Influence of age on clinical characteristics, pharmacological management and exacerbations in children with asthma

Implementation and Effectiveness of Guideline-Recommended Clinical Activities for Children With Asthma: Population-Based Cohort

BACKGROUND

Guidelines advise minimizing asthma exacerbation risk, which is achieved partially through good clinical practice activities, including scheduled asthma reviews, inhaler technique checks, and asthma management plans. We assessed how frequently these activities are provided and how effective they are in clinical practice.

RESEARCH QUESTION

Do guideline-recommended activities such as asthma reviews, inhaler technique checks, and asthma management plans prevent asthma exacerbations?

STUDY DESIGN AND METHODS

This retrospective chart review used United Kingdom primary care medical records between 2004 and 2021, linked to hospital records. Children were eligible from asthma diagnosis until age 16 years. Annual implementation of asthma review, inhaler technique check, and asthma management plan was measured. Risk factors for these activities not being undertaken were determined by using multivariable logistic regression. Self-controlled case series was adopted to assess the effectiveness of each activity over 12 months; this was divided into two 6-month periods.

RESULTS

A total of 126,483 children were eligible; 30% to 45% received each annual activity, and 8% received all 3 together. Risk factors for not receiving activities included younger age, more socioeconomic deprivation, and higher or no BMI measurement. Management plans and asthma reviews, as standalone activities, were associated with an approximately 15% exacerbation reduction over 12 months and 8% over 6 months, respectively (asthma management plan, n = 4,624; 0-6 months [incidence rate ratio (95% CI)]: 0.87 [0.79-0.96]; 6-12 months: 0.83 [0.73-0.95]; asthma review, n = 6,948; 0-6 months: 0.92 [0.85-0.99]; 6-12 months: 0.93 [0.83-1.03]). Standalone inhaler technique checks were not associated with exacerbations. Provision of all activities together was associated with an approximately 30% exacerbation reduction over 12 months (n = 3,643; 0-6 months: incidence rate ratio, 0.76 [0.68-0.85]; 6-12 months: incidence rate ratio, 0.69 [95% CI, 0.60-0.81]).

INTERPRETATION

Most children in the United Kingdom do not receive the guideline-recommended activities to monitor their asthma. This study suggests that these activities, if implemented, are effective in clinical practice and maximally effective when combined in the same visit.

Sphingosine kinase 1-specific inhibitor PF543 reduces goblet cell metaplasia of bronchial epithelium in an acute asthma model

Sphingosine kinase 1 (SPHK1) has been shown to play a key role in the pathogenesis of asthma where SPHK1-generated sphingosine-1-phosphate (S1P) is known to mediate innate and adaptive immunity while promoting mast cell degranulation. Goblet cell metaplasia (GCM) contributes to airway obstruction in asthma and has been demonstrated in animal models. We investigated the role of PF543, a SPHK1-specific inhibitor, in preventing the pathogenesis of GCM using a murine (C57BL/6) model of allergen-induced acute asthma. Treatment with PF543 before triple allergen exposure (DRA: House dust mite, Ragweed pollen, and Aspergillus) reduced inflammation, eosinophilic response, and GCM followed by reduced airway hyperreactivity to intravenous methacholine. Furthermore, DRA exposure was associated with increased expression of SPHK1 in the airway epithelium which was reduced by PF543. DRA-induced reduction of acetylated α-tubulin in airway epithelium was associated with an increased expression of NOTCH2 and SPDEF which was prevented by PF543. In vitro studies using human primary airway epithelial cells showed that inhibition of SPHK1 using PF543 prevented an allergen-induced increase of both NOTCH2 and SPDEF. siRNA silencing of SPHK1 prevented the allergen-induced increase of both NOTCH2 and SPDEF. NOTCH2 silencing was associated with a reduction of SPDEF but not that of SPHK1 upon allergen exposure. Our studies demonstrate that inhibition of SPHK1 protected allergen-challenged airways by preventing GCM and airway hyperreactivity, associated with downregulation of the NOTCH2-SPDEF signaling pathway. This suggests a potential novel link between SPHK1, GCM, and airway remodeling in asthma.NEW & NOTEWORTHY The role of SPHK1-specific inhibitor, PF543, in preventing goblet cell metaplasia (GCM) and airway hyperreactivity (AHR) is established in an allergen-induced mouse model. This protection was associated with the downregulation of NOTCH2-SPDEF signaling pathway, suggesting a novel link between SPHK1, GCM, and AHR.