Prognosis of adult asthma after normalization of bronchial hyperresponsiveness by inhaled corticosteroid therapy

STOP: an open label crossover trial to study ICS withdrawal in patients with a combination of obesity and low-inflammatory asthma and evaluate its effect on asthma control and quality of life

Background

Asthma patients with obesity often have a high disease burden, despite the use of high-dose inhaled corticosteroids (ICS). In contrast to asthmatics with normal weight, the efficacy of ICS in patients with obesity and asthma is often relatively low. Meanwhile, patients do suffer from side effects, such as weight gain, development of diabetes, cataract, or high blood pressure. The relatively poor response to ICS might be explained by the low prevalence of type 2 inflammatory patterns (T2-low) in patients with asthma and obesity. T2-low inflammation is characterized by low eosinophilic count, low Fractional exhaled NO (FeNO), no clinically allergy-driven asthma, and no need for maintenance oral corticosteroids (OCS). We aim to study whether ICS can be safely withdrawn in patients with T2-low asthma and obesity while maintaining an equal level of asthma control. Secondary outcomes focus on the prevalence of ‘false-negative’ T2-low phenotypes (i.e. T2-hidden) and the effect of ICS withdrawal on parameters of the metabolic syndrome. This study will lead to a better understanding of this poorly understood subgroup and might find new treatable traits.

Methods

The STOP trial is an investigator-initiated, multicenter, non-inferiority, open-label, crossover study aiming to assess whether ICS can be safely withdrawn in adults aged 17–75 years with T2-low asthma and obesity (body mass index (BMI) ≥ 30 kg/m2). Patients will be randomly divided into two arms (both n = 60). One arm will start with fixed-dose ICS (control group) and one arm will taper and subsequently stop ICS (intervention group). Patients in the intervention group will remain ICS naïve for ten weeks. After a washout of 4 weeks, patients will crossover to the other study arm. The crossover study takes 36 weeks to complete. Patients will be asked to participate in the extension study, to investigate the long-term metabolic benefits of ICS withdrawal.

Discussion

This study yields valuable data on ICS tapering in patients with T2-low asthma and obesity. It informs future guidelines and committees on corticosteroid-sparing algorithms in these patients.

Trial registration Netherlands Trial Register, NL8759, registered 2020–07-06, https://www.trialregister.nl/trial/8759.

Protocol version and date: version 2.1, 20 November 2020.

Prognosis of adult asthma: a 7-year follow-up study

BACKGROUND

Studies on adult-onset asthma and the contributing factors for its prognosis are few in the literature.

OBJECTIVE

To evaluate asthma prognosis, remission rate, and contributing factors in an adult patient population.

METHODS

Two hundred patients with a diagnosis of adult-onset asthma in 2006 were included in this study. Of these, 160 were contacted in 2013 and participated in the study. Their demographic features, family history, clinical symptoms, pulmonary function test results, and Asthma Control Test scores were re-evaluated. Patients' asthma control status was determined. Patients who had total control and had not used any asthma treatment for at least 2 years were classified as in remission.

RESULTS

The study group consisted of 160 patients (144 women and 16 men, mean age 52.9 ± 10.3 years). Nearly 70% of patients had adult-onset asthma before 40 years of age. According to asthma control status, 21.9% of patients had uncontrolled asthma, 29.4% had partially controlled asthma, and 48.8% had totally controlled asthma. Remission was observed in 11.3% of the entire study group. The mean age of the remission group was significantly younger. Disease duration was shorter and the proportion of patients with atopy was larger in the totally controlled and remission groups. Except in the remission group, patients showed weight gain from 2006 through 2013.

CONCLUSION

According to these 7-year follow up data, the remission rate of asthma was 11.3%. Patients with younger age, younger onset, atopy, allergic rhinitis, and few comorbidities seemed to have a greater possibility of remission.

Markers for step-down of inhaled corticosteroid therapy in adult asthmatics

BACKGROUND

Treatment guidelines recommend the use of inhaled corticosteroids (ICS) as first-line therapy for all stages of persistent asthma. However, it is unknown whether ICS dose reduction in adult asthmatics is compatible with maintaining asthma control. Moreover, there are no predictors of efficacy in maintaining asthma control upon ICS reduction.

METHODS

We recruited 90 adult patients with moderate or severe asthma but no clinical symptoms of asthma for at least 6 months. All patients reduced their ICS doses by half but continued taking other asthma-related medications. As a primary outcome, we measured asthma exacerbations during the 12 months following ICS reduction. We also further monitored patients from the above study who had maintained total asthma control for 12 months after ICS reduction and who had continued on their reduced doses of ICS or had further reduced, or stopped, their ICS.

RESULTS

Forty of ninety patients (44.4%) experienced exacerbations after ICS reduction (time to first exacerbation: 6.4 ± 3.6 months). Multivariate logistic regression modeling revealed a rank order of predictors of success in ICS reduction while retaining asthma control: acetylcholine (ACh) PC(20) (p < 0.01); length of time with no clinical symptoms before ICS reduction (p < 0.01); FeNO (p = 0.028); and forced expiratory volume in 1 s (FEV(1); % predicted) (p = 0.03). Finally thirty-nine of 50 patients maintained total asthma control for at least 2 years after the initial ICS reduction.

CONCLUSIONS

In asthma patients with normalized AChPC(20) of 20mg/mL or 10mg/mL and no clinical symptoms for at least 12 or 24 months it may be possible to successfully reduce ICS without increasing exacerbations for long time.

Stepping down asthma treatment: how and when

PURPOSE OF REVIEW

Guidelines suggest that asthma medication should be reduced once asthma control is sustained. Moderate-dose inhaled corticosteroids (ICS) can typically be reduced, but questions remain about the lowest effective ICS dose and the role of non-ICS controllers in treatment reduction. Long-acting beta agonist (LABA) safety concerns have created controversy about how to step down patients on ICS/LABA therapy. This review will focus on the current status of these issues.

RECENT FINDINGS

Intermittent ICS treatment, often in fixed combination with short-acting beta agonist, is an emerging strategy for control of mild asthma. Addition of leukotriene modifiers, LABAs, and omalizumab to ICS can allow for reduced ICS dosing. Doses of ICS that control symptoms may be inadequate to control exacerbations. Reducing ICS dose before discontinuing LABAs may be the more effective approach for patients on combination therapy.

SUMMARY

Use of non-ICS controllers allows for ICS dose reduction with superior outcomes. Tapering of ICS prior to LABA discontinuation may be the favored approach for patients on ICS/LABA therapy, but an understanding of long-term outcomes and further safety data are required. The lowest ICS dose that adequately controls both asthma impairment and risk remains to be determined.

Loss of asthma control in inner city children with asthma after withdraw of asthma controller medication

To determine what percentage of inner-city children with asthma would lose asthma control when taken off asthma controllers, a retrospective analysis was performed on inner-city asthmatic children who achieved asthma control in an asthma specific disease management program. Once disease control was achieved patients had stepwise reduction of asthma controllers based on the National Asthma Education and Prevention Program (NAEPP) Expert Review Panel (EPR) 2 guidelines. In patients who were taken off all controllers, probability of maintaining asthma control at the first visit after cessation of these medications was significantly lower compared to patients kept on inhaled corticosteroids. We conclude that cessation of asthma controllers in previously well controlled inner-city asthmatic children results in loss of asthma control in a significant number of these patients. Data support recommendations from national asthma guidelines to step down controller therapy, but clinical monitoring is important to reduce impairment due to loss of control.

Perception of dyspnea during acetylcholine-induced bronchoconstriction in asthmatic children

BACKGROUND

Few studies have examined the relationship between dyspnea perception and bronchial hyperresponsiveness (BHR) in asthmatic children.

OBJECTIVE

To test the hypothesis that severe BHR is associated with poor perception of the severity of airway obstruction.

METHODS

One hundred one asthmatic children (mean [SD] age, 11.1 [2.3] years) were evaluated using acetylcholine chloride (Ach) challenge. The BHR was assessed as the provocative concentration of Ach causing a 20% decrease in forced expiratory volume in 1 second (FEV1) (PC20). Perception of dyspnea was scored using a modified Borg scale after each dose of Ach and bronchodilator. The dyspnea threshold was defined as the point at which the Borg scale score became higher than 0. We evaluated the dyspnea perception score at a 20% decrease in FEV1 relative to baseline (PS20) and after bronchodilator administration (PS(BD)).

RESULTS

The mean (SD) PS20 and PS(BD) were significantly lower in the severe vs the mild BHR group (PS20: 2.1 [1.9] vs 4.2 [2.4], P < .001; PS(BD): 0.5 [1.0] vs 1.0 [1.3], P = .048). The mean (SD) % decrease in FEV1 at the dyspnea threshold was significantly greater in the severe vs the mild BHR group (14.1% [11%] vs 5.4% [11%], P < .001). The PS20 was correlated positively with the PC20 (r2 = 0.25, P < .001), and the decrease in FEV1 at the dyspnea threshold was correlated negatively with the PC20 (r2 = 0.18, P < .001).

CONCLUSIONS

Moderate to severe asthmatic children with severe BHR perceive dyspnea only after the stage of mild bronchoconstriction has passed. This relative insensitivity to dyspnea in asthmatic children with severe BHR may lead to undertreatment of asthma.