Bringing asthma care into the twenty-first century

Trends and characteristics of herpes zoster vaccination among older adults with asthma in the United States, 2008-2023: Findings from self-reported national surveys

BACKGROUND

Asthma is a risk factor for herpes zoster. However, evidence regarding herpes zoster vaccination among patients with asthma is limited. Since the recommendations and availability of herpes zoster vaccines in the U.S. have changed over time, a comprehensive investigation into herpes zoster vaccination is crucial.

OBJECTIVES

This study aimed to assess the trends and determinants of herpes zoster vaccination among U.S. adults with asthma aged 50 and over.

METHODS

Data from the 2008-2023 National Health Interview Survey were used. Data were analyzed in October 2024. Joinpoint regression analysis was performed to analyze trends in herpes zoster vaccination. A multivariable logistic regression model was used to identify factors associated with herpes zoster vaccination.

RESULTS

This study included 20,664 respondents, representing approximately 8.6 million U.S. adults with asthma aged 50 and over. From 2008 to 2023, a significantly increasing trend in herpes zoster vaccination was observed (average annual percent change = 13.48; 95 % CI, 9.35, 17.77; P < 0.01). This increasing trend was also observed when stratified by age groups. Several factors, including age, sex, race/ethnicity, region, educational level, income, asthma control, and flu vaccination, were associated with herpes zoster vaccination.

CONCLUSIONS

Over the past 16 years, herpes zoster vaccine coverage sharply increased among U.S. adults with asthma aged 50 and over. Disparities in several characteristics exist, underscoring the necessity for targeted policies and interventions to promote equity in herpes zoster vaccination rates.

Primary healthcare professionals' perceptions, attitudes and ideas regarding asthma management in Greece: A mixed-method study

BACKGROUND

Implementing asthma guideline recommendations is challenging and there is variation between countries, and different healthcare professionals (HCPs). The International Primary Care Respiratory Group (IPCRG) has introduced the Asthma Right Care (ARC) programme implemented in 24 low, middle, and high countries, including Greece. It offers a promising approach drawn from social movements for health to improve asthma care by engaging HCPs in implementing guideline-based asthma care.

OBJECTIVES

To explore HCPs' perspectives on current provision of asthma care and their willingness to improve implementation of recommended guidelines using ARC programme tools in Greece.

METHODS

A mixed methods study conducted from September 2020 to April 2021. A convenience sample of 30 pharmacists, and 10 General Practitioners (GPs), responded to a questionnaire investigating perceptions, and attitudes, towards implementation of asthma guidelines. Then, a qualitative survey followed with semi-structured interviews to evaluate the feedback obtained from HCPs to assess the content, and applicability of the ARC tools. Data were analysed using thematic analysis.

RESULTS

A range of practical challenges in implementing guideline-recommended interventions, improving asthma control and management were described by all HCPs, including lack of time and education, high workload, patients' perceptions, and poor communication contributing to poor management and inadequate follow-up of people with asthma. However, most HCPs were willing to use ARC interventions to improve guideline implementation.

CONCLUSION

HCPs in Greece encounter challenges in implementing asthma guidelines; however, they can overcome these challenges by using ARC interventions and engagement tools to address barriers and implement efficient asthma management strategies.

The Turkish adaptation of the Adherence to Asthma Medication Questionnaire

BACKGROUND

This study was conducted to adapt the Adherence to Asthma Medication Questionnaire (AAMQ-13) into Turkish.

METHODS

The research was conducted in the pulmonology outpatient clinic of a state hospital in Nigde/Turkey. The sample consisted of 229 volunteers with asthma for at least one year. First, language and content validity were assessed. After evaluating the language validity and content validity of the questionnaire, internal consistency, split-half reliability, and construct validity were examined. Questionnaire and demographic data were analyzed using numbers, percentages, dependent and independent groups t-tests, correlation analysis.

RESULTS

The AAMQ-13-TR has a Cronbach's alpha (α) score of 0.90 (p < 0.001). It has a split-half reliability coefficient of 0.86. The confirmatory factor analysis (CFA) shows that the factor structure of the AAMQ-13-TR agrees well with the two-factor model of the original questionnaire.

CONCLUSIONS

This study presented sources of evidence of validity of AAMQ-13-TR in Turkish population.

A Fully Decentralized Randomized Controlled Study of As-Needed Albuterol-Budesonide Fixed-Dose Inhaler in Mild Asthma: The BATURA Study Design

Purpose

Decentralized clinical trials, where trial-related activities occur at locations other than traditional clinical sites(eg participant homes, local healthcare facilities), have the potential to improve trial access for people for whom time and/or distance constraints may impede participation. Albuterol-budesonide 180/160 µg pressurized metered-dose inhaler (pMDI) is FDA approved for the as-needed treatment or prevention of bronchoconstriction and to reduce the risk of exacerbations in patients with asthma 18 years or older. BATURA (NCT05505734) is a fully decentralized study, investigating as-needed albuterol-budesonide in participants with mild asthma.

Methods

BATURA is a fully decentralized, phase 3b, randomized, double-blind, event-driven exacerbation study conducted in the United States. Participants aged ≥12 years using as-needed short-acting β2-agonist (SABA), alone or with low-dose inhaled corticosteroid or leukotriene receptor antagonist maintenance, are randomized 1:1 to as-needed albuterol-budesonide 180/160 µg or albuterol 180 µg pMDI for up to 52 weeks (minimum 12 weeks). Participants continue their current maintenance therapy, if applicable. Participants must have used SABA for ≥2 days in the 2 weeks pre-enrollment and have an Asthma Impairment Risk Questionnaire score ≥2 at screening and randomization. All trial-related visits, including screening and consent, are conducted virtually, with study medication shipped directly to each participant's residence. The primary objective is to evaluate the efficacy of as-needed albuterol-budesonide versus albuterol on severe asthma exacerbation risk, measured by time-to-first severe asthma exacerbation (primary endpoint). Secondary endpoints include annualized rate of severe asthma exacerbation and total systemic corticosteroid exposure. Study medication use is captured via a Hailie sensor attached to the study medication pMDI. The intended sample size is 2500 participants.

Conclusion

BATURA evaluates as-needed albuterol-budesonide in participants with mild asthma. The decentralized study model enables the trial to move out of research sites into participant homes, reducing participant burden and improving access.

Digital Self-Management Platform for Adult Asthma: Randomized Attention-Placebo Controlled Trial

BACKGROUND

Asthma is one of the most common chronic conditions worldwide, with a substantial individual and health care burden. Digital apps hold promise as a highly accessible, low-cost method of enhancing self-management in asthma, which is critical to effective asthma control.

OBJECTIVE

We conducted a fully remote randomized controlled trial (RCT) to assess the efficacy of juli, a commercially available smartphone self-management platform for asthma.

METHODS

We conducted a pragmatic single-blind, RCT of juli for asthma management. Our study included participants aged 18 years and older who self-identified as having asthma and had an Asthma Control Test (ACT) score of 19 or lower (indicating uncontrolled asthma) at the beginning of the trial. Participants were randomized (1:1 ratio) to receive juli for 8 weeks or a limited attention-placebo control version of the app. The primary outcome measure was the difference in ACT scores after 8 weeks. Secondary outcomes included remission (ACT score greater than 19), minimal clinically important difference (an improvement of 3 or more points on the ACT), worsening of asthma, and health-related quality of life. The primary analysis included participants using the app for 8 weeks (per-protocol analysis), and the secondary analysis used a modified intention-to-treat (ITT) analysis.

RESULTS

We randomized 411 participants between May 2021 and April 2023: a total of 152 (37%) participants engaged with the app for 8 weeks and were included in the per-protocol analysis, and 262 (63.7%) participants completed the week-2 outcome assessment and were included in the modified ITT analysis. Total attrition between baseline and week 8 was 259 (63%) individuals. In the per-protocol analysis, the intervention group had a higher mean ACT score (17.93, SD 4.72) than the control group (16.24, SD 5.78) by week 8 (baseline adjusted coefficient 1.91, 95% CI 0.31-3.51; P=.02). Participants using juli had greater odds of achieving or exceeding the minimal clinically important difference at 8 weeks (adjusted odds ratio 2.38, 95% CI 1.20-4.70; P=.01). There were no between group differences in the other secondary outcomes at 8 weeks. The results from the modified ITT analyses were similar.

CONCLUSIONS

Users of juli had improved asthma symptom control over 8 weeks compared with users of a version of the app with limited functionality. These findings suggest that juli is an effective digital self-management platform that could augment existing care pathways for asthma. The retention of patients in RCTs and real-world use of digital health care apps is a major challenge.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number (ISRCTN) registry ISRCTN87679686; https://www.isrctn.com/ISRCTN87679686.

Documentation of comorbidities, lifestyle factors, and asthma management during primary care scheduled asthma contacts

Systematically assessing asthma during follow-up contacts is important to accomplish comprehensive treatment. No previous long-term studies exist on how comorbidities, lifestyle factors, and asthma management details are documented in scheduled asthma contacts in primary health care (PHC). We showed comorbidities and lifestyle factors were poorly documented in PHC in this real-life, 12-year, follow-up study. Documented information on rhinitis was found in 8.9% and BMI, overweight, or obesity in ≤1.5% of the 542 scheduled asthma contacts. Of the 145 patients with scheduled asthma contacts, 6.9% had undergone revision of their inhalation technique; 16.6% had documentation of their asthma action plan. Screening of respiratory symptoms was recorded in 79% but nasal symptoms in only 15.5% of contacts. Lifestyle guidance interventions were found in <1% of contacts. These results, based on documented patient data, indicate a need exists to further improve the assessment and guidance of asthma patients in PHC.

Asthma and COPD: A Focus on β-Agonists - Past, Present and Future

Asthma has been recognised as a respiratory disorder for millennia and the focus of targeted drug development for the last 120 years. Asthma is one of the most common chronic non-communicable diseases worldwide. Chronic obstructive pulmonary disease (COPD), a leading cause of morbidity and mortality worldwide, is caused by exposure to tobacco smoke and other noxious particles and exerts a substantial economic and social burden. This chapter reviews the development of the treatments of asthma and COPD particularly focussing on the β-agonists, from the isolation of adrenaline, through the development of generations of short- and long-acting β-agonists. It reviews asthma death epidemics, considers the intrinsic efficacy of clinical compounds, and charts the improvement in selectivity and duration of action that has led to our current medications. Important β2-agonist compounds no longer used are considered, including some with additional properties, and how the different pharmacological properties of current β2-agonists underpin their different places in treatment guidelines. Finally, it concludes with a look forward to future developments that could improve the β-agonists still further, including extending their availability to areas of the world with less readily accessible healthcare.

Cytotoxic CD4+ tissue-resident memory T cells are associated with asthma severity

BACKGROUND

Patients with severe uncontrolled asthma represent a distinct endotype with persistent airway inflammation and remodeling that is refractory to corticosteroid treatment. CD4+ TH2 cells play a central role in orchestrating asthma pathogenesis, and biologic therapies targeting their cytokine pathways have had promising outcomes. However, not all patients respond well to such treatment, and their effects are not always durable nor reverse airway remodeling. This observation raises the possibility that other CD4+ T cell subsets and their effector molecules may drive airway inflammation and remodeling.

METHODS

We performed single-cell transcriptome analysis of >50,000 airway CD4+ T cells isolated from bronchoalveolar lavage samples from 30 patients with mild and severe asthma.

FINDINGS

We observed striking heterogeneity in the nature of CD4+ T cells present in asthmatics' airways, with tissue-resident memory T (TRM) cells making a dominant contribution. Notably, in severe asthmatics, a subset of CD4+ TRM cells (CD103-expressing) was significantly increased, comprising nearly 65% of all CD4+ T cells in the airways of male patients with severe asthma when compared to mild asthma (13%). This subset was enriched for transcripts linked to T cell receptor activation (HLA-DRB1, HLA-DPA1) and cytotoxicity (GZMB, GZMA) and, following stimulation, expressed high levels of transcripts encoding for pro-inflammatory non-TH2 cytokines (CCL3, CCL4, CCL5, TNF, LIGHT) that could fuel persistent airway inflammation and remodeling.

CONCLUSIONS

Our findings indicate the need to look beyond the traditional T2 model of severe asthma to better understand the heterogeneity of this disease.

FUNDING

This research was funded by the NIH.

Management of comorbidities in difficult and severe asthma

Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.

Inhaled drug delivery for the targeted treatment of asthma

Asthma is a chronic lung disease affecting millions worldwide. While classically acknowledged to result from allergen-driven type 2 inflammatory responses leading to IgE and cytokine production and the influx of immune cells such as mast cells and eosinophils, the wide range in asthmatic pathobiological subtypes lead to highly variable responses to anti-inflammatory therapies. Thus, there is a need to develop patient-specific therapies capable of addressing the full spectrum of asthmatic lung disease. Moreover, delivery of targeted treatments for asthma directly to the lung may help to maximize therapeutic benefit, but challenges remain in design of effective formulations for the inhaled route. In this review, we discuss the current understanding of asthmatic disease progression as well as genetic and epigenetic disease modifiers associated with asthma severity and exacerbation of disease. We also overview the limitations of clinically available treatments for asthma and discuss pre-clinical models of asthma used to evaluate new therapies. Based on the shortcomings of existing treatments, we highlight recent advances and new approaches to treat asthma via inhalation for monoclonal antibody delivery, mucolytic therapy to target airway mucus hypersecretion and gene therapies to address underlying drivers of disease. Finally, we conclude with discussion on the prospects for an inhaled vaccine to prevent asthma.

Male-biased association of endothelial nitric oxide synthase Asp298Glu substitution (NOS3-c.894G/T) with asthma risk and severity

OBJECTIVE

The nitric-oxide pathway plays a crucial role in the pathogeneses of asthma and NOS3-encoded endothelial nitric oxide synthase is one of the main components of the pathway. Variants of NOS3 are known to contribute to asthma development and pathophysiology.

METHODS

We investigated the association of NOS3-c.894G/T (rs1799983) with asthma risk and severity by studying frequencies of its genotypes and alleles in 555 asthmatics (93 intermittent, 240 mild, 158 moderate, and 64 severe asthma cases) and 351 control participants using the PCR-FRLP method, logistic regression analysis and generalized ordered logit estimates.

RESULTS

GT genotype (OR_adj: 1.39; CI: 1.04-1.85; p = 0.026), dominant model GT + TT (OR_adj: 1.41; CI: 1.07-1.87; p = 0.015), and T allele (OR_adj: 1.32; CI: 1.05-1.67; p = 0.018) was associated with increased ORs in asthmatics. Also, the frequency of GT + TT (OR_adj: 1.55; CI: 1.01-2.38; p = 0.044) was significantly higher in males. Furthermore, GT genotype (OR_adj: 1.39; CI: 1.04-1.85; p = 0.024), GT + TT (OR_adj: 1.42; CI: 1.07-1.87; p = 0.014), and T allele (OR_adj: 1.32; CI: 1.05-1.66; p = 0.018) in total population and GT + TT (OR_adj: 1.56; CI: 1.02-2.37; p = 0.04) in males were significantly associated with increased risk of severe, moderate, mild, intermittent asthma vs. controls. Also, GT genotype (OR_adj: 1.39; CI: 1.02-1.91; p = 0.039) was significantly more frequent in severe, moderate grades vs. lower severity grades in the total population. Frequencies of GT genotype (OR_adj: 1.77; CI: 1.05-3.00; p = 0.032) and GT + TT (OR_adj: 1.74; CI: 1.04-2.90; p = 0.036) in total population and GT genotype (OR_adj: 2.40; CI: 1.16-4.97; p = 0.018) and GT + TT (OR_adj: 2.30; CI: 1.12-4.74; p = 0.023) in male subpopulation were significantly higher in severe cases compared to lower grades.

CONCLUSIONS

NOS3-c.894G/T may be associated with asthma risk and its severer grades, with greater effects in men.

Pharmacometabolomics of Asthma as a Road Map to Precision Medicine

Pharmacometabolomics applies the principles of metabolomics to therapeutics in order to elucidate the biological mechanisms underlying the variation in responses to drugs between groups and individuals. Asthma is associated with broad systemic effects and heterogeneity in treatment response and as such is ideally suited to pharmacometabolomics. In this chapter, we discuss the state of the emerging field of asthma pharmacometabolomics, with a particular focus on studies of steroids, bronchodilators, and leukotriene inhibitors. We also consider those studies concerned with subtyping cases to better understand the pharmacology of those groups and those looking to leverage pharmacometabolomics for asthma prevention. We finish with a discussion of the challenges and opportunities of asthma pharmacometabolomics and reflect upon where this field must go next in order to realize its precision medicine potential.

Hospitalization Pattern for Chronic Lower Respiratory Diseases in Australia: A Retrospective Ecological Study

BACKGROUND

Chronic lower respiratory diseases are among the commonest causes of hospital admission worldwide. Identifying the trends in hospital admission due to chronic lower respiratory diseases is important for public health and policy makers.

AIM

The aim of this study was to examine the hospitalization profile related to chronic lower respiratory diseases in Australia during the past 21 years.

METHOD

A retrospective ecological study was conducted using hospital admission data taken from the National Hospital Morbidity Database (NHMD). Hospital admissions data for chronic lower respiratory diseases were extracted for the period between 1998 and 2019. The Pearson Chi-square test for independence was used to estimate the variation in hospital admission rates.

RESULTS

The hospitalization rate for chronic lower respiratory diseases rate decreased by 14.4%, from 568.90 (95%CI 565.50-572.30) in 1998 to 486.95 (95%CI 484.24-489.66) in 2019 per 100,000 persons, p<0.05. Rates of same-day hospitalization for chronic lower respiratory diseases increased by 62.7% from 1998 to 2019, while rates of overnight-stay hospital admission for chronic lower respiratory diseases decreased by 23.7% from 1998 to 2019. During the study duration, the hospitalization rates for bronchiectasis and other chronic obstructive pulmonary disease increased by 120.0% and 34.7%, respectively. The hospital admissions rates for emphysema, status asthmaticus, simple and mucopurulent chronic bronchitis, bronchitis, not specified as acute or chronic, unspecified chronic bronchitis, and asthma decreased by 94.8%, 92.6%, 70.7%, 66.3%, 46.0%, and 32.3%, respectively. The rates of hospitalization among patients aged 75 years and above increased by 3.9%, while younger age groups including those aged younger than 15 years, 15-59 years, and 60-74 years showed a reduction in the rate of hospitalization by 53%, 22.8%, and 19.7%, respectively.

CONCLUSION

Overall, the hospitalization rate for chronic lower respiratory diseases is seen to have decreased over the study period. Patients with chronic obstructive pulmonary disease (COPD) and the elderly group have a higher rate of hospitalization. Future studies are needed to investigate factors associated with the increase in the rate of hospitalization among the elderly age group.

Suboptimal Control of Asthma Among Diverse Patients: A US Mixed Methods Focus Group Study

Purpose

The US National Asthma Education and Prevention Program updates and Global Initiative for Asthma report encourage considering the patient perspective to improve asthma control. The objective of the present study was to collect data about the perceptions, experiences, and concerns of adult patients and caregivers of children with asthma regarding rescue, maintenance, and oral corticosteroid treatments.

Patients and Methods

In-person focus groups were conducted in three cities across the US. Participants also completed patient-reported outcome measures assessing asthma control and experiences.

Results

Focus groups were conducted in demographically and clinically diverse adults with asthma (five groups, n=34), caregivers of children with asthma (five groups, n=35), and adults with a dual diagnosis of asthma and chronic obstructive pulmonary disease (one group, n=5). Only 28% of patients were well-controlled by Asthma Control Test/Asthma Control Test-Caregiver Report and 18% by Asthma Impairment and Risk Questionnaire. Forty-four percent of participants reported not following their prescribed medical plan. Four key themes emerged from the focus groups: (1) asthma symptom control and monitoring are often inadequate; (2) treatments are often used incorrectly; (3) communication between health care professionals and patients or caregivers is often ineffective; and (4) concerns related to treatment and desires to improve treatment.

Conclusion

Control of asthma symptoms is suboptimal in the vast majority of patients and both patients and caregivers do not feel sufficiently informed about asthma. Health care providers should be encouraged to engage patients and caregivers in shared decision making for managing asthma and selecting treatments that integrate patient values, preferences, and lifestyles.

Study on Allopathic and Alternative Treatments of Asthma and Factors Influencing Treatment Choices

Materials and Methods

The cross-sectional survey was conducted; primary data were collected from asthmatic patients in different hospitals and clinics of allopathic, homeopathic, and herbal practitioners in Karachi, Pakistan. The study duration was from January 2020 to December 2020. Asthmatic patients aged over 13 years were selected for the study. A written informed consent was taken from the patients before the interview. Collected data were analyzed by the Statistical Package of Social Sciences (SPSS) 22.

Result

Among 255 asthmatic patients; 51.4% (n = 131) were male and 48.6% (n = 124) were female. For control of acute attacks of asthma 88.2% (p = 0.0001) of patients significantly preferred allopathic treatment while 6.3% (p = 0.008) used homeopathic treatment and 5.5% chose herbal treatment. For maintenance of asthma, 78.8% (p = 0.0001) patients used allopathic treatment while 12.4% (p = 0.0001) homeopathic and 8.8% (p = 0.0001) patients used herbal treatment. About 63.4% (p = 0.0001) of the asthmatic patients used short-acting β-2 agonists for managing acute asthmatic episodes while long-acting β-2 agonists (p = 0.0001) and inhaled corticosteroids (p = 0.0001) were found to be the preferred medicines for maintenance therapy. Effectiveness of treatment (p = 0.004) and cost effectiveness (p = 0.0001) significantly act as contributing factors for the selection of the treatment. The majority of the patients were satisfied with their chosen treatments for control of asthmatic symptoms.

Conclusion

Most asthmatic patients preferred allopathic treatment for the management of acute episodes and control of asthmatic symptoms. It was found that the major factors for selecting a specific treatment include effectiveness, cost, and minimal side effects.

Stressed out - The role of oxidative stress in airway smooth muscle dysfunction in asthma and COPD

The airway smooth muscle (ASM) surrounding the airways is dysfunctional in both asthma and chronic obstructive pulmonary disease (COPD), exhibiting; increased contraction, increased mass, increased inflammatory mediator release and decreased corticosteroid responsiveness. Due to this dysfunction, ASM is a key contributor to symptoms in patients that remain symptomatic despite optimal provision of currently available treatments. There is a significant body of research investigating the effects of oxidative stress/ROS on ASM behaviour, falling into the following categories; cigarette smoke and associated compounds, air pollutants, aero-allergens, asthma and COPD relevant mediators, and the anti-oxidant Nrf2/HO-1 signalling pathway. However, despite a number of recent reviews addressing the role of oxidative stress/ROS in asthma and COPD, the potential contribution of oxidative stress/ROS-related ASM dysfunction to asthma and COPD pathophysiology has not been comprehensively reviewed. We provide a thorough review of studies that have used primary airway, bronchial or tracheal smooth muscle cells to investigate the role of oxidative stress/ROS in ASM dysfunction and consider how they could contribute to the pathophysiology of asthma and COPD. We summarise the current state of play with regards to clinical trials/development of agents targeting oxidative stress and associated limitations, and the adverse effects of oxidative stress on the efficacy of current therapies, with reference to ASM related studies where appropriate. We also identify limitations in the current knowledge of the role of oxidative stress/ROS in ASM dysfunction and identify areas for future research.

Dapagliflozin mitigates ovalbumin-prompted airway inflammatory-oxidative successions and associated bronchospasm in a rat model of allergic asthma

BACKGROUND

Asthma is a chronic inflammatory lung disease that universally affects millions of people. Despite numerous well-defined medications, asthma is poorly managed. The study aimed to clarify the potential therapeutic effect of Dapagliflozin (DAPA) against lung inflammation, oxidative stress and associated bronchospasm in OVA-sensitized rat asthma model.

RESEARCH DESIGN AND METHODS

Twenty-five rats were allocated into (Control, Asthma, DEXA, DAPA, and DAPA+DEXA). All treatments were administered orally once a day for two weeks. BALF levels of IL-17, TNFα, IL-1β, and MCP-1 were determined to assess airway inflammation. For oxidative stress determination, BALF MDA levels and TAC were measured. The BALF S100A4 level and NO/sGC/cGMP pathway were detected. Lung histopathological findings and immunohistochemical investigation of eNOS and iNOS activities were recorded.

RESULTS

DAPA significantly reduced (p < 0.001) airway inflammatory-oxidative markers (IL-17, TNFα, IL-1β, MCP1, and MDA), but increased (p < 0.001) TAC, and mitigated bronchospasm by activating NO/sGC/cGMP and reducing S100A4 (p < 0.001). The biochemical and western blot studies were supported by histopathological and immunohistochemical investigations.

CONCLUSIONS

: DAPA is presenting a new prospective possibility for future asthma therapy due to its anti-inflammatory, anti-oxidant, and bronchodilator properties. DAPA has the property of reducing Dexamethasone (DEXA)-associated unfavorable effects during asthma treatment.

Challenges and recommendations for the management of asthma in the Middle East and Africa

Clinical presentation of asthma is variable, and its diagnosis can be a major challenge in routine health-care practice, especially in low-and-middle-income countries. The aim of asthma management is to achieve optimal asthma control and to reduce the risk of asthma exacerbations and mortality. In the Middle East and in Africa (MEA), several patient- and physician-related factors lead to misdiagnosis and suboptimal management of asthma. A panel of experts comprising of specialists as well as general health-care professionals met to identify challenges and provide recommendations for the management of asthma in MEA. The major challenges identified for diagnosis of asthma were lack of adequate knowledge about the disease, lack of specialized diagnostic facilities, limited access to spirometry, and social stigma associated with asthma. The prime challenges for management of asthma in MEA were identified as overreliance on short-acting β-agonists (SABAs), underprescription of inhaled corticosteroids (ICS), nonadherence to prescribed medications, and inadequate insurance coverage for its treatment. The experts endorsed adapting the Global Initiative for Asthma guidelines at country and regional levels for effective management of asthma and to alleviate the overuse of SABAs as reliever medications. Stringent control over SABA use, discouraging over-the-counter availability of SABA, and using as-needed low-dose ICS and formoterol as rescue medications in mild cases were suggested to reduce the overreliance on SABAs. Encouraging SABA alone-free clinical practice in both outpatient and emergency department settings is also imperative. We present the recommendations for the management of asthma along with proposed regional adaptations of international guidelines for MEA.

Participation in scheduled asthma follow-up contacts and adherence to treatment during 12-year follow-up in patients with adult-onset asthma

Background

Poor treatment compliance is a common problem in the treatment of asthma. To our knowledge, no previous long-term follow-up studies exist on how scheduled asthma follow-up contacts occur in primary health care (PHC) versus secondary care and how these contacts relate to adherence to medication and in participation to further scheduled asthma contacts. The aim of this study was to evaluate occurrence of scheduled asthma contacts and treatment compliance in PHC versus secondary care, and to identify the factors associated with non-participation to scheduled contacts.

Methods

Patients with new adult-onset asthma (n = 203) were followed for 12 years in a real-life asthma cohort of the Seinäjoki Adult Asthma Study (SAAS). The first contacts were mainly carried out in secondary care and therefore the actual follow-up time including PHC visits was 10 years.

Results

A majority (71%) of the patients had ≥ 2 scheduled asthma contacts during 10-year follow-up and most of them (79%) mainly in PHC. Patients with follow-up contacts mainly in PHC had better adherence to inhaled corticosteroid (ICS) medication during the whole 12-year period compared to patients in secondary care. In the study population, 29% of the patients had only 0–1 scheduled asthma contacts during the follow-up. Heavy alcohol consumption predicted poor participation in scheduled contacts.

Conclusions

Patients with mainly PHC scheduled asthma contacts were more adherent to ICS medication than patients in the secondary care. Based on our results it is necessary to pay more attention to actualization of asthma follow-up visits and systematic assessment of asthma patients including evaluation of alcohol consumption.

Trial registration Seinäjoki Adult Asthma Study is retrospectively registered at www.ClinicalTrials.gov with identifier number NCT02733016. Registered 11 April 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01850-1.

Efficacy and safety of as-needed albuterol/budesonide versus albuterol in adults and children aged ≥4 years with moderate-to-severe asthma: rationale and design of the randomised, double-blind, active-controlled MANDALA study

Introduction

Uncontrolled asthma is associated with substantial morbidity. While fast-acting bronchodilators provide quick relief from asthma symptoms, their use as rescue fails to address the underlying inflammation. Combining a short-acting beta₂-agonist, such as albuterol (salbutamol), with an inhaled corticosteroid, such as budesonide, in a single inhaler as rescue therapy could help control both bronchoconstriction and inflammation, and reduce the risk of asthma exacerbations.

Methods and analysis

The Phase 3 MANDALA study was designed to determine the efficacy of albuterol in combination with budesonide (albuterol/budesonide 180/160 µg or 180/80 µg, two actuations of 90/80 µg or 90/40 µg, respectively) versus albuterol (180 µg, two actuations of 90 µg) as rescue therapy in adult, adolescent and paediatric patients with moderate-to-severe asthma. This event-driven study enrolled symptomatic patients (3000 adults/adolescents and 100 children aged 4–11 years) who experienced ≥1 severe asthma exacerbation in the previous year and were receiving maintenance therapy for ≥3 months prior to study entry. The primary efficacy endpoint was time-to-first severe asthma exacerbation.

Ethics and dissemination

The study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki, and that are consistent with International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use and Good Clinical Practice and the applicable regulatory requirements.

Trial registration

NCT03769090.

Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries

BACKGROUND

Inhaled therapies are key components of asthma and chronic obstructive pulmonary disease (COPD) treatments. Although the use of pressurised metered-dose inhalers (pMDIs) accounts for <0.1% of global greenhouse gas emissions, their contribution to global warming has been debated and efforts are underway to reduce the carbon footprint of pMDIs. Our aim was to establish the extent to which different scenarios led to reductions in greenhouse gas emissions associated with inhaler use, and their clinical implications.

METHODS

We conducted a series of scenario analyses using asthma and COPD inhaler usage data from 2019 to model carbon dioxide equivalent (CO2e) emissions reductions over a 10-year period (2020-2030) in the UK, Italy, France, Germany and Spain: switching propellant-driven pMDIs for propellant-free dry-powder inhalers (DPIs)/soft mist inhalers (SMIs); transitioning to low global warming potential (GWP) propellant (hydrofluoroalkane (HFA)-152a) pMDIs; reducing short-acting β2-agonist (SABA) use; and inhaler recycling.

RESULTS

Transition to low-GWP pMDIs and forced switching to DPI/SMIs (excluding SABA inhalers) would reduce annual CO2e emissions by 68%-84% and 64%-71%, respectively, but with different clinical implications. Emission reductions would be greatest (82%-89%) with transition of both maintenance and SABA inhalers to low-GWP propellant. Only minimising SABA inhaler use would reduce CO2e emissions by 17%-48%. Although significant greenhouse gas emission reductions would be achieved with high rates of end-of-life recycling (81%-87% of the inhalers), transition to a low-GWP propellant would still result in greater reductions.

CONCLUSIONS

While the absolute contribution of pMDIs to global warming is very small, substantial reductions in the carbon footprint of pMDIs can be achieved with transition to low-GWP propellant (HFA-152a) inhalers. This approach outperforms the substitution of pMDIs with DPI/SMIs while preserving patient access and choice, which are essential for optimising treatment and outcomes. These findings require confirmation in independent studies.

Improving the risk-to-benefit ratio of inhaled corticosteroids through delivery and dose: current progress and future directions

INTRODUCTION

Inhaled corticosteroids (ICS) are known to increase the risk of systemic and local adverse effects, especially with high doses and long-term use. Hence, considerable resources are invested to improve pharmacokinetic/pharmacodynamic (PK/PD) properties of ICS, effective delivery systems and novel combination therapies to enhance the risk-to-benefit ratio of ICS.

AREAS COVERED

There is an unmet need for new solutions to achieve optimal clinical outcomes with minimal dose of ICS. This paper gives an overview of novel treatment strategies regarding the safety of ICS therapy on the basis of the three most recent molecules introduced to our everyday clinical practice - ciclesonide, mometasone furoate, and fluticasone furoate. Advances in aerosol devices and new areas of inhalation therapy are also discussed.

EXPERT OPINION

Current progress in improving the risk-to-benefit ratio of ICS through dose and delivery probably established pathways for further developments. This applies both to the improvement of the PK/PD properties of ICS molecules but also includes technical aspects that lead to simplified applicability of the device with simultaneous optimal drug deposition in the lungs. Indubitably, the future of medicine lies not only in the development of new molecules but also in technology and digital revolution.

Inhibition of the Inflammasome Activity of NLRP3 Attenuates HDM-Induced Allergic Asthma

Inhaled allergens promote inflammatory response, tissue damage, and airway hyperresponsiveness in the lungs, leading to allergic asthma. NLRP3, as an immune sensor of infections and cellular stress, is associated with the development and exacerbation of asthma. However, the mechanism by which NLRP3 affects asthma requires further investigation. Here, we showed that inhaled house dust mite (HDM) promotes NLRP3 inflammasome activation in the lungs and specifically induces the maturation of caspase-1 and IL-1β in alveolar macrophages (AMs). Using Nlrp3-mutant mice, we found that NLRP3 promotes the inflammatory response and pathogenesis in HDM-induced allergic asthma in an inflammasome-dependent manner. Treatment with RRx-001, an NLRP3 inhibitor, significantly reduced inflammatory cell infiltration and mucus secretion in the airway. Our results showed that NLRP3 in myeloid cells promoted the development and progression of allergic asthma in an inflammasome-dependent manner. Small molecules targeting the NLRP3 inflammasome may provide new treatment options for this disease.

Indacaterol/Glycopyrronium/Mometasone: A Review in Asthma

Indacaterol/glycopyrronium/mometasone (Enerzair^® Breezhaler^®) is a fixed-dose combination of the long-acting β₂ agonist (LABA) indacaterol, the long-acting muscarinic antagonist (LAMA) glycopyrronium and the inhaled corticosteroid (ICS) mometasone furoate (hereafter referred to as mometasone) delivered via a capsule-based dry-powder inhaler. It is approved in the EU for use as maintenance treatment in adult patients with inadequately controlled asthma who had experienced one or more exacerbations in the previous year. The approval also includes an optional digital companion (sensor and app) that provides data on the patient's use of the inhaler. In the 52-week IRIDIUM trial in patients with inadequately controlled asthma, indacaterol/glycopyrronium/mometasone improved lung function to a greater extent than LABA/ICS combinations (i.e. indacaterol/mometasone and fluticasone propionate/salmeterol), but superiority in Asthma Control Questionnaire 7 score was not shown. In the 24-week ARGON trial, indacaterol/glycopyrronium/mometasone via a single inhaler was non-inferior to fluticasone propionate/salmeterol + tiotropium via two inhalers with regard to Asthma Quality of Life Questionnaire score. Indacaterol/glycopyrronium/mometasone was generally well tolerated, and the most common adverse events were respiratory in nature. In conclusion, combination therapy with indacaterol/glycopyrronium/mometasone represents a valuable option for the maintenance treatment of asthma, with the convenience of once-daily administration via a single inhaler.

The Care of Asthma Patients in Communities with Limited Resources

Asthma care has undergone significant changes over the past several years. Our understanding of the pathophysiology, risk factors, diagnosis, treatment, follow-up and prognosis has changed as more investigations shed new light on all of these aspects. This complexity has resulted in global guidelines aimed at improving the management of asthma patients. Among the multitude of guidelines, those published by the Global Initiative for Asthma (GINA) have achieved widespread and global acceptance. These guidelines cover the spectrum of factors that impact asthma care and include specific recommendations that treating physicians should follow to provide optimal patient care. In this review of asthma care in adult patients, we will outline some of the recommendations issued by GINA and discuss the challenges and limitations to the implementation of these guidelines in communities with limited resources. We will also propose recommendations to overcome these limitations in adult patients.

Syringin alleviates ovalbumin-induced lung inflammation in BALB/c mice asthma model via NF-κB signaling pathway

Asthma is an allergic chronic inflammatory disease of the pulmonary airways, characterized by the infiltration of white blood cells and release of inflammatory cytokines of complex pathways linked to its pathogenesis. Syringin extracted from various medicinal plants has been used extensively for the treatment of inflammatory diseases. Hence, this study was conducted to further explore the protective effects of the syringin in ovalbumin (OVA) induced-asthma mice model. OVA-sensitized BALB mice were treated intraperitonealy with three doses (25, 50 and 100 mg/kg) of the syringin which was validated by the alteration in the immunoglobulin E (IgE) levels, cytokines levels, histopathological evaluation inflammatory cell count, lung weight, nitrite (NO) levels, oxidative stress biomarkers and gene markers. The treatment of syringin intensely reduced the increased IgE, inflammatory cytokines, WBC count and restored the antioxidant stress markers OVA stimulated animals. In addition, a significant reduction in inflammation and mucus production was evidenced in histopathological analysis which was further validated by suppression NF-κB pathway activation by syringin. These results suggest that syringin may improve asthma symptoms in OVA-induced mice by modulating NF-κB pathway activation.

The Myth of Mild: Severe Exacerbations in Mild Asthma: An Underappreciated, but Preventable Problem

Asthma is a common, chronic inflammatory airway disease, characterised by unpredictable episodes of worsening symptoms, or exacerbations. Causes of asthma exacerbations include viral infections, exposure to allergen and air pollution, all of which increase the underlying inflammation that typifies asthma. Most (50-75%) patients are classed as having mild asthma, with symptoms that can be readily controlled with available inhaled medications. Paradoxically, for the past 30 years, the first treatment recommended in asthma management guidelines was short-acting β2-agonists (SABA), which not only have no anti-inflammatory properties but may, in fact, worsen inflammation. The Global Initiative for Asthma (GINA) 2019/2020 broke with this paradox by stating clearly that SABA should no longer be used alone as a reliever, for safety reasons. Instead, GINA now recommends an anti-inflammatory rescue/reliever approach for adult and adolescent patients, based on the combination of an inhaled corticosteroid with a rapid onset β2-agonist such as formoterol. This commentary highlights the fact that even patients with well-controlled mild asthma are at risk of severe, potentially life-threatening exacerbations, similar to those in patients with moderate or severe asthma, and therefore 'mild asthma', is a misnomer. The commentary describes the case history of a patient with mild asthma to illustrate how increasing use of SABA alone can worsen and prolong exacerbations when they occur. The author goes on to describe how the management of this patient's exacerbation could have been improved, and provides up-to-date advice on broader aspects of the management of mild asthma and exacerbations, supported by the recent changes to the GINA recommendations.

The Therapeutic Effect of Extracellular Vesicles on Asthma in Pre-Clinical Models: A Systematic Review Protocol

Asthma is the most common pediatric disease, characterized by chronic airway inflammation and airway hyperresponsiveness. There are several management options for asthma, but no specific treatment. Extracellular vesicles (EVs) are powerful cellular mediators of endocrine, autocrine and paracrine signalling, and can modulate biophysiological function in vitro and in vivo. A thorough investigation of therapeutic effects of EVs in asthma has not been conducted. Therefore, this systematic review is designed to synthesize recent literature on the therapeutic effects of EVs on physiological and biological outcomes of asthma in pre-clinical studies. An electronic search of Web of Science, EMBASE, MEDLINE, and Scopus will be conducted on manuscripts published in the last five years that adhere to standardized guidelines for EV research. Grey literature will also be included. Two reviewers will independently screen the selected studies for title and abstract, and full text based on the eligibility criteria. Data will be extracted, narratively synthesized and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This systematic review will summarize the current knowledge from preclinical studies investigating the therapeutic effects of EVs on asthma. The results will delineate whether EVs can mitigate biological hallmarks of asthma, and if so, describe the underlying mechanisms involved in the process. This insight is crucial for identifying key pathways that can be targeted to alleviate the burden of asthma. The data will also reveal the origin, dosage and biophysical characteristics of beneficial EVs. Overall, our results will provide a scaffold for future intervention and translational studies on asthma treatment.