Inhaled corticosteroids: impact on asthma morbidity and mortality

Use of Technology to Improve Adherence in Allergy/Immunology

The integration of technology into health care has shown significant promise in enhancing patient adherence, particularly in the field of allergy/immunology. This article explores the multifaceted approaches through which digital health interventions can be used to improve adherence rates among patients with allergic diseases and immunologic disorders. By reviewing recent advancements in telemedicine, mobile health applications, wearable devices, and digital reminders, as well as smart inhalers, we aim to provide a comprehensive overview of how these technologies can support patients in managing their conditions. The analysis highlights the role of personalized digital health plans, which, through the use of artificial intelligence and machine learning algorithms, can offer tailored advice, monitor symptoms, and adjust treatment protocols in real time. Moreover, the article discusses the impact of electronic health records and patient portals in fostering a collaborative patient-provider relationship, thereby enhancing communication and adherence. The integration of these technologies has been shown to not only improve clinical outcomes but also increase patient satisfaction and engagement.

Participant Perspectives on the Implementation of a School-Linked Text-Message Intervention to Improve Pediatric Asthma Medication Adherence

Background: Poor adherence to inhaled corticosteroids (ICS) is a significant challenge in pediatric asthma, contributing to health inequities. Text-message reminders for ICS therapy are an evidence-based approach that improves pediatric asthma medication adherence, yet has not been widely adopted into practice, partly due to lack of (1) participant input on design and implementation and (2) use of sustainable community linkages. Remote Asthma Link™ (RAL) seeks to fill this gap as a school-linked text-message intervention wherein parents of children with poorly controlled asthma received daily, 2-way text-message reminders for preventive inhaler use. Responses were shared with school nurses who conducted remote check-ins with families. Enrolled children, largely from underserved backgrounds, experienced improvements in medication adherence and asthma health outcomes. While initial results were promising, we have yet to elicit participant input to refine the protocol for more widespread implementation. Objective: Examine participant perspectives on barriers and facilitators of RAL implementation. Methods: Semistructured interviews were conducted May-June 2022 with intervention participants: 10 parents, 7 school nurses, and 4 pediatric providers (n = 21) until thematic saturation was reached. Interview transcripts were coded using thematic analysis. Results: Several facilitators for RAL implementation were identified, including ease of use and accessibility, personal connection to the school nurse, and receipt of a visual notification for habit formation. Barriers included challenges with school nurses reaching parents, poor understanding of program expectations, and lack of reimbursement structure. Participant-proposed solutions to barriers included utilizing alternate communication methods (eg, social media), educational sessions, and meeting with payors to consider reimbursement models. Conclusion: RAL is a school-linked text-message intervention demonstrating promise in improving outcomes and equity in asthma care. Key implementation facilitators, barriers, and proposed solutions will inform protocol adaptations to promote successful implementation of this and other text-message interventions into clinical practice.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Perception of Illness and Fear of Inhaled Corticosteroid Use among Parents of Children with Asthma

The most prevalent children's chronic disease worldwide is asthma which has notable negative impacts on patients' and parent's quality of life. Daily inhaled corticosteroids (ICS) therapy is a preferred controller choice. This study was conducted on 148 parents of asthmatic children to establish parents' perception of illness and fear of inhaled corticosteroids using B-IPQ and TOPICOP questionnaires. Children were in the majority male (66.9%), older than five years (58.8%), with comorbidities, and family history of atopy. Parents were female, with a mean age of 38, employed, and with a history of some form of corticosteroid use. Most parents were not afraid of ICS usage (71.6%). Unemployed parents and parents who had no medical education had a statistically significantly higher fear of using ICS (p = 0.002, p = 0.03). A child's illness affects the parents' lives and parents who are afraid of using ICS react more emotionally to the child's illness. Better understanding and less concerned about child's disease are parents of children with controlled asthma. The parents' perspective of children's asthma will affect the duration and dose of ICS treatment they will give to their children and directly influence the level of asthma control.

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

Impact of Unmet Social Needs, Scarcity, and Future Discounting on Adherence to Treatment in Children With Asthma: Protocol for a Prospective Cohort Study

BACKGROUND

Asthma is one of the most prevalent chronic diseases of childhood and disproportionately affects children with lower socioeconomic status. Controller medications such as inhaled corticosteroids significantly reduce asthma exacerbations and improve symptoms. However, a large proportion of children still have poor asthma control, in part owing to suboptimal adherence. Financial barriers contribute to hindering adherence, as do behavioral factors related to low income. For example, unmet social needs for food, lodging, and childcare may create stress and worry in parents, negatively influencing medication adherence. These needs are also cognitively taxing and force families to focus on immediate needs, leading to scarcity and heightening future discounting; thus, there is the tendency to attribute greater value to the present than to the future in making decisions.

OBJECTIVE

In this project, we will investigate the relationship between unmet social needs, scarcity, and future discounting as well as their predictive power over time on medication adherence in children with asthma.

METHODS

This 12-month prospective observational cohort study will recruit 200 families of children aged 2 to 17 years at the Asthma Clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary care pediatric hospital in Montreal, Canada. The primary outcome will be adherence to controller medication, measured using the proportion of prescribed days covered during follow-up. Exploratory outcomes will include health care use. The main independent variables will be unmet social needs, scarcity, and future discounting, measured using validated instruments. These variables will be measured at recruitment as well as at 6- and 12-month follow-ups. Covariates will include sociodemographics, disease and treatment characteristics, and parental stress. Primary analysis will compare adherence to controller medication, measured using the proportion of prescribed days covered, between families with versus those without unmet social needs during the study period using multivariate linear regression.

RESULTS

The research activities of this study began in December 2021. Participant enrollment and data collection began in August 2022 and are expected to continue until September 2024.

CONCLUSIONS

This project will allow the documentation of the impact of unmet social needs, scarcity, and future discounting on adherence in children with asthma using robust metrics of adherence and validated measures of scarcity and future discounting. If the relationship between unmet social needs, behavioral factors, and adherence is supported by our findings, this will suggest the potential for novel targets for integrated social care interventions to improve adherence to controller medication and reduce risk across the life course for vulnerable children with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05278000; https://clinicaltrials.gov/ct2/show/NCT05278000.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37318.

A Meta-Analysis on Predictors of Mortality Among Patients Hospitalized for Acute Exacerbation of Asthma

The aim of this meta-analysis is to systematically review published studies and identify clinically important factors predicting mortality among patients hospitalized for acute exacerbation of asthma. This study was a meta-analysis conducted in accordance with the MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. A systematic search was carried out on online databases such as PubMed and EMBASE to identify articles on predictors of mortality among patients hospitalized for acute exacerbation of asthma. The search used keywords such as "asthma," "exacerbation," "mortality," and "factors." A total of six articles met the inclusion criteria and were included in the present meta-analysis. The incidence of short-term mortality among patients hospitalized for acute exacerbation of asthma was 6% (95% CI= 3-9%, I-square=99%) with a range of 0.79% to 18% across the studies. The factors significantly associated with short-term mortality in patients hospitalized for acute exacerbation of asthma including diabetes mellitus (RR=2.02, 95% CI: 1.63-2.52, p-value=0.001), pneumonia (RR=3.71, 95% CI: 3.02-4.56, p-value=0.001), and mechanical ventilation (RR: 29.98, 95% CI: 15.46-58.15, p-value=0.001). The present study found that diabetes mellitus, pneumonia, and the use of mechanical ventilation are independently associated with mortality among patients hospitalized for acute exacerbation of asthma. Healthcare professionals need to understand the comorbidities and risk factors associated with mortality in patients hospitalized for acute exacerbation of asthma in order to identify patients who are at increased risk and provide prompt treatment.

Healthcare resource consumption prior to asthma-related death: a nationwide descriptive study

BACKGROUND

Although asthma mortality declined sharply until the mid-2000s, a stagnation in mortality has been observed over the past decade in different countries.

OBJECTIVE

The objective of this study is to describe healthcare resource consumption for patients who died from asthma in France.

METHOD

This study was conducted using data from the French National Health Data System. Patients who died from asthma between 2013 and 2017 were identified by the ICD10 codes J45 and J46. Health care consumption data were collected. Patients were categorized into four categories according to age: ⩾75, (18-75), (12-18), (0-12). Daily doses of ICS were categorized according to GINA guidelines.

RESULTS

A total of 3829 patients were included. No ICS or an inadequate ICS dose was observed in 43.8%, 50.6%, 48.1%, and 54.0% of patients aged ⩾75, (18-74), (12-18), and (0-12) years, respectively. Dispensation of six or more SABA canisters was observed in 37.2%, 49.0%, and 70.3% of patients aged of ⩾75, (18-75), and (12-18) years, respectively. Omalizumab dispensation rate was very low [1.1% and 2.8% in patients aged ⩾75 and (18-75) years)]. The proportion of patients with a pulmonologist office visit was 13.8% and 14.6% in patients ⩾75 and (18-75) years, respectively. A lung function test was noted in only 18.6%, 28.3%, and 25.9% of patients ⩾75, (18-75) and (12-18) years, respectively.

CONCLUSION

Half of the patients who died from asthma received inadequate ICS doses and only a small proportion had access to biological therapies. Less than 15% were referred to a specialist.

Digital Inhalers and Remote Patient Monitoring for Asthma

Digital inhaler systems, remote patient monitoring, and remote therapeutic monitoring offer great promise as diagnostic tools and therapeutic interventions to improve adherence and inhaler technique for patients with difficult-to-control asthma. In turn, improvements in adherence and inhaler technique may translate into decreasing the need for high side effect treatments such as oral corticosteroids and costly therapies including biologics. Although more clinical trials are needed, studies that use digital inhaler systems to collect objective real-time data on medication-taking behavior via electronic medication monitors and feed this data back to patients on their mobile asthma app, and to health care professionals on the clinician dashboard to counsel patients, show positive outcomes. This article addresses the use of these diagnostic and therapeutic tools in asthma care, how to choose a digital inhaler system, how to teach patients to use the system, strategies for the adoption of these technologies in large health care systems as well as smaller practices, coding and reimbursement, liability concerns, and research gaps.

Asthma management in low and middle income countries: case for change

Asthma is the most common noncommunicable disease in children, and among the most common in adults. The great majority of people with asthma live in low and middle income countries (LMICs), which have disproportionately high asthma-related morbidity and mortality. Essential inhaled medications, particularly those containing inhaled corticosteroids (ICS), are often unavailable or unaffordable, and this explains much of the global burden of preventable asthma morbidity and mortality. Guidelines developed for LMICs are generally based on the outdated assumption that patients with asthma symptoms <1-3 times per week do not need (or benefit from) ICS. Even when ICS are prescribed, many patients manage their asthma with oral or inhaled short-acting β2-agonists (SABA) alone, owing to issues of availability and affordability. A single ICS-formoterol inhaler-based approach to asthma management for all severities of asthma, from mild to severe, starting at diagnosis, might overcome SABA overuse/over-reliance and reduce the burden of symptoms and severe exacerbations. However, ICS-formoterol inhalers are currently very poorly available or unaffordable in LMICs. There is a pressing need for pragmatic clinical trial evidence of the feasibility and cost-effectiveness of this and other strategies to improve asthma care in these countries. The global health inequality in asthma care that deprives so many children, adolescents and adults of healthy lives and puts them at increased risk of death, despite the availability of highly effective therapeutic approaches, is unacceptable. A World Health Assembly Resolution on universal access to affordable and effective asthma care is needed to focus attention and investment on addressing this need.

Crinum latifolium extract inhibits lipopolysaccharide-induced inflammation in human macrophages

Introduction: Crinum latifolium is a natural plant showing the anti-inflammatory effects. We aimed to evaluate the effects of Crinum latifolium extract on proinflammatory cytokine production and maturation of early and late endosomes in the lipopolysaccharide (LPS)-induced human macrophages at light microscopic and biochemical levels.

Material and Methods: The effects of Crinum latifolium extract in human macrophages stimulated with LPS was evaluated to optic densities of the lysosome-associated membrane protein-1 (LAMP-1) and early endo-some antigen 1 (EEA1) by immunohistochemistry staining and to level of the proinflammatory cytokine interleukin (IL)-6 by enzyme-linked immunosorbent assay (ELISA).

Results: Crinum latifolium group exhibited a significant decreased in the levels of IL-6 in the supernatant as compared to the LPS group for 2 and 72 hours (p<0.0001). Crinum latifolium group exhibited a significant increased in the optic density of the EEA1 and LAMP-1 in coverslips as compared to the control and lipopolysaccharide groups after 2 and 72 hours (p<0.0001).

Conclusions: Crinum latifolium may a therapeutic plant in the inflammatory diseases, such as sepsis, through anti-inflammatory effects, such as decrease in production of the proinflammatory cytokine and increase in maturations of the early and late endosomes in macrophages.

Adherence to inhaled corticosteroids prescribed once vs twice daily in children with asthma

BACKGROUND

Suboptimal adherence to inhaled corticosteroids (ICS) is associated with poor asthma control. Adult studies suggest that simplification of ICS regimen leads to better adherence.

OBJECTIVE

We aimed to determine whether once-daily, compared with twice-daily, ICS dosing was associated with better adherence among children with asthma.

METHODS

We conducted a retrospective observational study of children with asthma prescribed with either once-daily or twice-daily ICS monotherapy between 2011 and 2019. Our primary adherence outcome was the proportion of prescribed days covered (PPDC)-that is, the number of days for which the drug was dispensed by the pharmacy divided by the number of days for which it was prescribed. The impact of once-daily vs twice-daily ICS regimen on adherence was evaluated using linear multivariable regression analysis adjusting for covariates. Secondary outcomes included the proportion of patients with greater than or equal to 75% adherence analyzed using logistic regression models.

RESULTS

A total of 232 children (61% boys; mean age of 5.8 [3.6] years) were included; 120 children were prescribed once-daily, and 112 twice-daily, ICS. The median PPDC was 66.8% for the once-daily and 57.9% for the twice-daily group (P = .03). Children prescribed once-daily ICS had a 7.2% (95% confidence interval, 1.3-13.1) greater mean PPDC compared with the twice-daily group and greater odds of having PPDC greater than or equal to 75% (71.4% vs 45.5%; odds ratio, 1.80; 95% confidence interval, 1.01-3.26).

CONCLUSION

Our findings suggest that once-daily dosing of ICS is associated with better medication adherence than twice-daily dosing. Whether the gain in adherence leads to better asthma control and health outcomes remains to be evaluated.

Association between depression and mortality in persons with asthma: a population-based cohort study

BACKGROUND

The relation between depression and mortality in patients with asthma is not well known. This study aimed to assess the impact of depression on mortality in asthmatic patients in US adults.

METHODS

This observational study used data from the 2005 to 2014 National Health and Nutrition Examination Survey (NHANES). Depression was measured using the Patient Health Questionnaire-9 (PHQ-9). We used survey-weight adjusted Cox proportional hazard models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for the association between depression and all-cause mortality.

RESULTS

A total of 1865 participants with asthma were included in this study. Among them, 264 (14.16%) had depressive symptoms. During 9970 person-years of follow-up, there were 24 (9.1%) deaths in 264 patients with depression compared with 100 (6.3%) deaths in 1601 patients without depression. For unadjusted analyses, depression was associated with an increased risk of all-cause mortality (HR, 2.22 [95% CI 1.32-3.73]). This association was persistent after adjustment for age, sex, race/ethnicity, and body mass index (HR, 2.71 [95% CI 1.58-4.66]). However, we did not observe a significant association between depression and mortality after controlling for extensive co-morbidities (HR, 1.92 [95% CI 0.82-4.45]). Subgroup analyses further revealed that depression was an independent risk factor for mortality only in the females (HR, 3.78 [95% CI 1.17, 12.26]) but not all asthmatic patients.

CONCLUSIONS

The present study suggested that depressive disorder was common in asthmatic patients and depression in asthmatic patients was associated with a higher mortality rate. Depression was an independent risk factor for mortality in female patients.

Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: A narrative systematic review

INTRODUCTION

Nonadherence to inhaled corticosteroids (ICSs) in children with asthma leads to significant morbidity and mortality. Few adherence interventions have been effective and little is known about what contributes to intervention effectiveness. This systematic review summarizes the efficacy and the characteristics of effective interventions.

METHODS

Six databases were systematically searched on October 3, 2020 for randomized control trials measuring adherence to ICS in children with asthma. A narrative synthesis was conducted focusing on intervention efficacy and study reliability. Intervention content was coded based on the National Institute for Health and Care Excellence guidelines for medicines adherence (the Perceptions and Practicalities Approach, PAPA) and behavior change techniques (BCTs), to determine the effective aspects of the intervention.

RESULTS

Of 240 studies identified, 25 were eligible for inclusion. Thirteen of the 25 studies were categorized as being highly reliable. Nine of the 13 interventions were effective at increasing adherence and 6 of those met the criteria for a PAPA intervention. Techniques targeting perceptions and practicalities in successful interventions included rewards, reminders, feedback and monitoring of adherence, pharmacological support, instruction on how to take their ICS/adhere, and information about triggers for symptoms and nonadherence.

CONCLUSION

Adherence interventions in children with asthma have mixed effectiveness. Effective intervention studies were more frequently of higher quality, were tailored to individuals' perceptual and practical adherence barriers, and used multiple BCTs. However, due to the small number of included studies and varying study design quality, conclusions drawn here are preliminary. Future research is needed to test a PAPA-based intervention with a rigorous study design.

Evolving Concept of Severe Asthma: Transition From Diagnosis to Treatable Traits

In recent decades, the concept of severe asthma has evolved from an umbrella term encompassing patients with high-intensity treatment needs to a clinical syndrome with heterogeneous, albeit distinct, pathophysiological processes. Biased and unbiased cluster approaches have been used to identify several clinical phenotypes. In parallel, cellular and molecular approaches allow for the development of biological therapies, especially targeting type 2 (T2) cytokine pathways. Although T2-biologics have significantly improved clinical outcomes for patients with severe asthma in real-world practice, questions on the proper use of biologics remain open. Furthermore, a subset of severe asthma patients remains poorly controlled. The unmet needs require a new approach. The “treatable traits” concept has been suggested to address a diversity of pathophysiological factors in severe asthma and overcome the limitations of existing treatment strategies. With a tailored therapy that targets the treatable traits in individual patients, better personalized medical care and outcomes should be achieved.

Prescribing Patterns and Treatment Adherence in Patients with Asthma During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has witnessed a reduction in asthma exacerbations across the United Kingdom. Several factors may underpin this, including reduced transmission of seasonal viruses and improved adherence to inhaled corticosteroids (ICS). However, little is known about how ICS use has changed during the pandemic.

OBJECTIVE

To identify prescribing patterns for asthmatics during the pandemic.

METHODS

Using the OpenPrescribing database, we retrospectively analyzed prescribing patterns of ICS, salbutamol and peak flow meters from January 2019 to January 2021 across England. In addition, using a sample asthma cohort at 3 primary care practices in London, we assessed individual prescription patterns.

RESULTS

A sharp increase in national ICS prescriptions occurred in March 2020 representing a 49.9% increase compared with February 2020. The sample cohort included 1132 patients (762 ICS treated across both years). Overall ICS adherence improved in 2020 (P < .001), with the proportion of patients meeting "good adherence" (≥75%) increasing from 33.9% to 42.0% (P < .001). The March 2020 spike predominantly reflected improved adherence rather than a hoarding effect of multiple inhalers. Female gender and increasing age were associated with the most significant improvements in adherence. A similar spike in salbutamol occurred in March 2020; however, an overall reduction in salbutamol prescriptions occurred in 2020 (P = .039). National figures highlighted a progressive increase in prescription of peak flow meters over 2020.

CONCLUSION

ICS adherence rates remain low; however, a modest improvement in adherence was observed during the first year of the COVID-19 pandemic. Salbutamol prescription rates reduced over the same time period, whereas prescriptions for peak flow meters have steadily increased.

Criterios de derivación en asma: Actualización documento de consenso

Asthma is one of the most prevalent chronic diseases in Spain. In 2019, the Spanish Society of Allergology and Clinical Immunology (SEAIC), the Spanish Society of Primary Care Physicians (SEMERGEN), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of General and Family Physicians (SEMG) and the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) drafted a document laying down the criteria for referral and action guidelines in the diagnosis, control and monitoring of the asthmatic patient to facilitate ongoing care and improved attention in every setting. The new circumstances derived from the Covid-19 pandemic have demanded that some of the recommendations of the previous edition be updated and adapted to the new healthcare situation.

[What not to do in the therapeutic management of bronchial asthma. Delphi consensus recommendations for physicians who treat asthma]

Asthma is one of the most prevalent diseases in Spain, yet despite the great diagnostic and therapeutic advances made in this field, health outcomes suggest that up to 80% of patients do not have their asthma well controlled. Although the causes of this situation are diverse, there are some practices among the professionals who treat asthma that are not conducive to improving health outcomes in this disease. Our working group has prepared this document in order to remind clinicians of a series of basic guidelines, aligned with current guidelines and recent literature, and agreed by a multidisciplinary expert panel using Delphi methodology. These recommendations about what not to do in the management of asthma in the adult patient are structured into four areas: diagnosis, monitoring, treatment and prevention of exacerbations.

The prevalence and outcome of short-acting β2-agonists overuse in asthma patients in Taiwan

This study aims to investigate the prevalence of short-acting β2-agonist (SABA) overuse in asthma and the associated risk of acute exacerbation and mortality in Taiwan. We used the Taiwanese pay-for-performance asthma program database, which included patients aged between 12 and 100 years who were enrolled in the program between 2001 and 2015. Among a total of 218,039 patients, 34,641 (15.9%) patients are classified as SABA over-users. Compared with patients who did not receive inhaled corticosteroids (ICS) and collected ≤2 canisters, SABA over-users had a higher risk of severe exacerbations. SABA over-users had a higher risk of all-cause mortality compared with patients who did not receive ICS and collected ≤2 canisters. The overall prevalence of SABA overuse in Taiwan is 15.9%, and this is even higher in concomitant ICS users. In addition, the overuse of SABA is associated with an increased risk of severe exacerbation and death.

Artificial Intelligence/Machine Learning in Respiratory Medicine and Potential Role in Asthma and COPD Diagnosis

Artificial intelligence (AI) and machine learning, a subset of AI, are increasingly used in medicine. AI excels at performing well-defined tasks, such as image recognition; for example, classifying skin biopsy lesions, determining diabetic retinopathy severity, and detecting brain tumors. This article provides an overview of the use of AI in medicine and particularly in respiratory medicine, where it is used to evaluate lung cancer images, diagnose fibrotic lung disease, and more recently is being developed to aid the interpretation of pulmonary function tests and the diagnosis of a range of obstructive and restrictive lung diseases. The development and validation of AI algorithms requires large volumes of well-structured data, and the algorithms must work with variable levels of data quality. It is important that clinicians understand how AI can function in the context of heterogeneous conditions such as asthma and chronic obstructive pulmonary disease where diagnostic criteria overlap, how AI use fits into everyday clinical practice, and how issues of patient safety should be addressed. AI has a clear role in providing support for doctors in the clinical workplace, but its relatively recent introduction means that confidence in its use still has to be fully established. Overall, AI is expected to play a key role in aiding clinicians in the diagnosis and management of respiratory diseases in the future, and it will be exciting to see the benefits that arise for patients and doctors from its use in everyday clinical practice.

Mortality and morbidity in children with asthma: A nationwide study in Korea

OBJECTIVE

Childhood mortality due to asthma remains problematic; however, asthma-related mortality in Korean children has not been previously described. This study aimed to estimate asthma mortality and morbidity and determine to what extent asthma contributes to childhood mortality in Korea.

METHODS

Data from 9 to 12 million children (aged < 18 years) per year recorded for each year between 2002 and 2015 were retrieved from the Korea National Health Insurance claims database. Patients with asthma during the year preceding death were investigated. Causes of death were analysed using data obtained from the Korean Statistical Information Service database. Cause-specific mortality was examined, and the mortality rate of children with asthma was compared to that of the general paediatric population with respect to the cause of death and age. Hospital use by patients with asthma, including intensive care unit admission and hospitalisation, was analysed.

RESULTS

Asthma mortality decreased from 0.09 per 100,000 children in 2003 to 0.02 per 100,000 children in 2014, with an average mortality of 0.06 per 100,000 children. Mortality due to respiratory diseases was four times more common in patients with asthma than in the general population of children aged >5 years, despite decreases in asthma-related mortality. Asthma-related hospitalisations and intensive care interventions tended to decrease throughout the study period.

CONCLUSIONS

Asthma mortality declined in children between 2003 and 2015 in Korea. Children with asthma are at a higher risk of death from respiratory diseases than the general population.

Risks of poor asthma outcome in 14,405 children and young people in London

This is a 12-month retrospective data analysis (2018/19) of asthma risk factors in 350 North West London general practices. Fourteen thousand four hundred and five of the 482,029 (40% female) children and young people (CYP) had diagnosed asthma. Exacerbations are as follows: (i) 749 (5%) CYP had 797 hospital admissions; 32 (<1%) had 2-6; (ii) 910 (6%) had 1168 recorded asthma attacks; 170 (1%) had 2-12; (iii) 1485 (10%) had 2123 oral corticosteroid courses; 408 (3%) had 2-11. Excess short-acting bronchodilators were prescribed in over half of the CYP. Of the 10,077 (70%) CYP prescribed inhaled corticosteroid preventers, 7279 (72%) were issued with <4 ICS inhaler prescriptions during the year; these CYP accounted for 11% of the admission spells. In all, 30% of CYP had poor symptom control. At least 10% of the CYP having had recent attacks are at risk and dashboards such as those available in North West London could easily facilitate recognition of risk and optimisation of care.

The Impact of Patient Self-Monitoring Via Electronic Medication Monitor and Mobile App Plus Remote Clinician Feedback on Adherence to Inhaled Corticosteroids: A Randomized Controlled Trial

BACKGROUND

Poor adherence to inhaled corticosteroids (ICSs) and overuse of short-acting beta₂-agonists (SABAs) are associated with increased asthma morbidity.

OBJECTIVE

To assess whether patient self-monitoring via electronic medication monitoring and smartphone application plus remote clinician feedback influences ICS and SABA use.

METHODS

Adults with uncontrolled asthma and prescribed ICS and SABA were enrolled in this 14-week study. Inhalers were fitted with electronic medication monitoring to track real-time usage. After a 14-day baseline, participants were randomly assigned to the treatment group where they received reminders and feedback on ICS and SABA use via a smartphone application and clinician phone calls, or control group without feedback. Linear mixed models compared the baseline percentage of SABA-free days and ICS adherence to the last 14 study days.

RESULTS

Participants (n = 100) had a mean age of 48.5 years, 80% were female, 68% white, and 80% privately insured. The percentage of SABA-free days increased significantly in the treatment group (19%; 95% CI, 12 to 26; P < .01) and nonsignificantly in the control group (6%, 95% CI, -3 to 16; P = .18), representing a 13% (95% CI, 1-26; P = .04) difference. ICS adherence changed minimally in the treatment group (-2%; 95% CI, -7 to 3; P = .40), but decreased significantly (-17%; 95% CI, -26 to -8; P < .01) in the control group, representing a 15% (95% CI, 4 to 25; P < .01) difference.

CONCLUSIONS

Patient self-monitoring via a digital platform plus remote clinician feedback maintained high baseline ICS adherence and decreased SABA use.

The Clinical Course of Asthma After Withdrawal of Inhaled Corticosteroids

BACKGROUND

Maintenance of inhaled corticosteroids (ICSs) is recommended in adults with asthma. However, adherence rates in patients with mild asthma and side effects of long-term ICS use can lead to withdrawal.

OBJECTIVE

To analyze the real-world outcomes of ICS withdrawal by analyzing data from the Korean National Health Insurance database.

METHODS

Based on claims data from the National Health Insurance of Korea between 2011 and 2014, we identified patients diagnosed with asthma without chronic obstructive pulmonary disease or long-term systemic steroid use who had an ICS medication possession rate of more than 50% in a year. We compared patients who received ICS consistently (maintenance group) with patients who had no ICS prescription for more than 6 months (withdrawal group). We evaluated exacerbation leading to prescription of systemic steroid and emergency department visit or hospitalization.

RESULTS

Excluding patients with chronic obstructive pulmonary disease and long-term systemic steroid users, we identified 145,511 patients for the asthma cohort (mean age, 60.0 years; ever-smoker, 63.5%): 132,175 maintained ICS and 13,336 withdrew ICS for more than 6 months. Only 71 patients (0.5%) experienced exacerbation leading to an emergency department visit or hospitalization in the withdrawal group. ICS was restarted within 1 year for 33.6% of the withdrawal group, and 90% of these patients restarted ICS within 158 days.

CONCLUSIONS

This nationwide study of patients with asthma, characterized by a high proportion of elderly and smokers, showed that ICS withdrawal in about 10% of patients appeared to confer relatively minimal harm and exacerbation leading to hospitalization was not common. Further prospective studies are warranted to carefully explore the safety of ICS withdrawal in younger, nonsmoking, and well-controlled patients with asthma.

Health and cost impact of stepping down asthma medication for UK patients, 2001-2017: A population-based observational study

BACKGROUND

Guidelines recommend stepping down asthma treatment to the minimum effective dose to achieve symptom control, prevent adverse side effects, and reduce costs. Limited data exist on asthma prescription patterns in a real-world setting. We aimed to evaluate the appropriateness of doses prescribed to a UK general asthma population and assess whether stepping down medication increased exacerbations or reliever use, as well as its impact on costs.

METHODS AND FINDINGS

We used nationwide UK primary care medical records, 2001-2017, to identify 508,459 adult asthma patients managed with preventer medication. Prescriptions of higher-level medication: medium/high-dose inhaled corticosteroids (ICSs) or ICSs + add-on medication (long-acting β2-agonist [LABA], leukotriene receptor antagonist [LTRA], theophylline, or long-acting muscarinic antagonist [LAMA]) steadily increased over time (2001 = 49.8%, 2017 = 68.3%). Of those prescribed their first preventer, one-third were prescribed a higher-level medication, of whom half had no reliever prescription or exacerbation in the year prior. Of patients first prescribed ICSs + 1 add-on, 70.4% remained on the same medication during a mean follow-up of 6.6 years. Of those prescribed medium/high-dose ICSs as their first preventer, 13.0% already had documented diabetes, cataracts, glaucoma, or osteopenia/osteoporosis. A cohort of 125,341 patients were drawn to assess the impact of stepping down medication: mean age 50.4 years, 39.4% males, 39,881 stepped down. Exposed patients were stepped down by dropping their LABAs or another add-on or by halving their ICS dose (halving their mean-daily dose or their inhaler dose). The primary and secondary outcomes were, respectively, exacerbations and an increase in reliever prescriptions. Multivariable regression was used to assess outcomes and determine the prognostic factors for initiating stepdown. There was no increased exacerbation risk for each possible medication stepdown (adjusted hazard ratio, 95% CI, p-value: ICS inhaler dose = 0.86, 0.77-0.93, p < 0.001; ICS mean daily = 0.80, 0.74-0.87, p < 0.001; LABA = 1.01, 0.92-1.11, p = 0.87, other add-on = 1.00, 0.91-1.09, p = 0.79) and no increase in reliever prescriptions (adjusted odds ratio, 95% CI, p-value: ICS inhaler dose = 0.99, 0.98-1.00, p = 0.59; ICS mean daily = 0.78, 0.76-0.79, p < 0.001; LABA = 0.83, 0.82-0.85, p < 0.001; other add-on = 0.86, 0.85-0.87, p < 0.001). Prognostic factors to initiate stepdown included medication burden, but not medication side effects. National Health Service (NHS) indicative prices were used for cost estimates. Stepping down medication, either LABAs or ICSs, could save annually around £17,000,000 or £8,600,000, respectively. Study limitations include the possibility that prescribed medication may not have been dispensed or adhered to and the reason for stepdown was not documented.

CONCLUSION

In this UK study, we observed that asthma patients were increasingly prescribed higher levels of treatment, often without clear clinical indication for such high doses. Stepping down medication did not adversely affect outcomes and was associated with substantial cost savings.

Asthma mortality in children and adolescents of Brazil over a 20-year period

OBJECTIVE

To evaluate the number of asthma deaths and the temporal trend of the asthma-specific mortality rate in children and adolescents up to 19 years of age in Brazil.

METHODS

This is an ecological time-series study of asthma deaths reported in Brazil, in the population up to 19 years of age, between 1996 and 2015. The specific asthma mortality rate and its temporal trend were analyzed.

RESULTS

There were 5014 deaths during the 20 years evaluated, with the majority, 68.1%, being recorded in children under 5 years of age. The specific asthma mortality rate ranged from 0.57/100,000 in 1997 to 0.21/100,000 in 2014, with a significant reduction of 59.8%. Regarding the place of death, 79.4% occurred in a hospital setting. In this sample, the adolescents had a 1.5-fold higher chance of death out-of-hospital than children up to nine years of age. There was no significant difference in the temporal trend between the genders and no significant decrease in out-of-hospital deaths.

CONCLUSIONS

This study found a temporal trend for a reduction in asthma deaths over 20 years in children and adolescents in Brazil. Mortality rates varied across the geographic regions of the country and were higher in the Northeast. The prevalence of deaths under 5 years of age may be associated with the greater vulnerability of this age group in low-income countries. In adolescence, deaths outside the hospital environment are noteworthy. Asthma deaths are rare but unacceptable events, considering the treatable nature of the disease and the presence of avoidable factors in most of fatal outcomes.

Health literacy among asthma patients and treatment expectations: results of a Belgian survey

Objectives: Non-adherence to asthma medication can lead to lower disease control and asthma exacerbations that may be fatal. This survey assessed the attitude and expectations of Belgian asthma patients towards their treatment.Methods: This cross-sectional survey was conducted between June 2015 and February 2016 in 70 Belgian pharmacies. Participants completing the survey had to be ≥15 years, diagnosed with asthma, and on inhaled corticosteroid-based treatment. The analysis included 80 completed questionnaires.Results: Participants comprehended well that controller drugs are intended to prevent the occurrence of asthma symptoms and complications, and their long-term daily use should be maintained. Twenty seven percent of participants indicated fear of side effects concerning long-term daily use of a controller inhaler. Participants had a good understanding that quick-relief drugs are intended to (quickly) relieve asthma symptoms and do not need to be used on a systematic, daily basis. Out of 73 participants on long-term controller drugs, 33 (45%) were 'non-adherent' (used less frequently than prescribed). Suboptimal adherence to maintenance treatment appeared to increase nightly awakenings and the risk of restrictions in activities due to asthma. Out of 54 participants with available quick-relief drug adherence data, 18 (33%) were non-adherent (used their quick-relief drug more frequently than prescribed).Discussion: This survey confirms suboptimal adherence to maintenance controller therapy and overuse of short-acting reliever medications among Belgian patients, which affects asthma control and quality of life. A substantial proportion of patients expressed fear about their chronic therapy, indicating the need for patient education about their disease and its management.

Asthma mortality among Mexican children: Rural and urban comparison and trends, 1999-2016

OBJECTIVE

Although there are more studies showing higher asthma prevalence in urban rather than rural zones, few assessed asthma mortality by zone in children. The objective of this study is to compare asthma mortality rates (AMR) by zone of residence of Mexican children.

DESIGN

Using national death certificate and population projections data, AMR were compared in children aged 0 to 14 years by gender, age group, and zone of residence from 1999 to 2016. AMR trends were calculated using Joinpoint regression.

RESULTS

Of the 680 823 deaths, 2464 (0.36%) were due to asthma. Asthma mortality was higher in rural (0.65%) than urban (0.26%) zones, P < .0001. Whole period AMR median was also higher in rural vs urban zones (0.6 vs 0.3, respectively), P < .05. The average annual percent change (AAPC) of AMR for the whole period was -5.1 in all children with a higher percent decrease in rural vs urban zones (girls' AAPC = -6.3 vs -4.1, respectively and boys' AAPC = -4.8 vs -4.2, respectively). AMR decreased in children aged 0 to 4 from both zones (rural's AAPC: girls = -7.9, boys = -5.2; urban's AAPC: girls = -5.1, boys = -5.4), P < .05. No trend was found in children aged 5 to 14.

CONCLUSIONS

Asthma mortality in Mexican children is higher in rural than urban zones. The decrease of mortality over time in early childhood is reassuring. More research is needed to determine reasons for higher mortality in rural Mexico and for the lack of a favorable decreasing trend in children aged 5 to 14 from both zones.

[The management of asthma as a chronic inflammatory disease and global health problem: A position paper from the scientific societies]

Asthma is the most prevalent respiratory disease worldwide and it can affect people of all ages and is potentially fatal. Today, maintenance treatments are available that are effective in most patients, yet a significant proportion have poorly controlled disease, despite the resources on offer. This document, endorsed by members of the Spanish medical societies involved in the treatment of asthma, is intended to draw the attention of society and professionals to this problem in Spain. It focuses on the clinical, diagnostic and therapeutic aspects of asthma, and proposes some actions for improvement as regards patients and healthcare professionals which, in view of the current results arising from inadequate asthma control, might be beneficial to improve outcomes for both patients and public health.

Independent risk factors for death in patients admitted for asthma exacerbation in Taiwan

The independent risk factors for death in patients admitted for asthma exacerbation have not been thoroughly investigated. This study aimed to investigate these independent risk factors and the relationship between mortality and the prescription patterns of anti-asthmatic medications in patients admitted for asthma exacerbation. Using a nested case-control design, we identified 267 cases (death after asthma admission) and 1035 controls (survival after asthma admission) from the Taiwan National Health Insurance Research Database (NHIRD) from 2001 to 2010. Conditional logistic regressions were used to estimate the odds ratios (ORs) with 95% confidence intervals (CIs). We identified the independent risk factors for death as the comorbidities of pneumonia (aOR 3.82, 95% CI 2.41-6.05), genitourinary disease (aOR 1.75, 95% CI 1.17-2.62), septicemia (aOR 4.26, 95% CI 2.61-6.94), diabetes mellitus (aOR 2.10, 95% CI 1.30-3.38), arrhythmia (aOR 2.00, 95% CI 1.14-3.50), and a history of asthmatic hospitalization (aOR 4.48, 95% CI 2.77-7.25). Moreover, the use of short-acting β2-agonist (SABA) and the dosage of oral corticosteroids (OCSs) >70 mg prednisolone during previous hospitalization (all p < 0.05) and the dosage of OCSs ≥110 mg prednisolone/month (aOR 2.21, 95% CI 1.08-4.50) during outpatient treatment independently increased the risk of death. The inhaled corticosteroids (ICSs) ≥4 canisters/year (aOR 0.39, 95% CI 0.19-0.78) independently reduced the risk of death. Specific comorbidities, asthma severity, and prescription patterns of SABA, OCSs, and ICSs were independently associated with mortality in patients admitted for asthma exacerbation. These results can be utilized to help physicians identify asthmatic patients who are at a higher mortality risk and to refine the management of the condition.

Physcion-Matured Dendritic Cells Induce the Differentiation of Th1 Cells

In addition to their use as colorants, anthraquinone derivatives have numerous medical applications, for example, as antibacterial and antiinflammatory agents. We confirmed that physcion (an anthraquinone derivative) induces TNF-alpha production by macrophages and increased the expressions of surface molecules (CD40, CD80, and CD86) and major histocompatibility complex (MHC) II. Based on these results, we hypothesized that physcion might induce the maturation of dendritic cells (DCs) to antigen-presenting cells (APCs), and decided to conduct in vitro experiments using bone-marrow-derived DCs (BMDCs). Physcion was not toxic to DCs and increased the expression of surface molecules (e.g., CD40, CD80, CD86, and MHC II) and the production of cytokines (e.g., IL-12p70, IL-1beta, IL-6, and TNF-alpha), but not of IL-10. To confirm that DCs matured by physcion induce T-cell-immune responses, naive CD4⁺ T cells were treated with physcion-treated DCs or their supernatants. Physcion induced the maturation of DCs, which promoted the polarization of Th1 cells. Our results show physcion-induced DC maturation via TLR4, and that mature DCs promote the differentiation of Th1 cells without affecting the differentiation of Th2 cells. These findings show that physcion has potential use as a treatment for inflammatory diseases associated with Th1/Th2 cell imbalance.

Acute Severe Asthma in Adolescent and Adult Patients: Current Perspectives on Assessment and Management

Asthma is a chronic airway inflammatory disease that is associated with variable expiratory flow, variable respiratory symptoms, and exacerbations which sometimes require hospitalization or may be fatal. It is not only patients with severe and poorly controlled asthma that are at risk for an acute severe exacerbation, but this has also been observed in patients with otherwise mild or moderate asthma. This review discusses current aspects on the pathogenesis and pathophysiology of acute severe asthma exacerbations and provides the current perspectives on the management of acute severe asthma attacks in the emergency department and the intensive care unit.

Asthma progression and mortality: the role of inhaled corticosteroids

Overall, asthma mortality rates have declined dramatically in the last 30 years, due to improved diagnosis and to better treatment, particularly in the 1990s following the more widespread use of inhaled corticosteroids (ICSs). The impact of ICS on other long-term outcomes, such as lung function decline, is less certain, in part because the factors associated with these outcomes are incompletely understood. The purpose of this review is to evaluate the effect of pharmacological interventions, particularly ICS, on asthma progression and mortality. Furthermore, we review the potential mechanisms of action of pharmacotherapy on asthma progression and mortality, the effects of ICS on long-term changes in lung function, and the role of ICS in various asthma phenotypes.Overall, there is compelling evidence of the value of ICS in improving asthma control, as measured by improved symptoms, pulmonary function and reduced exacerbations. There is, however, less convincing evidence that ICS prevents the decline in pulmonary function that occurs in some, although not all, patients with asthma. Severe exacerbations are associated with a more rapid decline in pulmonary function, and by reducing the risk of severe exacerbations, it is likely that ICS will, at least partially, prevent this decline. Studies using administrative databases also support an important role for ICS in reducing asthma mortality, but the fact that asthma mortality is, fortunately, an uncommon event makes it highly improbable that this will be demonstrated in prospective trials.

Treat to target approach for asthma

Recognition that about half of asthma deaths might be preventable if recommended guidelines are followed suggests that better implementation of established management strategies is needed. However, to achieve a further substantive reduction in asthma mortality, novel strategies will also be required. It is well established that asthma is a disease of chronic inflammation, with episodes of worsening inflammation associated with increased symptoms and/or exacerbations; however, current guidelines paradoxically recommend that initial treatment is only symptomatic, rather than directed at the underlying inflammatory mechanism. The "Treat to target" (TTT) approach has become a popular concept in the medical management of several common chronic conditions, including rheumatoid arthritis (RA), diabetes, hypertension and hyperlipidemia. For example, as part of a TTT approach, rheumatologists recommend methotrexate for RA with onset within 6 months. Applying the TTT approach to asthma, the primary target could be clinical remission and the primary goals as follows: eliminate symptoms and exacerbation risk; prevent airway remodeling; and normalize lung function. To construct a TTT algorithm for chronic asthma, the proposal is to eradicate short-acting β2-agonists (SABA) at all asthma severity levels and replace SABA with "Anti-Inflammatory Reliever Therapy" (AIR), using inhaled corticosteroids (ICS)/SABA or ICS/formoterol. For individuals with equal to or less than 12 months' history of symptoms, fewer than two symptoms per month, no exacerbations in the last 12 months and normal lung function, the recommendation is early initiation of ICS/SABA or ICS/formoterol as AIR.

Sex-Specific Association between Childhood BMI Trajectories and Asthma Phenotypes

BACKGROUND

Asthma and obesity are two common health problems in the pediatric population. Obesity is associated with several comorbidities which are of great consequence. Excess adipose tissue has been linked to asthma in a number of studies. However, little is known about childhood body mass index (BMI) trajectories and the development of asthma phenotypes.

OBJECTIVE

The current study aims to investigate the significance of BMI trajectories over childhood and the risk of asthma phenotypes.

METHODS

The current study is a prospective cohort of children aged 0-2 years who were followed every two years for eight years through cycles one to five in the National Longitudinal Survey of Children and Youths (NLSCY). Statistical analysis: a latent class growth modelling (LCGM) method was used to identify BMI trajectory patterns from cycles one to five. Multiple imputation (number of imputations=5) was carried out to impute children with missing values on height or weight information. Sampling weights and 1,000 bootstrap weights were used in SAS PROC SURVEYLOGISTIC to examine the association between BMI trajectory and asthma phenotypes (persistent or transient asthma) in a multivariate analysis.

RESULTS

The study consisted of 571,790 males and 549,230 females. Among them, 46% of children showed an increasing trajectory in terms of change in BMI percentile during childhood, followed by the stable-trajectory group (41%) and decreasing-trajectory group (13%). After controlling for confounding factors, females in the increasing BMI trajectory group were four times more likely to be associated with persistent asthma (OR = 4.09; 95% CI:1.04-16.15; p = 0.0442) than females in the stable BMI trajectory group. No such relationship was found in males. The BMI trajectory was not significantly associated with risk of transient asthma for either sex.

CONCLUSION

We report a female-specific association between increasing adiposity, measured by BMI, and persistent asthma.

Targeting inhaled aerosol delivery to upper airways in children: Insight from computational fluid dynamics (CFD)

Despite the prevalence of inhalation therapy in the treatment of pediatric respiratory disorders, most prominently asthma, the fraction of inhaled drugs reaching the lungs for maximal efficacy remains adversely low. By and large drug delivery devices and their inhalation guidelines are typically derived from adult studies with child dosages adapted according to body weight. While it has long been recognized that physiological (e.g. airway sizes, breathing maneuvers) and physical transport (e.g. aerosol dynamics) characteristics are critical in governing deposition outcomes, such knowledge has yet to be extensively adapted to younger populations. Motivated by such shortcomings, the present work leverages in a first step in silico computational fluid dynamics (CFD) to explore opportunities for augmenting aerosol deposition in children based on respiratory physiological and physical transport determinants. Using an idealized, anatomically-faithful upper airway geometry, airflow and aerosol motion are simulated as a function of age, spanning a five year old to an adult. Breathing conditions mimic realistic age-specific inhalation maneuvers representative of Dry Powder Inhalers (DPI) and nebulizer inhalation. Our findings point to the existence of a single dimensionless curve governing deposition in the conductive airways via the dimensionless Stokes number (Stk). Most significantly, we uncover the existence of a distinct deposition peak irrespective of age. For the DPI simulations, this peak (∼ 80%) occurs at Stk ≈ 0.06 whereas for nebulizer simulations, the corresponding peak (∼ 45%) occurs in the range of Stk between 0.03-0.04. Such dimensionless findings hence translate to an optimal window of micron-sized aerosols that evolves with age and varies with inhalation device. The existence of such deposition optima advocates revisiting design guidelines for optimizing deposition outcomes in pediatric inhalation therapy.

Integrative approach identifies corticosteroid response variant in diverse populations with asthma

BACKGROUND

Although inhaled corticosteroid (ICS) medication is considered the cornerstone treatment for patients with persistent asthma, few ICS pharmacogenomic studies have involved nonwhite populations.

OBJECTIVE

We sought to identify genetic predictors of ICS response in multiple population groups with asthma.

METHODS

The discovery group comprised African American participants from the Study of Asthma Phenotypes and Pharmacogenomic Interactions by Race-Ethnicity (SAPPHIRE) who underwent 6 weeks of monitored ICS therapy (n = 244). A genome-wide scan was performed to identify single nucleotide polymorphism (SNP) variants jointly associated (ie, the combined effect of the SNP and SNP × ICS treatment interaction) with changes in asthma control. Top associations were validated by assessing the joint association with asthma exacerbations in 3 additional groups: African Americans (n = 803 and n = 563) and Latinos (n = 1461). RNA sequencing data from 408 asthmatic patients and 405 control subjects were used to examine whether genotype was associated with gene expression.

RESULTS

One variant, rs3827907, was significantly associated with ICS-mediated changes in asthma control in the discovery set (P = 7.79 × 10^-8) and was jointly associated with asthma exacerbations in 3 validation cohorts (P = .023, P = .029, and P = .041). RNA sequencing analysis found the rs3827907 C-allele to be associated with lower RNASE2 expression (P = 6.10 × 10^-4). RNASE2 encodes eosinophil-derived neurotoxin, and the rs3827907 C-allele appeared to particularly influence ICS treatment response in the presence of eosinophilic inflammation (ie, high pretreatment eosinophil-derived neurotoxin levels or blood eosinophil counts).

CONCLUSION

We identified a variant, rs3827907, that appears to influence response to ICS treatment in multiple population groups and likely mediates its effect through eosinophils.

A review of asthma care in 50 general practices in Bedfordshire, United Kingdom

The United Kingdom (UK) National Review of Asthma Deaths (NRAD) (2011–2014) identified a number of contributory risk factors which had not previously been recognized by those caring for people with asthma. Only one of the 19 NRAD recommendations has so far been implemented nationally, and that only partially, and as yet systems are not in place to identify patients at risk of attacks and dying from asthma. In 2015/2016 Bedfordshire Clinical Commissioning Group (CCG) in England, UK, initiated a quality asthma audit of people with asthma to identify some of the risk factors identified in the NRAD report with the aim of optimizing patient care. Fifty (89%) of the General Practices caring for 415,152 patients (27,587 diagnosed with asthma (prevalence 7%; range 4–12%)), participated and the results identified a wide variation in process of care and presence of risk factors including: excess short acting reliever and insufficient preventer prescriptions, failure to issue personal asthma action plans, and to perform annual reviews or check inhaler technique. Identification of these patients involved high-intensity input by trained asthma nurses using sophisticated data extraction software. GP computer systems used in primary care currently do not have the functionally, without the need for manual audit, to implement the NRAD recommendations, starting with the identification of patients at risk. Modifications to existing systems within both primary and secondary care are required in order to prevent unnecessary deaths related to asthma. There is a pressing need to move towards a more pro-active model of care.

Pro-active disease management for patients with asthma is crucial and could be vastly improved with an overhaul of computer systems in primary care. Following the UK National Review of Asthma Deaths (NRAD) in 2011–2014, multiple mortality risk factors were identified that have yet to be factored into asthma care. The NHS Bedfordshire Clinical Commissioning Group, with support from NSHI and Dr Mark L Levy (Harrow CCG), conducted a manual audit of 50 Bedfordshire doctors’ surgeries to identify relevant NRAD recommendations to optimize patient care. Levy’s team found marked variations in asthma care between the surgeries. Risk factors present included excessive short-acting reliever inhaler prescriptions and inadequate prescribing of preventer inhalers, together with limited implementation of personal asthma plans and annual reviews. The researchers highlight the limitations of existing computer systems for these purposes and recommend an overhaul of asthma tracking and automated alerts.

Beware of beta! A case of salbutamol-induced lactic acidosis in severe asthma

A 22-year-old woman presented with symptoms and signs consistent with acute severe asthma. After significant doses of beta-agonist, she developed a significant lactic acidosis. Significant issues arose in this patient's history with regards to purchase of medications, compliance and follow-up with respiratory service. Beta-adrenergic receptors when stimulated have been hypothesised to increase lipolysis, producing free fatty acids, which inhibit the conversion of pyruvate to coenzyme A within the Krebs cycle. Additional pyruvate is generated through stimulation of glycolysis and glycogenolysis through simultaneous catecholamine surge. This increased pyruvate load is shunted through anaerobic glycolysis, producing increased lactate. Steroid use during an asthma attack enhances the beta-2 receptor sensitivity, further potentiating lactate production. The hyperadrenergic state in this young asthmatic likely resulted in pyruvate and therefore lactate rise and thus metabolic acidosis as mentioned before. This piece highlights a physiological phenomenon that may occur in the context of iatrogenic hyperadrenergism.

A Quality Improvement Intervention to Improve Inpatient Pediatric Asthma Controller Accuracy

OBJECTIVES

Our objective was to investigate if a rigorous quality improvement (QI) intervention could increase accuracy of pediatric asthma controller medications on discharge from an inpatient hospitalization.

METHODS

Our interprofessional QI team developed interventions such as improving documentation and creating standardized language to ensure patients were discharged on an appropriate asthma controller medication and improve assessment of asthma symptom control. Each week of 2015-2016, the first 5 patients discharged with status asthmaticus from the pediatric wards were reviewed for documentation of the 6 asthma control questions and accuracy of the discharge controller therapy. Correct discharge medication was defined as being prescribed the age-appropriate medication and dose on the basis of baseline controller therapy, compliance with baseline medication, and responses to asthma control assessment. The weekly proportion of control questions that were accessed and correct controller medications that were prescribed were analyzed by using Nelson rules and interrupted time series.

RESULTS

A total of 240 preintervention and 252 postintervention charts were reviewed. The primary outcome of the median proportion of patients discharged on appropriate controller therapy improved from 60% in preintervention data to 80% in the postintervention period. The process measure of proportion of asthma control questions that were assessed improved from 43% in the preintervention period to 98% by the final months of the intervention period. Both of these changes were statistically significant as per Nelson's rules and interrupted time series analyses (P = .02 and P < .001, respectively, for postintervention break).

CONCLUSIONS

An interdisciplinary QI team successfully improved the accuracy of asthma controller therapy on discharge and the inpatient assessment of asthma control questions.

Revisiting asthma therapeutics: focus on WNT signal transduction

Asthma is a complex disease of the airways that develops as a consequence of both genetic and environmental factors. This interaction has highlighted genes important in early life, particularly those that control lung development, such as the Wingless/Integrase-1 (WNT) signalling pathway. Although aberrant WNT signalling is involved with an array of human conditions, it has received little attention within the context of asthma. Yet it is highly relevant, driving events involved with inflammation, airway remodelling, and airway hyper-responsiveness (AHR). In this review, we revisit asthma therapeutics by examining whether WNT signalling is a valid therapeutic target for asthma.

Trends in international asthma mortality: analysis of data from the WHO Mortality Database from 46 countries (1993-2012)

BACKGROUND

International time trends in asthma mortality have been strongly affected by changes in management and in particular drug treatments. However, little is known about how asthma mortality has changed over the past decade. In this study, we assessed these international trends.

METHODS

We collated age-standardised country-specific asthma mortality rates in the 5-34 year age group from the online WHO Mortality Database for 46 countries. To be included in the analysis, we specified that a country must have 10 years of complete data in the WHO Mortality Database between 1993 and 2012. In the absence of consistent and accurate asthma prevalence and prescribing data, we chose to use a locally weighted scatter plot smoother (LOESS) curve, weighted by the individual country population in the 5-34-year age group to show the global trends in asthma mortality rates with time.

FINDINGS

Of the 46 countries included in the analysis of asthma mortality, 36 were high-income countries, and 10 were middle-income countries. The LOESS estimate of the global asthma mortality rate was 0·44 deaths per 100 000 people (90% CI 0·39-0·48) in 1993 and 0·19 deaths per 100 000 people (0·18-0·21) in 2006. Despite apparent further reductions in some countries and regions of the world, there was no appreciable change in global asthma mortality rates from 2006 through to 2012, when the LOESS estimate was also 0·19 deaths per 100 000 people (0·16-0·21).

INTERPRETATION

The trend for reduction in global asthma mortality observed since the late 1980s might have stalled, with no appreciable difference in a smoothed LOESS curve of asthma mortality from 2006 to 2012. Although better implementation of established management strategies that have been shown to reduce mortality risk is needed, to achieve a further substantive reduction in global asthma mortality novel strategies will also be required.

FUNDING

The Medical Research Institute of New Zealand, which is supported by Health Research Council of New Zealand Independent Research Organisation.

Pneumonia risk in asthma patients using inhaled corticosteroids: a quasi-cohort study

AIM

Studies have linked the use of inhaled corticosteroids (ICSs) to excess pneumonia risk in chronic obstructive pulmonary disease patients. The risk in asthma patients remains unclear. The objective of the present study was to examine the risk of pneumonia with ICSs in asthma patients aged 12-35 years.

METHODS

We formed a cohort of asthma patients treated from 1990 to 2007 using Quebec health insurance databases. Subjects were considered currently exposed if they had had an ICS dispensed within the 60 days prior to their pneumonia index event or matched person-moment. Secondary analyses investigated the risk of pneumonia according to ICS dose and type. Rate ratios (RRs) and rate differences (RDs) were both estimated through a quasi-cohort approach.

RESULTS

The cohort included 152 412 subjects, of whom 1928 had a pneumonia event during follow-up. There was an increased risk of pneumonia associated with current use of ICSs [RR 1.83; 95% confidence interval (CI) 1.57, 2.14] or an excess risk of 1.44 cases per 1000 person-years (RD 1.44; 95% CI 1.03, 1.85). There was an excess pneumonia risk with low doses (RR 1.60; 95% CI 1.06, 2.45), moderate doses (RR 1.53; 95% CI 1.12, 2.08) and high doses (RR 1.96; 95% CI 1.64, 2.34) of ICSs, and with budesonide (RR 2.67; 95% CI 2.05, 3.49) and fluticasone (RR 1.93; 95% CI 1.58, 2.36), specifically relative to no use. When accounting for potential protopathic bias, the risk with current use of ICSs was attenuated (RR 1.48; 95% CI 1.22, 1.78).

CONCLUSION

ICS use in asthma patients appears to be associated with an increased risk of pneumonia and is present for both budesonide and fluticasone.

Long-term treatment in pediatric asthma: an update on chemical pharmacotherapy

INTRODUCTION

Asthma is the most common chronic disease in childhood, affecting approximately 10% of all children, and is the leading cause of hospitalization in developed countries. In this paper we aimed to review the evidence on chemical pharmacotherapy for long-term treatment of pediatric asthma, according to the latest updates. Area covered: Long-term treatment, essential for controlling symptoms and reducing future risks including exacerbations and decline in lung function, includes control agents such as inhaled corticosteroids, long-acting beta2-adrenergic agonists, and leukotriene modifiers. More recent strategies based on the use of a biological drug such as omalizumab, which is a monoclonal antibody directed against immunoglobulin E (IgE), can be considered in selected patients with severe asthma. Expert opinion: In the near future, the challenge of childhood asthma treatment will be to improve the chemical drugs that already exist as well as to carefully characterize the several different asthma subtypes, with special regard to children with severe disease. A better definition of patient features, made possible by the current advanced knowledge of the pathobiology of severe asthma, can ultimately allow the identification of specific phenotypes and endotypes of severe asthma, aimed to personalize pharmacological treatment.