Comparative features of Asthma with frequent or infrequent exacerbations: A longitudinal study of retrospective and prospective events

Effects of Pregnancy-Onset Asthma on Perinatal Outcomes: A Retrospective Cohort Study

BACKGROUND

It is unknown whether women with pregnancy-onset asthma are predisposed to worse pregnancy outcomes compared with women with pre-pregnancy asthma.

OBJECTIVE

To explore whether pregnancy-onset asthma leads to worse perinatal outcomes compared with pre-pregnancy asthma.

METHODS

Women who were discharged with a diagnosis of asthma and gave birth to a live singleton were included in this retrospective cohort analysis. Women were separated into groups based on whether the asthma was diagnosed during or before pregnancy. We compared clinical characteristics, perinatal outcomes, and asthma exacerbations (AEs) between groups.

RESULTS

A total of 335 women were included in this study, 39 of whom (11.6%) had pregnancy-onset asthma and 296 had pre-pregnancy asthma. All pregnant women in the pregnancy-onset group experienced AEs during pregnancy. The proportion of chronic hypertension, chronic hypertension with superimposed preeclampsia, and spontaneous preterm births in the pregnancy-onset group was significantly higher than that in the pre-pregnancy asthma group. After adjusting for age, body mass index, onset of asthma during pregnancy, and severity of AEs through multivariate analysis, pregnancy-onset asthma was an independent risk factor for spontaneous preterm birth (adjusted odds ratio = 7.71; 95% CI, 1.30-46.12) and severe AE was an independent risk factor for gestational hypertension and preeclampsia (adjusted odds ratio = 3.58; 95% CI, 1.30-9.87).

CONCLUSIONS

During pregnancy, pregnancy-onset asthma in women is associated with an exacerbation of the condition. Obstetricians should be vigilant for signs of asthma onset during pregnancy. Other health care providers should watch for symptoms of gestational hypertension and preeclampsia in pregnant women with preexisting or new-onset asthma.

Real-world effectiveness of dupilumab versus benralizumab and mepolizumab

Introduction: In the United States, this real-world study compared the effectiveness of dupilumab, benralizumab, and mepolizumab in reducing exacerbations and systemic corticosteroid (SCS) prescriptions among patients with asthma. Methods: Patients (≥12 years old) who initiated dupilumab, benralizumab, or mepolizumab (index) between November 2018 and September 2020 were identified by using electronic medical record data. Subjects were included if they had ≥ 12 months of data before and after the index date and two or more severe asthma-related exacerbations before the index date. Differences in baseline characteristics were addressed by using inverse probability treatment weighting (IPTW). Pairwise comparisons between dupilumab and benralizumab, or mepolizumab were conducted by using negative binomial regression, adjusting for baseline rates and unbalance characteristics (≥10% standardized differences) after IPTW. Results: Overall, a total of 1737 subjects met all criteria: 825 dupilumab, 461 benralizumab, and 451 mepolizumab initiators. In the postindex period, dupilumab was associated with a 24% and 28% significant reduction in the risk of severe asthma exacerbations versus benralizumab (incidence rate ratio [IRR] 0.76 [95% confidence interval {CI}, 0.67-0.86)] and mepolizumab (IRR 0.72 [95% CI, 0.63-0.82]), respectively. In addition, dupilumab treatment significantly reduced SCS prescriptions by 16% and 25% versus benralizumab and mepolizumab, respectively (p < 0.05). Conclusion: This study represents one of the largest real-world comparisons of biologics (dupilumab, benralizumab, and mepolizumab) for asthma in the United States to date. This analysis shows that the use of dupilumab was associated with a significantly greater reduction in both severe asthma exacerbations and SCS prescriptions compared with benralizumab and mepolizumab.

Maternal and perinatal outcomes of asthma exacerbation during pregnancy in a Chinese population: a retrospective cohort study

BACKGROUND

Asthma exacerbation (AE) is a significant clinical problem during pregnancy. This study aimed to identify maternal and perinatal outcomes associated with AE during pregnancy.

METHODS

We conducted a retrospective cohort study using the Peking University Third Hospital database from January 1, 2013 to December 31, 2020. We compared the clinical characteristics and maternal, perinatal and offspring outcomes of asthma with and without exacerbations among women who delivered during this period. The primary outcome was hypertensive disorders of pregnancy (HDP). Univariable and multivariable logistic regression analyses were used to analyze the clinical characteristics of AE during pregnancy and the association between AE and adverse maternal and perinatal outcomes.

RESULTS

The prevalence of asthma during pregnancy increased from 0.52% in 2013 to 0.98% in 2020. Of the 220 patients with asthma during pregnancy included in the study, 105 experienced AE during pregnancy: 62.9% (n = 66) had mild-to-moderate AE and 37.1% (n = 39) had severe AE. Pregnant women with allergic rhinitis have a higher risk of AE during pregnancy. Women who experienced AE were more at risk for hypertensive disorders of pregnancy than women who did not experience any exacerbation (12.4%vs3.5%, p < 0.05).

CONCLUSIONS

The prevalence of asthma among pregnant women in China is on the rise. There is a notable correlation between pregnant women who suffer from allergic rhinitis and an elevated risk of AE during pregnancy. Studies have shown that AE during pregnancy are associated with an increased risk of hypertensive disorders of pregnancy.

Association of rhinitis with asthma prevalence and severity

Asthma and rhinitis often co-exist in the same patient. Although some authors observed a higher prevalence and/or greater severity of asthma in patients with rhinitis, this view is not homogeneous and the debate continues. The aim of our study is to describe the prevalence of rhinitis in children and adolescents and to analyse their relationship with the prevalence of asthma. A multicentre study was conducted using the methodology of the International Study of Asthma and Allergies in Childhood (ISAAC). The target population of the study was all those school children aged 6–7 and 13–14 years from 6 of the main health catchment areas of Galicia (1.9 million inhabitants). The schools required were randomly selected, and all children in the targeted age ranges were included. Multiple logistic regression was used to obtain adjusted prevalence odds ratios (OR) between asthma symptoms of the schoolchildren and rhinitis prevalence. The results were adjusted for parental smoking habits, maternal education level, cat and dog exposure, and obesity. A total of 21,420 valid questionnaires were finally obtained. Rhinitis was associated with a significant increase in the prevalence of asthma in both age groups. The highest OR were 11.375 for exercise induced asthma (EIA) for children with recent rhinoconjunctivitis and 9.807 for children with recent rhinitis in 6–7 years old group. The prevalence OR’s are higher in EIA and severe asthmatics. Rhinitis in children and adolescents is associated with a higher prevalence and severity of asthma.

Obese, non-eosinophilic asthma: frequent exacerbators in a real-world setting

OBJECTIVE

In the UK, asthma deaths are at their highest level this century. Increased recognition of at-risk patients is needed. This study phenotyped frequent asthma exacerbators and used machine learning to predict frequent exacerbators.

METHODS

Patients admitted to a district general hospital with an asthma exacerbation between 1st March 2018 and 1st March 2020 were included. Patients were organized into two groups: "Infrequent Exacerbators" (1 admission in the previous 12 months) and "Frequent Exacerbators" (≥2 admissions in the previous 12 months). Patient data were retrospectively collected from hospital and primary care records. Machine learning models were used to predict frequent exacerbators.

RESULTS

200 patients admitted for asthma exacerbations were randomly selected (73% female; mean age 47.8 years). Peripheral eosinophilia was uncommon in either group (21% vs 19%). More frequent exacerbators were being treated with high-dose ICS than infrequent exacerbators (46.5% vs 23.2%; P < 0.001), and frequent exacerbators used more SABA inhalers (10.9 vs 7.40; P = 0.01) in the year preceding the current admission. BMI was raised in both groups (34.2 vs 30.9). Logistic regression was the most accurate machine learning model for predicting frequent exacerbators (AUC = 0.80).

CONCLUSIONS

Patients admitted for asthma are predominately female, obese and non-eosinophilic. Patients who require multiple admissions per year have poorer asthma control at baseline. Machine learning algorithms can predict frequent exacerbators using clinical data available in primary care. Instead of simply increasing the dose of corticosteroids, multidisciplinary management targeting Th2-low inflammation should be considered for these patients.

Developing a short-term prediction model for asthma exacerbations from Swedish primary care patients' data using machine learning - Based on the ARCTIC study

OBJECTIVE

The ability to predict impending asthma exacerbations may allow better utilization of healthcare resources, prevention of hospitalization and improve patient outcomes. We aimed to develop models using machine learning to predict risk of exacerbations.

METHODS

Data from 29,396 asthma patients was collected from electronic medical records and national registers covering clinical and epidemiological factors (e.g. comorbidities, health care contacts), between 2000 and 2013. Machine-learning classifiers were used to create models to predict exacerbations within the next 15 days. Model selection was done using the mean cross validation score of area under precision-recall curve (AUPRC).

RESULTS

The most important predictors of exacerbation were comorbidity burden and previous exacerbations. Model validation on test data yielded an AUPRC = 0.007 (95% CI: ± 0.0002), indicating that historic clinical information alone may not be sufficient to predict a near future risk of asthma exacerbation.

CONCLUSIONS

Supplementation with additional data on environmental triggers, (e.g. weather, pollen count, air quality) and from wearables, might be necessary to improve performance of the short-term predictive model to develop a more clinically useful tool.

Clinical and Inflammatory Features of Exacerbation-Prone Asthma: A Cross-Sectional Study Using Multidimensional Assessment

BACKGROUND

Reducing asthma exacerbations is a major target of current clinical guidelines, but identifying features of exacerbation-prone asthma (EPA) using multidimensional assessment (MDA) is lacking.

OBJECTIVE

To systemically explore the clinical and inflammatory features of adults with EPA in a Chinese population.

METHODS

We designed a cross-sectional study using the Severe Asthma Web-based Database from the Australasian Severe Asthma Network (ASAN). Eligible Chinese adults with asthma (n = 546) were assessed using MDA. We stratified patients based on exacerbation frequency: none, few (1 or 2), and exacerbation prone (≥3). Univariate and multivariable negative binomial regression analyses were performed to investigate features associated with the frequency of exacerbations.

RESULTS

Of 546 participants, 61.9% had no exacerbations (n = 338), 29.6% had few exacerbations (n = 162), and 8.4% were exacerbation prone (n = 46) within the preceding year. EPA patients were characterized by elevated blood and sputum eosinophils but less atopy, with more controller therapies but worse asthma control and quality of life (all p < 0.05). In multivariable models, blood and sputum eosinophils (adjusted rate ratio = 2.23, 95% confidence interval = [1.26, 3.84] and 1.67 [1.27, 2.21], respectively), FEV1 (0.90 [0.84, 0.96]), bronchodilator responsiveness (1.16 [1.05, 1.27]), COPD (2.22 [1.41, 3.51]), bronchiectasis (2.87 [1.69, 4.89]), anxiety (2.56 [1.10, 5.95]), and depression (1.94 [1.20, 3.13]) were found. Further, upper respiratory tract infection (1.83 [1.32, 2.54]) and food allergy (1.67 [1.23, 2.25]) were at high risk of asthma symptom triggers.

CONCLUSION

EPA is a clinically recognizable phenotype associated with several recognizable traits that could be addressed by targeted treatment.

Exacerbation Patterns in Adults with Asthma in England. A Population-based Study

RATIONALE

Asthma is heterogeneous and knowledge on exacerbation patterns is lacking. Previous studies have had a relatively short follow-up or focused on severe disease.

OBJECTIVES

To describe exacerbation patterns over a prolonged follow-up in a population that includes patients of all disease severity.

METHODS

We used electronic health care records to identify patients with asthma aged 18-55 years and their exacerbations from 2007 to 2015. A cohort with greater than or equal to 7 years of data was used to describe exacerbation patterns by asthma severity defined by medication use. Effect estimates for risk factors were calculated for sporadic (single year of exacerbations) and recurrent (>1 yr) exacerbation patterns, using logistic regression. In a nested case-control design, the association between a history of exacerbations, spanning 5 years, and a future exacerbation was examined.

MEASUREMENTS AND MAIN RESULTS

A total of 51,462 patients were eligible for the 7-year cohort; 64% had no exacerbations. Of those who exacerbated, 51% did so only once; exacerbation frequency increased with disease severity. Only 370 patients (0.7%) were characterized by a frequent-exacerbator phenotype (yearly exacerbations), of whom 58% had mild/moderate asthma. Exacerbation risk factors were not uniquely associated with a particular exacerbation pattern. A past exacerbation increased the risk of a future exacerbation more than all other factors, although this effect dissipated over 5 years.

CONCLUSIONS

During 7 years of follow-up, exacerbations occur in around one-third of patients. Of those who exacerbate, half do not do so again; the timing of future exacerbations is largely unpredictable. Just 2% exhibit a frequent-exacerbator phenotype. Past exacerbation patterns are the most informative risk factor for predicting future exacerbations.

Exacerbation-Prone Asthma

Patients who are prone to exacerbations of asthma experience significant costs in terms of missed work and school, acute care visits, and hospitalizations. Exacerbations are largely driven by environmental exposures including pollutants, stress, and viral and bacterial pathogens. These exposures are most likely to induce acute severe "asthma attacks" in high-risk patients. These personal risk factors for exacerbations can vary with the phenotype of asthma and age of the patient. In children, allergic sensitization is a strong risk factor, especially for those children who develop sensitization early in life. Airway inflammation is an important risk factor, and biomarkers are under evaluation for utility in detecting eosinophilic and type 2 inflammation and neutrophilic inflammation as indicators of risk for recurrent exacerbations. Insights into inflammatory mechanisms have led to new approaches to prevent exacerbations using mAb-based biologics that target specific type 2 pathways. Challenges remain in developing an evidence base to support precision interventions with these effective yet expensive therapies, and in determining whether these treatments will be safe and effective in young children. Unfortunately, there has been less progress in developing treatments for acute exacerbations. Hopefully, greater understanding of mechanisms relating airway viruses, bacteria, mucin production, and neutrophilic inflammatory responses will lead to additional treatment options for patients experiencing acute exacerbations.

[Asthma exacerbations in adults: Preventing and treat]

Exacerbations of asthma are still responsible for 900 deaths per year in France, most of which are considered preventable. They have a major impact on the quality of life of patients and are responsible for a large part of the socio-economic cost of asthma in France. Exacerbations of asthma can be partly prevented by inhaled corticosteroid treatment as controller therapy, at a dose adapted to the level of control of symptoms and the management of aggravating factors. Every patient should benefit from a written action plan that allows them to start oral corticosteroid therapy as soon as possible during an exacerbation. The treatment combines short-acting bronchodilators with systemic corticosteroids. Systemic antibiotic therapy has no place in the treatment of exacerbations. The patient must be seen early in the course of an exacerbation of asthma to review all of his follow-up.