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

Impact of Omalizumab in Patients with Severe Uncontrolled Asthma and Possible Predictive Biomarkers of Response: A Real-Life Study

Most patients with asthma can control their symptoms with a basic standard of medical care and with maintenance and rescue medication. However, between 5% and 10% of asthmatics worldwide do not achieve control of their symptoms and have recurrent exacerbations and respiratory difficulties. The objective of the study was the real-life evaluation of the clinical improvement of patients with severe eosinophilic asthma treated with omalizumab, together with the search for biomarkers associated with the response. An observational retrospective cohort study was conducted that included patients with severe uncontrolled allergic asthma being treated with omalizumab. Three types of response were evaluated: lower use of oral corticosteroids, improvement in lung function, and reduction in exacerbations. A total of 110 patients under treatment with omalizumab were included, with a mean age of 48 ± 16 years. After 12 months had elapsed, significant reductions were found in the number of exacerbations, use of oral cortico-steroids and doses of inhaled corticosteroids (p < 0.001). Lung function and asthma control improved significantly (p < 0.001; p = 0.004) and eosinophil levels were significantly reduced (p = 0.004). Low scores in the Asthma Control Test were associated with the oral corticosteroid-saving effect; lower previous FEV1 levels and absence of chronic obstructive pulmonary disease (COPD) were related to improvement in lung function, and prior FEV1 values higher than 80% and absence of gastroesophageal reflux disease (GERD) with a reduction in exacerbations. The results of this study confirm the clinical benefit obtained after the introduction of omalizumab and the possible predictive biomarkers of response to the treatment.

Eosinophilic inflammation: An Appealing Target for Pharmacologic Treatments in Severe Asthma

Severe asthma is characterized by different endotypes driven by complex pathologic mechanisms. In most patients with both allergic and non-allergic asthma, predominant eosinophilic airway inflammation is present. Given the central role of eosinophilic inflammation in the pathophysiology of most cases of severe asthma and considering that severe eosinophilic asthmatic patients respond partially or poorly to corticosteroids, in recent years, research has focused on the development of targeted anti-eosinophil biological therapies; this review will focus on the unique and particular biology of the eosinophil, as well as on the current knowledge about the pathobiology of eosinophilic inflammation in asthmatic airways. Finally, current and prospective anti-eosinophil therapeutic strategies will be discussed, examining the reason why eosinophilic inflammation represents an appealing target for the pharmacological treatment of patients with severe asthma.

S-nitrosylation is required for β2AR desensitization and experimental asthma

The β2-adrenergic receptor (β2AR), a prototypic G-protein-coupled receptor (GPCR), is a powerful driver of bronchorelaxation, but the effectiveness of β-agonist drugs in asthma is limited by desensitization and tachyphylaxis. We find that during activation, the β2AR is modified by S-nitrosylation, which is essential for both classic desensitization by PKA as well as desensitization of NO-based signaling that mediates bronchorelaxation. Strikingly, S-nitrosylation alone can drive β2AR internalization in the absence of traditional agonist. Mutant β2AR refractory to S-nitrosylation (Cys265Ser) exhibits reduced desensitization and internalization, thereby amplifying NO-based signaling, and mice with Cys265Ser mutation are resistant to bronchoconstriction, inflammation, and the development of asthma. S-nitrosylation is thus a central mechanism in β2AR signaling that may be operative widely among GPCRs and targeted for therapeutic gain.

Pharmacogenomics and Pediatric Asthmatic Medications

Asthma is a respiratory condition often stemming from childhood, characterized by difficulty breathing and/or chest tightness. Current treatment options for both adults and children include beta-2 agonists, inhaled corticosteroids (ICS), and leukotriene modifiers (LTM). Despite recommendations by the Global Initiative for Asthma, a substantial number of patients are unresponsive to treatment and unable to control symptoms. Pharmacogenomics have increasingly become the front line of precision medicine, especially with the recent use of candidate gene and genome- wide association studies (GWAS). Screening patients preemptively could likely decrease adverse events and therapeutic failure. However, research in asthma, specifically in pediatrics, has been low. Although numerous adult trials have evaluated the impact of pharmacogenomics and treatment response, the lack of evidence in children has hindered progress towards clinical application. This review aims to discuss the impact of genetic variability and response to asthmatic medications in the pediatric population.

Clinical profile of chronic bronchial asthma patients in Poland: results of the PROKSAL study

Introduction

Asthma is a complex condition characterized by the presence of chronic inflammation in the lower respiratory tract resulting in many disturbing symptoms. The study of the clinical profile of the population with asthma allows us to understand a trend of a specific disease taking into account several indicators and its clinical characteristics.

Aim

Evaluation of the clinical profile of patients with chronic bronchial asthma in Poland.

Material and methods

The study included 10400 adult patients, of both sexes, diagnosed with chronic bronchial asthma who started therapy based on inhaled glucocorticosteroids accompanied by salmeterol, and 52 allergists. The examination was performed in a doctor's surgery. Standardized questionnaire interviews were used in order to carry out the procedure.

Results

The age of the patients ranged from 18 up to 97 years. Most of them suffer from overweight and obesity. 45.3% of the patients smoked cigarettes or declared to be passive smokers. Current asthma control was poor: over 56% of the patients suffered from diurnal symptoms more often than twice a week, almost 55% from nocturnal symptoms, in 72% of the patients' physical activity was limited, whereas 57% required immediate treatment. Most commonly used drugs were inhaled glucocorticosteroids and short acting β2-mimetics. After treatment change, fewer patients suffered from asthma symptoms.

Conclusions

Adjusting the therapy according to the current guidelines and to the patient's needs helps to improve asthma control.

Pharmacotherapeutic strategies for critical asthma syndrome: a look at the state of the art

INTRODUCTION

'Critical Asthma Syndrome' (CAS) is an umbrella term proposed to include several forms of asthma, responsible for acute and life-threatening exacerbations. CAS requires urgent and adequate supportive and pharmacological treatments to prevent serious outcomes.

AREAS COVERED

The purpose of this review is to discuss current knowledge on the pharmacotherapeutic strategies for treatment of CAS.

EXPERT OPINION

Airflow limitation, airway wall edema, and mucus plugs are the pathophysiological targets of pharmacological therapies. Strategies to achieve these goals are based on the use of various classes of drugs. Inhaled beta2-agonists are the mainstay of the initial therapy of CAS. Inhaled anticholinergic agents may be considered in the treatment of CAS in addition to beta 2 agonists. Systemic corticosteroids should be administered as soon as possible in order to counteract airway inflammation and restore normal airway sensitivity. The effectiveness of pharmacological therapies in CAS is linked not only to the timely use of drugsbut also to the dosage and route of administration. Early recognition and aggressive treatment are essential for the management of CAS; however, prevention is the best cure. Although significant progress has been made, further efforts are needed to implement an optimal exacerbation prevention strategy.

Omalizumab, the first available antibody for biological treatment of severe asthma: more than a decade of real-life effectiveness

Omalizumab was the first, and for a long time the only available monoclonal antibody for the add-on treatment of severe allergic asthma. In particular, omalizumab selectively targets human immunoglobulin (Ig)E, forming small-size immune complexes that inhibit IgE binding to its high- and low-affinity receptors. Therefore, omalizumab effectively blunts the immune response in atopic asthmatic patients, thus significantly improving the control of asthma symptoms and successfully preventing disease exacerbations. These very positive effects of omalizumab make it possible to drastically decrease both referrals to the emergency room and hospitalizations for asthma exacerbations. Such important therapeutic actions of omalizumab have been documented by several randomized clinical trials, and especially by more than 10 years of real-life experience in daily clinical practice. Omalizumab can also interfere with airway remodelling by inhibiting the activation of IgE receptors located on structural cells such as bronchial epithelial cells and airway smooth muscle cells. Moreover, omalizumab is characterized by a very good safety and tolerability profile. Hence, omalizumab represents a valuable therapeutic option for the add-on biological treatment of severe allergic asthma.

Biological mechanisms underlying the clinical effects of allergen-specific immunotherapy in asthmatic children

INTRODUCTION

Allergen-specific immunotherapy (AIT) is indicated for patients with allergic asthma and/or allergic rhinitis, and can be implemented by either subcutaneous injection (SCIT) or sublingual administration (SLIT). AIT reduces asthma symptoms, lowers the use of pharmacologic controller therapy, and decreases the need for rescue medications. SLIT appears to be safer than SCIT, but SCIT seems to be more efficacious and acts earlier in allergic asthmatic children.

AREAS COVERED

This review looks at the pathobiology of allergic asthma as well as the role of regulatory T and B cells in allergen tolerance. It also reviews the immunological mechanisms underlying the clinical effects induced by AIT in allergic asthmatic children.

EXPERT OPINION

AIT is very effective in allergic asthmatic children, who can significantly benefit from this particular type of immunotherapy in order to achieve a better control of their disease. AIT is also capable of modifying the natural history of allergic asthma. Furthermore, AIT can potentially represent a valuable therapeutic tool within the context of precision medicine, as recombinant allergen technology might allow the creation of targeted extracts able to be effective against specific proteins to which individual asthmatic children are allergic, thus helping to implement a personalized approach to treatment.

Dupilumab for the treatment of asthma

INTRODUCTION

Dupilumab is a fully human IgG4 monoclonal antibody directed against the α subunit of the interleukin (IL)-4 receptor (IL-4Rα). Since the activation of IL-4Rα is utilized by both IL-4 and IL-13 to mediate their pathophysiological effects, dupilumab behaves as a dual antagonist of these two sister cytokines, which blocks IL-4/IL-13-dependent signal transduction. Areas covered: Herein, the authors review the cellular and molecular pathways activated by IL-4 and IL-13, which are relevant to asthma pathobiology. They also review: the mechanism of action of dupilumab, the phase I, II and III studies evaluating the pharmacokinetics as well as the safety, tolerability and clinical efficacy of dupilumab in asthma therapy. Expert opinion: Supported by a strategic mechanism of action, as well as by convincing preliminary clinical results, dupilumab currently appears to be a very promising biological drug for the treatment of severe uncontrolled asthma. It also may have benefits to comorbidities of asthma including atopic dermatitis, chronic sinusitis and nasal polyposis.