would probably not be enough to provide a complete picture. There is also an important variability among authors concerning FeNO cutoff values and the percentage of sensibility and specificity for diagnosis. Its high specificity indicates a potential role to “rule in” asthma; however, its lower sensibility could suggest a lower capacity to “rule out” this pathology. For this reason, if a diagnosis of asthma is being considered, FeNO should be considered along with other tests. FeNO has also shown its utility to detect response to steroids, adherence to treatment, and risk of exacerbation. Even though there is not enough quality of evidence to establish overall conclusions, FeNO could be an alternative procedure to diagnose or exclude asthma and also a predictive tool in asthma treated with corticosteroids.
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Couillard S. The alarmin(g) effect of interleukin-5 blockade on residual eosinophil function is of clinical consequence. Eur Respir J 2022; 60:13993003.00597-2022. [PMID: 35777763 DOI: 10.1183/13993003.00597-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Simon Couillard
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
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Van Hulst G, Jorssen J, Jacobs N, Henket M, Louis R, Schleich F, Bureau F, Desmet CJ. Response to Couillard: Ex vivo SOCS3 gene responsiveness to alarmins in eosinophils of mepolizumab-treated patients is yet of unknown biological significance. Eur Respir J 2022; 60:13993003.00981-2022. [PMID: 35777778 DOI: 10.1183/13993003.00981-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/16/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Glenn Van Hulst
- Laboratory of Cellular and Molecular Immunology, GIGA Institute and Faculty of Veterinary Medicine, Liege University, Liege, Belgium.,Equal contributors
| | - Joseph Jorssen
- Laboratory of Cellular and Molecular Immunology, GIGA Institute and Faculty of Veterinary Medicine, Liege University, Liege, Belgium.,Equal contributors
| | - Nathalie Jacobs
- Laboratory of Cellular and Molecular Immunology, GIGA Institute and Faculty of Veterinary Medicine, Liege University, Liege, Belgium
| | - Monique Henket
- Laboratory of Pneumology, GIGA Institute, Faculty of Medicine and University Hospital Center, Liege University, Liege, Belgium
| | - Renaud Louis
- Laboratory of Pneumology, GIGA Institute, Faculty of Medicine and University Hospital Center, Liege University, Liege, Belgium
| | - Florence Schleich
- Laboratory of Pneumology, GIGA Institute, Faculty of Medicine and University Hospital Center, Liege University, Liege, Belgium
| | - Fabrice Bureau
- Laboratory of Cellular and Molecular Immunology, GIGA Institute and Faculty of Veterinary Medicine, Liege University, Liege, Belgium.,Walloon Excellence in Life Sciences and Biotechnology (Welbio), Wavres, Belgium.,Equal contributors
| | - Christophe J Desmet
- Laboratory of Cellular and Molecular Immunology, GIGA Institute and Faculty of Veterinary Medicine, Liege University, Liege, Belgium .,Laboratory of Pneumology, GIGA Institute, Faculty of Medicine and University Hospital Center, Liege University, Liege, Belgium.,Equal contributors
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Wark PAB. We need to understand why viral infections lead to acute asthma. Eur Respir J 2022; 60:60/1/2200194. [PMID: 35902102 DOI: 10.1183/13993003.00194-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Peter A B Wark
- Immune Health Program, Hunter Medical Research institute, University of Newcastle, New Lambton, Australia
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Hoshino Y, Soma T, Uchida Y, Shiko Y, Nakagome K, Nagata M. Treatment Resistance in Severe Asthma Patients With a Combination of High Fraction of Exhaled Nitric Oxide and Low Blood Eosinophil Counts. Front Pharmacol 2022; 13:836635. [PMID: 35517829 PMCID: PMC9065285 DOI: 10.3389/fphar.2022.836635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/14/2022] [Indexed: 01/01/2023] Open
Abstract
Background: Combining a fraction of exhaled nitric oxide (FeNO) and blood eosinophil count (B-EOS) may be a useful strategy for administration of biologics such as anti-IgE or anti-IL-5 to patients with type 2 inflammatory-predominant severe asthma and is important to be elucidated considering the increasing use of biologics. Methods: This cross-sectional study analyzed the clinical data from 114 adult patients with severe asthma, who were treated at Saitama Medical University Hospital. The eligible patients were stratified into four subgroups defined by thresholds of FeNO and blood eosinophil (B-EOS) counts to detect sputum eosinophilia, using the receiver operating characteristic curve analysis. A total of 75 patients with optimal samples were stratified into four subtypes defined by thresholds of sputum eosinophilia and neutrophilia. Clinical characteristics, pattern of biologics, and distribution of sputum subtypes were analyzed in the stratified subclasses according to the FeNO and B-EOS thresholds. The asthma exacerbation (AE)-free time of the FeNO/B-EOS subgroups and any biologics treatment including anti-IgE or anti-IL-5 use were examined using the Kaplan–Meier method. The hazard ratios (HRs) for AE-free time were examined using the Cox proportional hazard model. Results: The optimal cutoff values for prediction of sputum eosinophilia were defined as ≥2.7% wherein for FeNO as ≥27 ppb and B-EOS as ≥265/µL were considered. The high-FeNO subgroups showed significant high total IgE, compared with the low FeNO. The high-FeNO/high-B-EOS and the high-FeNO/low-B-EOS subgroups showed the largest prevalence of mepolizumab and benralizumab use among the other FeNO/B-EOS, respectively. The high-FeNO/low-B-EOS showed the largest frequency of AEs, high HR, and the shortest AE-free time, among the other FeNO/B-EOS. The sputum eosinophil-predominant subtype was the great majority in the high FeNO/high B-EOS. A diverse distribution of sputum leukocyte-predominant subtype was observed in the other FeNO/B-EOS. The subsequent AE-free time and its HR were comparable among the biologics use groups. Conclusion: The strategy of classifying severe asthma based on the combination of FeNO and B-EOS proposes particular refractory type 2 severe asthma and underlying airway inflammation as a feasible trait for optimal biologics use.
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Affiliation(s)
- Yuki Hoshino
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan
- Allergy Center, Saitama Medical University, Saitama, Japan
| | - Tomoyuki Soma
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan
- Allergy Center, Saitama Medical University, Saitama, Japan
- *Correspondence: Tomoyuki Soma,
| | - Yoshitaka Uchida
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan
- Allergy Center, Saitama Medical University, Saitama, Japan
| | - Yuki Shiko
- Research Administration Center, Saitama Medical University, Saitama, Japan
| | - Kazuyuki Nakagome
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan
- Allergy Center, Saitama Medical University, Saitama, Japan
| | - Makoto Nagata
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan
- Allergy Center, Saitama Medical University, Saitama, Japan
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Janson C, Bjermer L, Lehtimäki L, Kankaanranta H, Karjalainen J, Altraja A, Yasinska V, Aarli B, Rådinger M, Hellgren J, Lofdahl M, Howarth PH, Porsbjerg C. Eosinophilic airway diseases: basic science, clinical manifestations and future challenges. Eur Clin Respir J 2022; 9:2040707. [PMID: 35251534 PMCID: PMC8896196 DOI: 10.1080/20018525.2022.2040707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Eosinophils have a broad range of functions, both homeostatic and pathological, mediated through an array of cell surface receptors and specific secretory granules that promote interactions with their microenvironment. Eosinophil development, differentiation, activation, survival and recruitment are closely regulated by a number of type 2 cytokines, including interleukin (IL)-5, the key driver of eosinophilopoiesis. Evidence shows that type 2 inflammation, driven mainly by interleukin (IL)-4, IL-5 and IL-13, plays an important role in the pathophysiology of eosinophilic airway diseases, including asthma, chronic rhinosinusitis with nasal polyps, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome. Several biologic therapies have been developed to suppress type 2 inflammation, namely mepolizumab, reslizumab, benralizumab, dupilumab, omalizumab and tezepelumab. While these therapies have been associated with clinical benefits in a range of eosinophilic diseases, their development has highlighted several challenges and directions for future research. These include the need for further information on disease progression and identification of treatable traits, including clinical characteristics or biomarkers that will improve the prediction of treatment response. The Nordic countries have a long tradition of collaboration using patient registries and Nordic asthma registries provide unique opportunities to address these research questions. One example of such a registry is the NORdic Dataset for aSThmA Research (NORDSTAR), a longitudinal population-based dataset containing all 3.3 million individuals with asthma from four Nordic countries (Denmark, Finland, Norway and Sweden). Large-scale, real-world registry data such as those from Nordic countries may provide important information regarding the progression of eosinophilic asthma, in addition to clinical characteristics or biomarkers that could allow targeted treatment and ensure optimal patient outcomes.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Skane University Hospital, Lund, Sweden
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Hannu Kankaanranta
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Alan Altraja
- Department of Pulmonology, University of Tartu and Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Valentyna Yasinska
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Huddinge, Sweden
| | - Bernt Aarli
- Department of Clinical Science, University of Bergen and Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Madeleine Rådinger
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Johan Hellgren
- Department of Otorhinolaryngology, University of Gothenburg, Gothenburg, Sweden
| | | | - Peter H Howarth
- Respiratory Medical Franchise, GSK, Brentford, Middlesex, UK
| | - Celeste Porsbjerg
- Department of Respiratory Medicine, Bispebjerg Hospital and Copenhagen University, Copenhagen, Denmark
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41
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Kavanagh JE, Hearn AP, Jackson DJ. A pragmatic guide to choosing biologic therapies in severe asthma. Breathe (Sheff) 2022; 17:210144. [PMID: 35296105 PMCID: PMC8919802 DOI: 10.1183/20734735.0144-2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/30/2021] [Indexed: 11/05/2022] Open
Abstract
There are now several monoclonal antibody (mAb) therapies (“biologics”) available to treat severe asthma. Omalizumab is an anti-IgE mAb and is licensed in severe allergic asthma. Current evidence suggests it may decrease exacerbations by augmenting deficient antiviral immune responses in asthma. Like all other biologics, clinical efficacy is greatest in those with elevated T2 biomarkers. Three biologics target the interleukin (IL)-5–eosinophil pathway, including mepolizumab and reslizumab that target IL-5 itself, and benralizumab that targets the IL-5 receptor (IL-5R-α). These drugs all reduce the exacerbation rate in those with raised blood eosinophil counts. Mepolizumab and benralizumab have also demonstrated steroid-sparing efficacy. Reslizumab is the only biologic that is given intravenously rather than by the subcutaneous route. Dupilumab targets the IL-4 receptor and like mepolizumab and benralizumab is effective at reducing exacerbation rate as well as oral corticosteroid requirements. It is also effective for the treatment of nasal polyposis and atopic dermatitis. Tezepelumab is an anti-TSLP (thymic stromal lymphopoietin) mAb that has recently completed phase 3 trials demonstrating significant reductions in exacerbation rate even at lower T2 biomarker thresholds.Many patients with severe asthma qualify for more than one biologic. To date, there are no head-to-head trials to aid physicians in this choice. However, post-hoc analyses have identified certain clinical characteristics that are associated with superior responses to some therapies. The presence of allergic and/or eosinophilic comorbidities, such as atopic dermatitis, nasal polyposis or eosinophilic granulomatosis with polyangiitis, that may additionally benefit by the choice of biologic should also be taken into consideration, as should patient preferences which may include dosing frequency. To date, all biologics have been shown to have excellent safety profiles.
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42
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Nomura N, Matsumoto H, Yokoyama A, Nishimura Y, Asano K, Niimi A, Tohda Y, Harada N, Nagase H, Nagata M, Inoue H, Kondo M, Horiguchi T, Miyahara N, Hizawa N, Hojo M, Hattori N, Hashimoto N, Yamasaki A, Kadowaki T, Kimura T, Miki M, Taniguchi H, Toyoshima M, Kawamura T, Matsuno O, Sato Y, Sunadome H, Nagasaki T, Oguma T, Hirai T. Nationwide survey of refractory asthma with bronchiectasis by inflammatory subtypes. Respir Res 2022; 23:365. [PMID: 36539765 PMCID: PMC9763800 DOI: 10.1186/s12931-022-02289-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Bronchiectasis and bronchiolitis are differential diagnoses of asthma; moreover, they are factors associated with worse asthma control. OBJECTIVE We determined clinical courses of bronchiectasis/bronchiolitis-complicated asthma by inflammatory subtypes as well as factors affecting them. METHODS We conducted a survey of refractory asthma with non-cystic fibrosis bronchiectasis/bronchiolitis in Japan. Cases were classified into three groups, based on the latest fractional exhaled NO (FeNO) level (32 ppb for the threshold) and blood eosinophil counts (320/µL for the threshold): high (type 2-high) or low (type 2-low) FeNO and eosinophil and high FeNO or eosinophil (type 2-intermediate). Clinical courses in groups and factors affecting them were analysed. RESULTS In total, 216 cases from 81 facilities were reported, and 142 were stratified: 34, 40 and 68 into the type 2-high, -intermediate and -low groups, respectively. The frequency of bronchopneumonia and exacerbations requiring antibiotics and gram-negative bacteria detection rates were highest in the type 2-low group. Eighty-seven cases had paired latest and oldest available data of FeNO and eosinophil counts; they were analysed for inflammatory transition patterns. Among former type 2-high and -intermediate groups, 32% had recently transitioned to the -low group, to which relatively low FeNO in the past and oral corticosteroid use contributed. Lastly, in cases treated with moderate to high doses of inhaled corticosteroids, the frequencies of exacerbations requiring antibiotics were found to be higher in cases with more severe airway lesions and lower FeNO. CONCLUSIONS Bronchiectasis/bronchiolitis-complicated refractory asthma is heterogeneous. In patients with sputum symptoms and low FeNO, airway colonisation of pathogenic bacteria and infectious episodes are common; thus, corticosteroids should be carefully used.
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Affiliation(s)
- Natsuko Nomura
- grid.258799.80000 0004 0372 2033Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hisako Matsumoto
- grid.258799.80000 0004 0372 2033Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan ,grid.258622.90000 0004 1936 9967Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka Japan
| | - Akihito Yokoyama
- grid.278276.e0000 0001 0659 9825Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Yoshihiro Nishimura
- grid.31432.370000 0001 1092 3077Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Koichiro Asano
- grid.265061.60000 0001 1516 6626Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Akio Niimi
- grid.260433.00000 0001 0728 1069Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuji Tohda
- grid.258622.90000 0004 1936 9967Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka Japan
| | - Norihiro Harada
- grid.258269.20000 0004 1762 2738Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Hiroyuki Nagase
- grid.264706.10000 0000 9239 9995Department of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Makoto Nagata
- grid.410802.f0000 0001 2216 2631Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan
| | - Hiromasa Inoue
- grid.258333.c0000 0001 1167 1801Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Mitsuko Kondo
- grid.410818.40000 0001 0720 6587Department of Respiratory Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takahiko Horiguchi
- Department of Respiratory Medicine, Toyota Regional Medical Center, Toyota, Japan
| | - Nobuaki Miyahara
- grid.261356.50000 0001 1302 4472Department of Medical Technology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Nobuyuki Hizawa
- grid.20515.330000 0001 2369 4728Department of Pulmonary Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masayuki Hojo
- grid.45203.300000 0004 0489 0290Department of Respiratory Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Noboru Hattori
- grid.257022.00000 0000 8711 3200Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naozumi Hashimoto
- grid.27476.300000 0001 0943 978XDepartment of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akira Yamasaki
- grid.265107.70000 0001 0663 5064Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, School of Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Toru Kadowaki
- Department of Pulmonary Medicine, National Hospital Organization Matsue Medical Center, Matsue, Japan
| | - Tomoki Kimura
- grid.417192.80000 0004 1772 6756Department of Respiratory Medicine and Allergy, Tosei General Hospital, Aichi, Japan
| | - Mari Miki
- grid.416803.80000 0004 0377 7966Department of Respiratory Medicine, National Hospital Organization Toneyama Medical Center, Osaka, Japan
| | - Hirokazu Taniguchi
- grid.417235.60000 0001 0498 6004Department of Respiratory Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Mikio Toyoshima
- grid.413556.00000 0004 1773 8511Department of Respiratory Medicine, Hamamatsu Rosai Hospital, Hamamatsu, Japan
| | - Tetsuji Kawamura
- grid.414101.10000 0004 0569 3280Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Osamu Matsuno
- Department of Allergy and Rheumatoid disease, Osaka Habikino Medical Center, Osaka, Japan
| | - Yoko Sato
- Department of Respiratory Medicine, Yuuai Medical Center, Okinawa, Japan
| | - Hironobu Sunadome
- grid.258799.80000 0004 0372 2033Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan ,grid.258799.80000 0004 0372 2033Department of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tadao Nagasaki
- grid.258799.80000 0004 0372 2033Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan ,grid.258799.80000 0004 0372 2033Department of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tsuyoshi Oguma
- grid.258799.80000 0004 0372 2033Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toyohiro Hirai
- grid.258799.80000 0004 0372 2033Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Alcázar-Navarrete B, Díaz-Lopez JM, García-Flores P, Ortega-Antelo M, Aguilar-Cruz I, Ruiz-Rodríguez O, Santiago-Diaz P, Romero Palacios PJ. T2 Biomarkers as Predictors of Exacerbations of Chronic Obstructive Pulmonary Disease. Arch Bronconeumol 2021; 58:595-600. [PMID: 35312535 DOI: 10.1016/j.arbres.2021.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/01/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Type 2 (T2) biomarkers such as blood eosinophil count (BEC) and FeNO have been related to a higher risk of exacerbations in COPD. It is unknown whether combining these biomarkers could be useful in forecasting COPD exacerbations. METHODS COPD patients were enrolled in this prospective, multicenter, observational study and followed up for 1 year, during which BEC were analysed at baseline (V0) while FeNO analyses were performed at baseline (V0), 6 months (V1) and 12 months (V2). The risk of moderate or severe exacerbation during follow up was assessed by Cox regression analysis, and the predictive capacity of both measurements was assessed by ROC curves and the DeLong test. Statistical significance was assumed at P<.05. RESULTS Of the 322 COPD patients initially recruited, 287 were followed up. At baseline, 28.0% were active smokers, and experienced moderate airflow limitation (mean FEV1 56.4%±17.0% predicted). Patients with at least one elevated T2 biomarker (n=125, 42.5%) were at increased risk of COPD exacerbation (HR 1.75, 95% CI 1.25-2.45, P=.001) and of shorter time to first COPD exacerbation. There was no difference between BEC and FeNO regarding the predictive capacity for moderate to severe exacerbation (AUC 0.584 vs 0.576, P=.183) but FeNO predicted severe episodes more accurately than BEC (AUC 0.607 vs 0.539, P<.05). Combining the two biomarkers enhanced the detection of moderate and severe COPD exacerbations. CONCLUSIONS Both eosinophil count and FeNO have limited utility for predicting COPD exacerbations. Combining these T2 biomarkers could enhance the detection of future COPD exacerbations.
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Affiliation(s)
- Bernardino Alcázar-Navarrete
- Respiratory Department, HU Virgen de las Nieves, Granada, Spain; Facultad de Medicina, Universidad de Granada, Granada, Spain; Centro de Investigación Biomédica en red Enfermedades Respiratorias (CIBERES), Spain.
| | | | | | | | | | - Oliverio Ruiz-Rodríguez
- Respiratory Department, AIG de Medicina, Hospital de Alta Resolución de Loja, Agencia Sanitaria Hospital de Poniente, Loja, Granada, Spain
| | - Pablo Santiago-Diaz
- Cardiology Department, AIG de Medicina, Hospital de Alta Resolución de Loja, Agencia Sanitaria Hospital de Poniente, Loja, Granada, Spain
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Li M, Zhu W, Wang C, Zheng Y, Sun S, Fang Y, Luo Z. Weighted gene co-expression network analysis to identify key modules and hub genes associated with paucigranulocytic asthma. BMC Pulm Med 2021; 21:343. [PMID: 34727921 PMCID: PMC8565058 DOI: 10.1186/s12890-021-01711-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/25/2021] [Indexed: 02/08/2023] Open
Abstract
Background Asthma is a heterogeneous disease that can be divided into four inflammatory phenotypes: eosinophilic asthma (EA), neutrophilic asthma (NA), mixed granulocytic asthma (MGA), and paucigranulocytic asthma (PGA). While research has mainly focused on EA and NA, the understanding of PGA is limited. In this study, we aimed to identify underlying mechanisms and hub genes of PGA. Methods Based on the dataset from Gene Expression Omnibus(GEO), weighted gene coexpression network analysis (WGCNA), differentially expressed genes (DEGs) analysis and protein–protein interaction (PPI) network analysis were conducted to construct a gene network and to identify key gene modules and hub genes. Functional enrichment analyses were performed to investigate the biological process, pathways and immune status of PGA. The hub genes were validated in a separate dataset. Results Compared to non-PGA, PGA had a different gene expression pattern, in which 449 genes were differentially expressed. One gene module significantly associated with PGA was identified. Intersection between the differentially expressed genes (DEGs) and the genes from the module that were most relevant to PGA were mainly enriched in inflammation and immune response regulation. The single sample Gene Set Enrichment Analysis (ssGSEA) suggested a decreased immune infiltration and function in PGA. Finally six hub genes of PGA were identified, including ADCY2, CXCL1, FPRL1, GPR109B, GPR109A and ADCY3, which were validated in a separate dataset of GSE137268. Conclusions Our study characterized distinct gene expression patterns, biological processes and immune status of PGA and identified hub genes, which may improve the understanding of underlying mechanism and provide potential therapeutic targets for PGA. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01711-3.
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Affiliation(s)
- Min Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, The People's Republic of China.,Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, Kunming, The People's Republic of China
| | - Wenye Zhu
- Department of Pharmacy, First Affiliated Hospital of Kunming Medical University, Kunming, The People's Republic of China
| | - Chu Wang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, Kunming, The People's Republic of China
| | - Yuanyuan Zheng
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, Kunming, The People's Republic of China
| | - Shibo Sun
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, Kunming, The People's Republic of China
| | - Yan Fang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, Kunming, The People's Republic of China
| | - Zhuang Luo
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, Kunming, The People's Republic of China.
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Using FeNO Measurement in Clinical Asthma Management. Chest 2021; 161:906-917. [PMID: 34673021 DOI: 10.1016/j.chest.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/30/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Abstract
Asthma is a common and heterogeneous disease, characterised by lower airway inflammation and airflow limitation. Critical factors in asthma management include establishing an accurate diagnosis and ensuring appropriate selection and dosage of anti-inflammatory therapies. The majority of asthma patients exhibit type 2 (T2) inflammation, with increased interleukin (IL)-4, IL-5, and IL-13 signalling, often with associated eosinophilia. Identifying lower airway eosinophilia with sputum induction improves asthma outcomes, but is time consuming and costly. Increased T2-inflammation leads to upregulation of nitric oxide (NO) release into the airway, with increasing fractional exhaled NO (FeNO) reflecting greater T2-inflammation. FeNO can be easily and quickly measured in the clinic, offering a point of care surrogate measure of the degree of lower airway inflammation. FeNO testing can be used to help confirm an asthma diagnosis, to guide inhaled corticosteroid therapy, to assess adherence to treatment, and to aid selection of appropriate biologic therapy. However, FeNO levels may also be influenced by a variety of intrinsic and extrinsic factors other than asthma, including nasal polyposis and cigarette smoking, and must be interpreted in the broader clinical context rather than viewed in isolation. This review discusses the clinical application of FeNO measurement in asthma care, from diagnosis to treatment selection, and describes its place in current international expert guidelines.
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Chung KF. Increasing utility of FeNO as a biomarker of type-2 inflammation in severe asthma. THE LANCET. RESPIRATORY MEDICINE 2021; 9:1083-1084. [PMID: 34181878 DOI: 10.1016/s2213-2600(21)00170-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Kian Fan Chung
- National Heart & Lung Institute, Imperial College London, London SW3 6LY, UK; Royal Brompton and Harefield NHS Trust, London, UK.
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Eosinophils as Drivers of Severe Eosinophilic Asthma: Endotypes or Plasticity? Int J Mol Sci 2021; 22:ijms221810150. [PMID: 34576313 PMCID: PMC8467265 DOI: 10.3390/ijms221810150] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 01/04/2023] Open
Abstract
Asthma is now recognized as a heterogeneous disease, encompassing different phenotypes driven by distinct pathophysiological mechanisms called endotypes. Common phenotypes of asthma, referred to as eosinophilic asthma, are characterized by the presence of eosinophilia. Eosinophils are usually considered invariant, terminally differentiated effector cells and have become a primary therapeutic target in severe eosinophilic asthma (SEA) and other eosinophil-associated diseases (EADs). Biological treatments that target eosinophils reveal an unexpectedly complex role of eosinophils in asthma, including in SEA, suggesting that "not all eosinophils are equal". In this review, we address our current understanding of the role of eosinophils in asthma with regard to asthma phenotypes and endotypes. We further address the possibility that different SEA phenotypes may involve differences in eosinophil biology. We discuss how these differences could arise through eosinophil "endotyping", viz. adaptations of eosinophil function imprinted during their development, or through tissue-induced plasticity, viz. local adaptations of eosinophil function through interaction with their lung tissue niches. In doing so, we also discuss opportunities, technical challenges, and open questions that, if addressed, might provide considerable benefits in guiding the choice of the most efficient precision therapies of SEA and, by extension, other EADs.
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Factors Associated with Frequent Exacerbations in the UK Severe Asthma Registry. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2691-2701.e1. [PMID: 33460858 DOI: 10.1016/j.jaip.2020.12.062] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/21/2020] [Accepted: 12/31/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Frequent exacerbations are an important cause of morbidity in patients with severe asthma. OBJECTIVE Our aim was to identify factors associated with frequent exacerbations in a large well-characterized severe asthma population and determine whether factors differed in patients treated with and without maintenance oral corticosteroids (OCS). METHODS Adults with severe asthma from specialized asthma centers across the United Kingdom were recruited to the UK Severe Asthma Registry. Demography, comorbidities and physiological measurements were collected. We conducted univariable and multivariable logistic regression analyses to identify factors associated with frequent exacerbations, defined as 3 or more exacerbations treated with high-dose systemic corticosteroids in the past year. RESULTS Of 1,592 patients with severe asthma from the UK Severe Asthma Registry, 1,137 (71%) were frequent exacerbators and 833 (52%) were on maintenance OCS. The frequent exacerbators were more likely to be ex-smokers, have gastroesophageal reflux disease, higher Asthma Control Questionnaire-6 (ACQ-6) score, and higher blood eosinophilia. Multivariable regression analyses showed ACQ-6 score greater than 1.5 (odds ratio [OR] 4.25; P < .001), past smoking history (OR 1.55; P = .024), and fractional exhaled nitric oxide greater than 50ppb (OR 1.54; P = .044) were independently associated with frequent exacerbations. Past smoking history correlated with frequent exacerbations only in patients on maintenance OCS (OR 2.25; P = .004), whereas ACQ-6 score greater than 1.5 was independently associated with frequent exacerbations in those treated with and without maintenance OCS (OR 2.74; P = .017 and OR 6.42; P < .001, respectively). CONCLUSIONS Several factors were associated with frequent exacerbations in a large UK severe asthma registry population. High ACQ-6 score had the strongest association with frequent exacerbations irrespective of maintenance OCS status.
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