Inhaled corticosteroids and decline of lung function in community residents with asthma

Impulse oscillometry in children and adolescents with persistent asthma and its correlation with spirometry

INTRODUCTION

Asthma is one of the most common chronic diseases of childhood. Spirometry is the traditional test for assessing lung function, while impulse oscillometrics is an alternative resource that measures the impedance of the respiratory system.

OBJECTIVE

: To evaluate the pulmonary function of children and adolescents with asthma by impulse oscillometry and correlate the findings with those obtained by spirometry.

METHODS

A cross-sectional study in which the pulmonary function of asthmatic children and adolescents aged between 6 and 18 years was evaluated, categorized by the level of disease control according to the Asthma Control Test (ACT) or Children Asthma Control Test (C-ACT) into controlled (ACT/C-ACT>19; n = 70) and uncontrolled (ACT/C-ACT ≤ 19; n = 60).

RESULTS

A total of 130 asthmatic children and adolescents were evaluated (51% were males). There were no significant differences in the parameter values of both tests when patients were divided by the level of asthma control. Altered impulse oscillometry and spirometry were performed in 20 and 25% of the cases, respectively. Changes in impulse oscillometry were more frequent in patients with controlled asthma. R5 (%), X5 (%), and Fres showed moderate correlation with the main spirometric parameters, being stronger between X5 (%) and FEV₁/FVC (%) (r: -0,58; P < 0,05) in patients with controlled asthma. Bronchodilator response was observed in a similar number of patients in both exams, but with reasonable agreement.

CONCLUSIONS

Impulse oscillometry values showed a weak or moderate correlation with spirometry values.

Cigarette Smoking and Asthma

Globally, around half the adult asthma population are current or former cigarette smokers. Cigarette smoking and asthma interact to induce an "asthma-smoking phenotype(s)," which has important implications for diagnosis, pathogenic mechanisms, and management. The lack of progress in understanding the effects of smoking on adults with asthma is due in part to their exclusion from most investigative studies and large clinical trials. In this review, we summarize the adverse clinical outcomes associated with cigarette smoking in asthma, highlight challenges in diagnosing asthma among cigarette smokers with chronic respiratory symptoms, particularly in older individuals with a long-standing smoking history, and review pathogenic mechanisms involving smoking- and asthma-related airway inflammation, tissue remodeling, corticosteroid insensitivity, and low-grade systemic inflammation. We discuss the key components of management including the importance of smoking cessation strategies, evidence for the effectiveness of the Global Initiative for Asthma recommendations on treatment in cigarette smokers, and the role of treatable traits such as type 2 eosinophilic airway inflammation. Lastly, we provide an algorithm to aid clinicians to manage current and former smokers with asthma. In the future, controlled and pragmatic trials in real-world populations should include cigarette smokers with asthma to provide an evidence base for treatment recommendations.

Association of demographic variables and smoking habits with the severity of lung function in adult smokers

Background:

This study aims to evaluate the association between demographic and smoking variables with the severity of lung function loss (Stage I to IV) and spirometry data in smokers.

Materials and Methods:

Three hundred and fifty smoker men over the age of 20 who had visited in AL-Zahra hospital were involved. Spirometry tests were performed for measuring forced vital capacity (FVC), FEV1, and FEV1%FVC. COPD was categorized into four stages by the (Global Initiative for Chronic Obstructive Lung Disease) criteria of postbronchodilator FEV1/FVC <0.70. FEV1/FVC <70%, in combination with FEV1 ≥80% (Stage I), or 50%≤FEV1 <80% (Stage II), or 30%≤FEV1 <50% (Stage III), or FEV1 ≤30% (Stage IV). Independent t-test, Spearman correlation analysis was used for data analysis. To determine the predicting factors for pulmonary function multiple regressions analysis was performed.

Results:

43 (19.5%) of men were defined as Chronic Obstructive Lung Disease (COPD) which 7% of them were Stage I, 23.3% were Stage II, 39.5% were III and 30.2% were stage IV. In 60 (27.1%) of men, the index of Fev1/FVC was <80%. The criteria of PRIS in 74 (33.5%) of the patients and BDR in 59 (26.7%) of participation was positive. There were significant differences in the mean of FEV1 with respect to history of lung disease in relatives (P = 0.035), lung disease hospitalization (P < 0.001) and previous diagnosis of asthma variables (P < 0.001). The mean of FVC was significantly different in patients categorized based on lung disease hospitalization (P < 0.001) and previous diagnosis of asthma (P = 0.018). Furthermore, there was a significant difference in the mean of FEV1/FVC for variables as follows: Time to start smoking after waking up (P = 0.007), lung disease hospitalization (P < 0.001) and previous diagnosis of asthma (P < 0.001). There was a significant association between stages of lung function loss and age of onset of smoking (β-0.355 P = 0.019) and pack per year (β = 0.354 P = 0.02). A linear regression model showed that lung disease hospitalization and age were the influential variables on FEV1 with (B = −21.79 confidence interval [CI]: −28.7, −14.87, P < 0.001and B = −0.418 CI: −0.63, −0.21, P < 0.001), respectively. The only significant influential variable on FVC was lung disease hospitalization (B = −15.89 CI: −21.49, −10.296, P < 0.001). Body mass index, lung disease hospitalization, time to start smoking after waking up in the morning and age had significant relationship on FEV1/FVC with (B = 0.71CI: 0.32, 1.11, P < 0.001, B = −14.29, CI: −19.61,-8.97, P < 0.001, B = 6.54, CI: 2.26, 10.82, P = 0.003 and B = −0.44, CI: −0.59, −0.28, P < 0.001), respectively.

Conclusion:

The age of onset of smoking and pack-year appears to be associated with the severity of COPD. Hospitalization history due to lung disease, age, the time between waking up in the morning and first cigarette use, BMI, lung disease history in relatives, previous diagnosis of asthma have a negative relationship with lung function.

The Effects of Inhaled Airway Directed Pharmacotherapy on Decline in Lung Function Parameters Among Indigenous Australian Adults With and Without Underlying Airway Disease

BACKGROUND

The trajectory of lung function decline among Indigenous patients with or without underlying chronic airway disease (COPD and concomitant bronchiectasis) and with use of inhaled pharmacotherapy, including inhaled corticosteroids (ICS), has not been reported in the past.

METHODS

Adult Indigenous Australian patients identified to have undergone at least two or more lung function tests (LFTs) between 2012 and 2020 were assessed for changes in the lung function parameters (LFPs) between the first and last recorded LFTs.

RESULTS

Of the total 1350 patients identified to have undergone LFTs, 965 were assessed to fulfil session quality, 115 (n=58 females) were eligible to be included with two or more LFTs. Among the 115 patients, 49% showed radiological evidence of airway diseases, and 77% were on airway directed inhaled pharmacotherapy. Median time between LFTs was 1.5 years (IQR 0.86,5.85), with no significant differences in LFPs noted between first and last LFT. Overall rate of change (mL/year) showed considerable variation for FVC (median -37.55 mL/year [IQR -159.88,92.67]) and FEV1 (-18.74 mL/year [-102.49,71.44]) with minimal change in FEV1/FVC (0.00 ratio/year [-0.03,0.01]). When stratified by inhaled pharmacotherapy group, however, patients using ICS showed significantly greater rate of FEV1 decline (-48.64 mL/year [-110.18,62.5]) compared to those using pharmacotherapy with no ICS (15.46 mL/year [-73.5,74.62]) and those using no pharmacotherapy (-5.76 mL/year [-63.19,67.34]) (p=0.022). Additionally, a greater proportion of these patients reached the threshold for excessive FEV1 decline (64%) compared to those using pharmacotherapy without ICS (44%) and those using no pharmacotherapy (52%).

CONCLUSION

Decline in LFPs occurs commonly among adult Indigenous population, especially, excessive so among those using inhaled pharmacotherapy containing ICS.

Lung Function Decline in Adult Asthmatics-A 10-Year Follow-Up Retrospective and Prospective Study

Asthma may have an impact on lung function decline but conflicting results are reported in forced expiratory volume in one second (FEV₁) decline. We aimed to describe the changes in FEV₁ in lifelong non-smoking adult asthmatic outpatients during a 10-year follow-up comparing years 1–5 (1st period) with years 6–10 (2nd period) to assess factors affecting these changes. A total of 100 outpatients performed spirometry every 3 months during a 10-year survey. FEV₁/Ht³ slope values of the 2nd period reduced significantly respect to the 1st period (p < 0.0001). FEV₁ slopes of years 1–5 and 6–10 were inversely associated with FEV₁ at enrolment (p = 0.02, p = 0.01, respectively). Reversibility and variability FEV₁ showed a significant effect on the 1st period slopes (p = 0.01 and p < 0.04, respectively). Frequent exacerbators in the 1st year had steeper FEV₁/Ht³ slopes in the 1st period (p = 0.01). The number of subjects using higher doses of ICS was significantly lower at the 10th years respect to the 5th and the 1st year (p < 0.001, p = 0.003, respectively). This study shows that FEV₁ decline in treated adult asthmatics non-smokers, over 10-year follow-up, is not constant. In particular, it slows down over time, and is influenced by FEV₁ at enrolment, reversibility, variability FEV₁ and exacerbation score in the 1st year.

Responsiveness to Parenteral Corticosteroids and Lung Function Trajectory in Adults with Moderate-to-Severe Asthma

Rationale: It is unclear why select patients with moderate-to-severe asthma continue to lose lung function despite therapy. We hypothesized that participants with the smallest responses to parenteral corticosteroids have the greatest risk of undergoing a severe decline in lung function.Objectives: To evaluate corticosteroid-response phenotypes as longitudinal predictors of lung decline.Methods: Adults within the NHLBI SARP III (Severe Asthma Research Program III) who had undergone a course of intramuscular triamcinolone at baseline and at ≥2 annual follow-up visits were evaluated. Longitudinal slopes were calculated for each participant's post-bronchodilator FEV₁% predicted. Categories of participant FEV₁ slope were defined: severe decline, >2% loss/yr; mild decline, >0.5-2.0% loss/yr; no change, 0.5% loss/yr to <1% gain/yr; and improvement, ≥1% gain/yr. Regression models were used to develop predictors of severe decline.Measurements and Main Results: Of 396 participants, 78 had severe decline, 91 had mild decline, 114 had no change, and 113 showed improvement. The triamcinolone-induced difference in the post-bronchodilator FEV₁% predicted (derived by baseline subtraction) was related to the 4-year change in lung function or slope category in univariable models (P < 0.001). For each 5% decrement in the triamcinolone-induced difference the FEV1% predicted, there was a 50% increase in the odds of being in the severe decline group (odds ratio, 1.5; 95% confidence interval, 1.3-1.8), when adjusted for baseline FEV₁, exacerbation history, blood eosinophils and body mass index.Conclusions: Failure to improve the post-bronchodilator FEV₁ after a challenge with parenteral corticosteroids is an evoked biomarker for patients at risk for a severe decline in lung function.

Lessons learned from targeting eosinophils in human disease

Eosinophils are a minor subset of the granulocyte lineage distinguished by their unique morphology, phenotype, cytoplasmic contents, and function. Evolutionarily, these are ancient cells whose existence has been conserved within vertebrates for millions of years, suggesting that their contribution to innate immunity and other pathologic and homeostatic responses are important to the host. Knowledge regarding the role of eosinophils in health and disease took a leap forward in 2004 with the creation of mouse strains deficient in eosinophils. This advance was paralleled in humans using pharmacology, namely, with the development of drugs capable of selectively reducing and sometimes even eliminating human eosinophils in those receiving these agents. As a result, a more definitive picture of what eosinophils do, and do not do, is emerging. This review will summarize recent advances in our understanding of the role of eosinophils in human disease by focusing mainly on data from clinical studies with anti-eosinophil therapies, even though the first of such agents, mepolizumab, was only approved in the USA in November 2015. Information regarding both efficacy and safety will be highlighted, and where relevant, intriguing data from animal models will also be mentioned, especially if there are conflicting effects seen in humans.

Does the use of inhaled corticosteroids in asthma benefit lung function in the long-term? A systematic review and meta-analysis

While asthma is known to be associated with an increased risk of progressive lung function impairments and fixed airflow obstruction, there is ongoing debate on whether inhaled corticosteroids (ICS) modify these long-term risks. Searches were performed of the PubMed, Embase and CENTRAL databases up to 22 July 2019 for studies with follow-up ≥1 year that investigated the effects of maintenance ICS on changes in lung function in asthma.Inclusion criteria were met by 13 randomised controlled trials (RCTs) (n=11 678) and 11 observational studies (n=3720). Median (interquartile range) follow-up was 1.0 (1-4) and 8.4 (3-28) years, respectively. In the RCTs, predominantly in individuals with mild asthma, ICS use was associated with improved pre-bronchodilator (BD) forced expiratory volume in 1 s (FEV1) across all age groups (2.22% predicted (95% CI 1.32-3.12), n=8332), with similar estimates of strength in association for children and adults. Improvements in post-BD FEV1 were observed in adults (1.54% (0.87-2.21), n=3970), but not in children (0.20% (-0.49-0.90), n=3924) (subgroup difference, p=0.006). Estimates were similar between smokers and nonsmokers. There were no RCT data on incidence of fixed airflow obstruction. In the observational studies, ICS use was associated with improved pre-BD FEV1 in children and adults. There were limited observational data for post-BD outcomes.In patients with mild asthma, maintenance ICS are associated with modest, age-dependent improvements in long-term lung function, representing an added benefit to the broader clinical actions of ICS in asthma. There is currently insufficient evidence to determine whether treatment reduces incidence of fixed airflow obstruction in later life.

Trajectories of asthma and allergies from 7 years to 53 years and associations with lung function and extrapulmonary comorbidity profiles: a prospective cohort study

BACKGROUND

Longitudinal trajectories of asthma and allergies from childhood to adulthood might be differentially associated with lung function and chronic obstructive pulmonary disease (COPD), but associations with extrapulmonary comorbidities have not been well investigated. We aimed to assess these trajectories and examine their associations with lung function outcomes and profiles of comorbidities.

METHODS

In this prospective cohort study, data for asthma and related allergic conditions (ie, eczema, hay fever, and food allergy) were prospectively collected from the Tasmanian Longitudinal Health Study for participants aged 7-53 years originally recruited in Tasmania, Australia. All surviving individuals in the database with contact details were invited in the most recent follow-up (mean age 53 years). There were no exclusion criteria. With use of latent class analysis, we identified longitudinal trajectories of asthma and allergic conditions from 7-53 years, and profiles of self-reported extrapulmonary conditions recorded at 53 years. The associations between asthma and allergy trajectories and morbidity profiles and lung function at 53 years were investigated with regression models.

FINDINGS

Between Sept 3, 2012, and Nov 8, 2016, of 6128 individuals invited, 3609 (58·9%) individuals were enrolled. We identified five asthma and allergy trajectories: minimal and least asthma and allergies (n= 1767 [49·0%]); late-onset hay fever, no asthma (n=1065 [29·5%]); early-onset remitted asthma and allergies (n=236 [6·5%]); late-onset asthma and allergies (n=317 [8·8%]); and early-onset persistent asthma and allergies (n=224 [6·2%]); and four profiles of extrapulmonary morbidities: minimal or least disease (n=2206 [61·1%]); dominant mental health disorders (n=861 [23·9%]); dominant cardiovascular diseases or risks (n=424 [11·7%]); and multiple disorders (n=117 [3·2%]). The late-onset asthma and allergies trajectory was predominantly associated with the multiple disorders profile (relative risk ratio 3·3 [95% CI 1·9-5·9]), whereas the other asthma and allergy trajectories were associated only with the dominant mental health disorders profile. Both spirometrically defined and clinical COPD were most strongly associated with the early-onset persistent asthma and allergies trajectory (odds ratio [OR] 5·3 [95% CI 3·2-8·6]) and also with the late-onset asthma and allergies trajectory (OR 3·8 [2·4-6·1]).

INTERPRETATION

Distinct longitudinal trajectories of asthma and allergic disease from childhood to 53 years are associated with different profiles of extrapulmonary comorbidities and varying risk of COPD. These findings can inform a personalised approach in clinical guidelines and management focusing on treatable traits. Comorbidity profiles are a new target for early identification and intervention.

FUNDING

National Health and Medical Research Council of Australia, EU's Horizon 2020, The University of Melbourne, Clifford Craig Medical Research Trust of Tasmania, The Victorian, Queensland & Tasmanian Asthma Foundations, The Royal Hobart Hospital, Helen MacPherson Smith Trust, and GlaxoSmithKline.

Transient childhood wheeze is associated with less atopy in adolescence

BACKGROUND

The relationships between childhood wheeze phenotypes and subsequent allergic conditions other than asthma, including hay fever, eczema and sensitization, have not been widely reported. We aimed to investigate this relationship up to late adolescence.

METHODS

Using five childhood wheeze phenotypes defined from 620 children in a high-atopy risk birth cohort (Melbourne Atopy Cohort Study), we investigated their relationships with sensitization, eczema, hay fever and fractional exhaled nitric oxide (FeNO) at ages 12 and/or 18 years using logistic and linear regression models.

RESULTS

'Early Persistent wheeze' was associated with the increased risk of eczema (odds ratio: 3.69; 95% CI: 1.23, 11.12) and sensitization (4.52; 1.50, 13.64) at 12 years. 'Intermediate Onset wheeze' was associated with the increased risk of eczema at 12 years (2.57; 1.11, 5.97), hay fever at 12 (2.87; 1.44, 5.74) and 18 years (2.19; 1.20, 4.02), sensitization at 12 (2.25; 1.17, 4.34) and 18 years (2.46; 1.18, 5.12), and raised FeNO at 18 years. 'Late Onset wheeze' was associated with the increased risk of hay fever at 12 (5.18; 1.11, 24.20) and 18 years (4.20; 1.03, 17.11) and sensitization at 12 years (3.27; 0.81, 13.27). In contrast, 'Early Transient wheeze' was associated with the reduced risk of eczema (0.44; 0.20, 0.96), hay fever (0.57; 0.33, 0.99) and sensitization (0.59; 0.35, 0.99) at 18 years and a lower FeNO compared with 'Never/Infrequent wheezers'.

CONCLUSIONS

Persistent wheeze phenotypes were associated with allergic outcomes up to 18 years with 'Intermediate Onset wheeze' being the most atopic group. In contrast, 'Early Transient wheezers' had less risk of allergic outcomes at 18 years. This protective effect may reassure parents of wheezy infants and young children.

Advances with glucocorticoids in the treatment of asthma: state of the art

INTRODUCTION

Asthma is one of the most frequent chronic diseases all over the world. Glucocorticoids (GCs), both inhaled (ICSs) and oral (OCSs), are the most effective treatment in asthma because they control symptoms and prevent exacerbations.

AREAS COVERED

The present article reviews the new therapeutic indications of GCs for the treatment of asthma and focuses on new molecules and safety issues.

EXPERT OPINION

Most patients with asthma benefit from corticosteroid-based treatments. Side effects are mainly due to prolonged use of oral GCs, while they are minor with inhaled GCs. Interesting insights come from the new ICSs, which are characterized by lower oral bioavailability and higher lipophilicity and are more effective with less side effects. Recent trials have shown the efficacy of early use of ICSs in mild asthma. Furthermore, the possibility to prescribe targeted therapies using specific biomarkers in steroid-sensitive asthma can reduce doses and duration of treatment, while biological agents should be reserved for non-responding patients. All this evidence confirm the need to continue on the path toward precision medicine, in which the treatments are based on clinical and molecular traits.

Predictors of accelerated FEV1 decline in adults with airflow limitation-Findings from the Health2006 cohort

To investigate predictors of accelerated decline in forced expiratory volume in 1 s (FEV₁) in individuals with preexisting airflow limitation (AL). Participants in the Health2006 baseline study aged ≥ 35 with FEV₁/ forced vital capacity (FVC) < lower limit of normal (LLN) were invited for a 10-year follow-up. At both examinations, data were obtained on demographics, spirometry, fitness level, allergy, and exhaled nitric oxide. We used multiple regression modeling to predict the annual decline in FEV₁, reported as regression coefficients ( R) and 95% confidence intervals (CIs). A total of 123 (43% of those invited) participated in the follow-up examination, where more had exercise-induced dyspnea but fewer had asthma symptoms. Being female ( R = -29.8 ml, CI: -39.7 to -19.8), diagnosed with asthma ( R = -13.7, CI: -20.4 to -7.0) or atopic dermatitis ( R = -29.0, CI: -39.7 to -18.4), and having current asthma symptoms or nightly respiratory symptoms ( R = -22.1, CI: -31.9 to -12.4 and R = -14.3, CI: -19.9 to -8.7, respectively) were significantly associated with a steeper decline in FEV₁. Although to a smaller extent, a steeper decline was also predicted by age, baseline FEV₁, waist/hip-ratio, and number of pack-years smoked. In individuals with preexisting AL, being female and having ever or current respiratory symptoms were associated with an accelerated annual decline in FEV₁.

Predictive factors of response to inhaled corticosteroids in newly diagnosed asthma: A real-world observational study

BACKGROUND

Asthma is characterized by chronic airway inflammation, and inhaled corticosteroids (ICSs) have been recommended as first-line treatment. However, response to ICS treatment is various, and the prediction of response to ICSs is still difficult, especially in individuals with newly diagnosed asthma.

OBJECTIVE

To assess the clinical factors and biomarkers associated with response to ICSs in newly diagnosed asthma.

METHODS

A total of 150 ICS-naive patients with newly diagnosed asthma in the allergy clinic of a single tertiary hospital in Korea from January 2014 to January 2019 were included in this study. All patients initially received moderate-dose ICSs and were treated for more than 1 year. We compared the clinical characteristics and parameters between patients with and without acute exacerbation (AE) during the study period.

RESULTS

In this study, 99 patients had no AE (stable asthma group), and 51 patients presented with more than 1 AE (unstable asthma group). The mean (SD) blood eosinophil count (635.7 [780.3] × 10³/μL vs 373.4 [266.8] × 10³/μL, P = .003) and sputum eosinophil count (15.2% [23.9%] vs 8.3% [15.4%], P = .051) were higher and the sputum neutrophil count (42.9% [35.1%] vs 61.3% [35.1%], P = .057) was lower in the stable asthma group than in the unstable asthma group.

CONCLUSION

High blood and sputum eosinophil counts can predict a good response to ICS treatment in terms of prevention of AE in individuals with newly diagnosed asthma. The sputum neutrophil count may be an effective predictor of response to ICSs, even though additional studies must be conducted.

FEV1 decline in relation to blood eosinophils and neutrophils in a population-based asthma cohort

Background

The relationship between lung function decline and eosinophils and neutrophils has important therapeutic implications among asthmatics, but it has rarely been studied in large cohort studies.

Objective

The aim is to study the relationship between blood eosinophils and neutrophils and FEV₁ decline in a long-term follow-up of a population-based adult asthma cohort.

Methods

In 2012–2014, an adult asthma cohort was invited to a follow-up including spirometry, blood sampling, and structured interviews, and n = 892 participated (55% women, mean age 59 y, 32–92 y). Blood eosinophils, neutrophils and FEV ₁ decline were analyzed both as continuous variables and divided into categories with different cut-offs. Regression models adjusted for smoking, exposure to vapors, gas, dust, or fumes (VGDF), use of inhaled and oral corticosteroids, and other possible confounders were utilized to analyze the relationship between eosinophils and neutrophils at follow-up and FEV₁ decline.

Results

The mean follow-up time was 18 years, and the mean FEV ₁ decline was 27 ml/year. The annual FEV₁ decline was related to higher levels of both blood eosinophils and neutrophils at follow-up, but only the association with eosinophils remained when adjusted for confounders. Further, the association between FEV₁ decline and eosinophils was stronger among those using ICS. With EOS <0.3 × 10⁹/L as reference, a more rapid decline in FEV1 was independently related to EOS ≥0.4 × 10⁹/L in adjusted analyses.

Conclusions and clinical relevance

Besides emphasizing the importance of smoking cessation and reduction of other harmful exposures, our real-world results indicate that there is an independent relationship between blood eosinophils and FEV₁ decline among adults with asthma.

Disease Burden and Long-Term Risk of Persistent Very Poorly Controlled Asthma: TENOR II

BACKGROUND

Severe/difficult-to-treat disease occurs in 5% to 10% of patients with asthma, but accounts for more than 50% of related economic costs. Understanding factors associated with persistent very poorly controlled (VPC) asthma may improve outcomes.

OBJECTIVE

To characterize persistent VPC asthma after more than 10 years of standard of care.

METHODS

The Epidemiology and Natural history of asthma: Outcomes and treatment Regimens (TENOR) II (N = 341) was a multicenter, observational study of patients with severe/difficult-to-treat asthma with a single, cross-sectional visit more than 10 years after TENOR I. Persistent VPC asthma was defined as VPC asthma at TENOR I and TENOR II enrollment; without VPC asthma was defined as well- or not well-controlled asthma at either or both visits. Multivariable logistic regression assessed long-term predictors of persistent VPC asthma using TENOR I baseline variables.

RESULTS

Of 327 patients, nearly half (48.0%, n = 157) had persistent VPC asthma. Comorbidities and asthma triggers were more frequent in patients with persistent VPC asthma than in patients without VPC asthma. Total geometric mean IgE was higher in patients with persistent VPC asthma (89.3 IU/mL vs 55.7 IU/mL); there was no difference in eosinophil levels. Lung function was lower in patients with persistent VPC asthma (mean % predicted pre- and postbronchodilator FEV₁, 63.0% vs 82.8% and 69.6% vs 87.2%, respectively). Exacerbations in the previous year were more likely in patients with persistent VPC asthma (29.7% vs 9.0%, respectively). Predictors of persistent VPC asthma were black versus white race/ethnicity, allergic trigger count (4 vs 0), systemic corticosteroid use, and postbronchodilator FEV₁ (per 10% decrease).

CONCLUSIONS

The burden of persistent VPC asthma is high in severe/difficult-to-treat disease; management of modifiable risk factors, maximization of lung function, and trigger avoidance may improve outcomes.

The equine asthma model of airway remodeling: from a veterinary to a human perspective

Human asthma is a complex and heterogeneous disorder characterized by chronic inflammation, bronchospasm and airway remodeling. The latter is a major determinant of the structure-function relationship of the respiratory system and likely contributes to the progressive and accelerated decline in lung function observed in patients over time. Corticosteroids are the cornerstone of asthma treatment. While their action on inflammation and lung function is well characterized, their effect on remodeling remains largely unknown. An important hindrance to the study of airway remodeling as a major focus in asthma research is the lack of reliable non-invasive biomarkers. In consequence, the physiologic and clinical consequences of airway wall thickening and altered composition are not well understood. In this perspective, equine asthma provides a unique and ethical (non-terminal) preclinical model for hypothesis testing and generation. Severe equine asthma is a spontaneous disease affecting adult horses characterized by recurrent and reversible episodes of disease exacerbations. It is associated with bronchoalveolar neutrophilic inflammation, bronchospasm, and excessive mucus secretion. Severe equine asthma is also characterized by bronchial remodeling, which is only partially improved by prolonged period of disease remission induced by therapy or antigen avoidance strategies. This review will focus on the similarities and differences of airway remodeling in equine and human asthma, on the strengths and limitations of the equine model, and on the challenges the model has to face to keep up with human asthma research.

Atopy Modifies the Association Between Inhaled Corticosteroid Use and Lung Function Decline in Patients with Asthma

BACKGROUND

Inhaled corticosteroids (ICSs) are the mainstay of asthma treatment, but response to medication is variable. Patients with allergic inflammation generally show a better short-term response to ICSs; however, studies on predictors of long-term response are few.

OBJECTIVE

To assess whether allergic sensitization can modify the association between ICS use and lung function decline over 20 years in adult asthma.

METHODS

We used data from the 3 clinical examinations of the European Community Respiratory Health Survey. We measured ICS use (no use, and use for <1.3, 1.3-8, and >8 years) and FEV₁ decline among subjects with asthma over the 2 periods between consecutive examinations. We conducted a cohort study combining data of the 2 periods (906 observations from 745 subjects) to assess whether the association between ICS use and FEV₁ decline was modified by allergic sensitization (IgE > 0.35 kU/L for any of house-dust mite, timothy grass, cat, or Cladosporium).

RESULTS

FEV₁ decline was similar for non-ICS users, as well as ICS users for less than 1.3 years, with and without allergic sensitization. However, among subjects on ICSs for a longer period, sensitization was associated with an attenuated decline (P_interaction = .006): in the group treated for more than 8 years, FEV₁ decline was on average 27 mL/y (95% CI_{Bonferroni-adjusted}, 11-42) lower for subjects with sensitization compared with nonsensitized subjects.

CONCLUSIONS

Our study suggests that biomarkers of atopy can predict a more favorable long-term response to ICSs. Randomized controlled studies are needed to confirm these findings.

Rhinovirus-16 induced temporal interferon responses in nasal epithelium links with viral clearance and symptoms

BACKGROUND

The temporal in vivo response of epithelial cells to a viral challenge and its association with viral clearance and clinical outcomes has been largely unexplored in asthma.

OBJECTIVE

To determine gene expression profiles over time in nasal epithelial cells (NECs) challenged in vivo with rhinovirus-16 (RV16) and compare to nasal symptoms and viral clearance.

METHODS

Patients with stable mild to moderate asthma (n = 20) were challenged intranasally with RV16. Nasal brush samples for RNA sequencing were taken 7 days prior to infection and 3, 6 and 14 days post-infection, and blood samples 4 days prior to infection and day 6 post-infection. Viral load was measured in nasal lavage fluid at day 3, 6 and 14.

RESULTS

Top differentially (>2.5-fold increase) expressed gene sets in NECs post-RV16 at days 3 and 6, compared with baseline, were interferon alpha and gamma response genes. Patients clearing the virus within 6 days (early resolvers) had a significantly increased interferon response at day 6, whereas those having cleared the virus by day 14 (late resolvers) had significantly increased responses at day 3, 6 and 14. Interestingly, patients not having cleared the virus by day 14 (non-resolvers) had no enhanced interferon responses at any of these days. The daily Cold Symptom Scores (CSS) peaked at days 3 to 5 and correlated positively with interferon response genes at day 3 (R = 0.48), but not at other time-points. Interferon response genes were also enhanced in blood at day 6 after RV16 challenge.

CONCLUSION AND CLINICAL RELEVANCE

This study shows that viral load and clearance varies markedly over time in mild to moderate asthma patients exposed to a fixed RV16 dose. The host's nasal interferon response to RV16 at day 3 is associated with upper respiratory tract symptoms. The temporal interferon response in nasal epithelium associates with viral clearance in the nasal compartment.

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.

Structural lung abnormalities on computed tomography correlate with asthma inflammation in bronchoscopic alveolar lavage fluid

Objective: Image scoring systems have been developed to assess the severity of specific lung abnormalities in patients diagnosed with various pulmonary diseases except for asthma. A comprehensive asthma imaging scoring system may identify specific abnormalities potentially linking these to inflammatory phenotypes.Methods: Computed tomography (CT) images of 88 children with asthma (50 M/38 F, mean age 7.8 ± 5.4 years) acquired within 12 months of bronchoscopic alveolar lavage fluid (BALF) sampling that assessed airway inflammation cell types were reviewed along with CT images of 49 controls (27 M/22 F, mean age 3.4 ± 2.2 years). Images were scored using a comprehensive scoring system to quantify bronchiectasis (BR), bronchial wall thickening (BWT), ground glass opacity, mucus plugging (MP), consolidations, linear densities (LD), and air trapping (AT). Each category was scored 0-2 in each of six lobar regions (with lingula separated from left upper lobe).Results: Absolute average overall scores of the controls and children with asthma were 0.72 ± 1.59 and 5.39 ± 5.83, respectively (P < 0.0001). Children with asthma scored significantly higher for BR (N = 20, 0.33 ± 0.80, P = 0.0002), BWT (N = 28, 0.72 ± 1.40, P < 0.0001), MP (N = 28, 0.37 ± 1.12, P = 0.0052), consolidation (N = 31, 0.67 ± 1.22, P < 0.0001), LD (N = 58, 1.12 ± 1.44, P < 0.0001), and AT (N = 52, 1.78 ± 2.31, P < 0.0001). There was a significant difference between the BR score of children with positive inflammatory response in BALF (N = 53) and those who were negative for airway inflammation cells (0.14 ± 0.36, P = 0.040).Conclusions: Significant lung structural abnormalities were readily identified on CT of children with asthma, with image differentiation of those with an inflammatory response on BALF. Chest imaging demonstrates potential as a noninvasive clinical tool for additional characterization of asthma phenotypes.

Determinants of airflow limitation in Danish adults - findings from the Health2006 cohort

Background and aim

Airflow limitation may be found in patients with both asthma and COPD and is often associated with more symptoms and poorer outcome. We aimed to identify factors associated with airflow limitation in a well-characterized, population-based sample of adults.

Methods

From the Health2006 cohort, we selected participants aged ≥35 years at enrolment (n=2,959). Airflow limitation was defined as FEV₁/FVC < lower limit of normal. Participants with (cases) and without (controls) airflow limitation were compared with regard to self-reported symptoms, medical history, atopy, lung function and exhaled nitric oxide. Between-group differences were analyzed using Chi-square and Mann–Whitney U tests, and effect size was estimated by logistic regression (reported as OR and 95% CI).

Results

We identified 313 cases, majority of which were female, reported poor overall health, physically inactivity and experienced respiratory symptoms within the previous year. The presence of airflow limitation was associated with BMI (OR 3.1 for overweight, P<0.001, CI 1.97–4.78), age (OR 2.3, P<0.001 for age 55+, CI 1.7–3.2), tobacco exposure (OR 1.6, P=0.01, CI 1.1–2.32, and OR 1.76, P=0.019, CI 1.2–2.3 for former and current smokers, respectively), sex (OR 1.6 for being female, P=0.002, CI 1.2–2.2), presence of specific IgE to common aeroallergen(s) (OR 1.4, P=0.041, CI 1.2–2.0), and ever being diagnosed with asthma (OR 1.6, P=0.003, CI 1.3–2.0).

Conclusion

Apart from tobacco exposure and age, the presence of airflow limitation was associated with being overweight, female, sensitized to common aeroallergens or ever having a diagnosis of asthma.

Challenges in the management of asthma associated with smoking-induced airway diseases

INTRODUCTION

Smoking-induced airway diseases such as chronic bronchitis, emphysema, and small airway dysfunction contribute to the chronic respiratory symptoms experienced by adults with asthma, including those with spirometric chronic obstructive pulmonary disease (COPD), termed asthma-COPD overlap (ACO). Drug treatment of symptomatic smokers with asthma or ACO is uncertain due to their exclusion from most clinical trials.

AREAS COVERED

This review summarizes evidence for the efficacy of small molecule drugs used in the clinic to treat current and former smokers with a diagnostic label of asthma or ACO. Other therapeutic interventions are reviewed, including smoking cessation and biologics.

EXPERT OPINION

Clinical trials and observational studies suggest that smoking cessation and approved drugs used to treat non-smokers with asthma produce clinical benefits in smokers with asthma or ACO, although the overall quality of evidence is low. The efficacy of some treatments for asthma is altered in current smokers, including reduced responsiveness to short-term inhaled corticosteroids and possibly improved responsiveness to leukotriene receptor antagonists. Preliminary findings suggest that low-dose theophylline, statins, and biologics, such as omalizumab, mepolizumab, and dupilumab, may improve clinical outcomes in smokers with asthma or ACO. Improved phenotyping and endotyping of asthma and smoking-induced airway diseases should lead to better targeted therapies.

Fluticasone/salmeterol reduces remodelling and neutrophilic inflammation in severe equine asthma

Asthmatic airways are inflamed and undergo remodelling. Inhaled corticosteroids and long-acting β2-agonist combinations are more effective than inhaled corticosteroid monotherapy in controlling disease exacerbations, but their effect on airway remodelling and inflammation remains ill-defined. This study evaluates the contribution of inhaled fluticasone and salmeterol, alone or combined, to the reversal of bronchial remodelling and inflammation. Severely asthmatic horses (6 horses/group) were treated with fluticasone, salmeterol, fluticasone/salmeterol, or with antigen avoidance for 12 weeks. Lung function, central and peripheral airway remodelling, and bronchoalveolar inflammation were assessed. Fluticasone/salmeterol and fluticasone monotherapy decreased peripheral airway smooth muscle remodelling after 12 weeks (p = 0.007 and p = 0.02, respectively). On average, a 30% decrease was observed with both treatments. In central airways, fluticasone/salmeterol reversed extracellular matrix remodelling after 12 weeks, both within the lamina propria (decreased thickness, p = 0.005) and within the smooth muscle layer (p = 0.004). Only fluticasone/salmeterol decreased bronchoalveolar neutrophilia (p = 0.03) to the same extent as antigen avoidance already after 8 weeks. In conclusion, this study shows that fluticasone/salmeterol combination decreases extracellular matrix remodelling in central airways and intraluminal neutrophilia. Fluticasone/salmeterol and fluticasone monotherapy equally reverse peripheral airway smooth muscle remodelling.

Asthma and smoking-induced airway disease without spirometric COPD

Due to the high prevalence rates of cigarette smoking and asthma, current and ex-smokers frequently develop chronic airway disease without spirometric evidence of chronic obstructive pulmonary disease (COPD), either alone or associated with asthma. This review considers the classification, clinical outcomes, inflammatory and imaging variables, phenotypes, and management of current and ex-smokers with airway disease without COPD, focusing on overlaps in those with and without asthma. These individuals have more respiratory symptoms, worse quality of life, increased exacerbation rates, reduced lung function and more comorbidities than never-smokers with asthma or healthy never-smokers. As well as clinical features, airway inflammatory and structural changes in smoking-induced airway disease without COPD overlap with those found in smokers with asthma. Cigarette smoking is associated with worse clinical outcomes in some phenotypes of asthma. Management involves public health measures to control exposure to tobacco smoke, personal advice on smoking cessation and the use of appropriate targeted therapies, although evidence is limited on their effectiveness. Understanding the mechanisms, natural history and management of current and ex-smokers with asthma and smoking-induced airway disease without COPD is a priority for future research.

Longitudinal trends in clinical characteristics and lung function of patients with severe asthma under treatment in Brazil

BACKGROUND

The structural changes of the respiratory system related to ageing determine lung function decline in healthy subjects after 25 years of age. An annual reduction of 25 ml in Forced Expiratory Volume in 1 s (FEV1) is expected. We aimed to describe the longitudinal lung function variation of subjects with severe asthma receiving appropriate treatment.

METHODS

Consecutive patients enrolled in a Brazilian reference clinic between 2003 and 2006 were invited to participate. The study participants were followed up for a median of 8 years, and were evaluated with spirometry in three distinct occasions (V0, V1 and V8), at least. At V0, upon enrollment, subjects with previous severe untreated asthma were evaluated by a specialist, had their health resource utilization in the last 12 months recorded, and performed spirometry. In V1, 1 year after V0, under proper management, subjects repeated the procedures and answered the Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ). In the last study visit (V8), 7 years after V1, all patients underwent a pre and post-broncodilator (postBD) spirometry, skin prick test for aeroallergens, answered the ACQ and the AQLQ and had another interview with the specialist.

RESULTS

Two hundred thirty-four subjects were followed up between V0 and V8. A comparison between spirometries of V1 and V8, after the initial improvement has supposedly reached a plateau, shows that the FEV₁ and FVC declined significantly both in absolute and percent of predicted values. FEV_1postBD did not change significantly between V0 and V1, but declined by -27.1 (-51.1-1.4) ml/yr between V1 and V8.

CONCLUSIONS

Currently available treatment with a combination of inhaled corticosteroids and LABA may not be sufficient to prevent lung function decline in subjects with severe asthma.

The Danish National Database for Asthma: establishing clinical quality indicators

Asthma is one of the most common chronic diseases worldwide affecting more than 300 million people. Symptoms are often non-specific and include coughing, wheezing, chest tightness, and shortness of breath. Asthma may be highly variable within the same individual over time. Although asthma results in death only in extreme cases, the disease is associated with significant morbidity, reduced quality of life, increased absenteeism, and large costs for society. Asthma can be diagnosed based on report of characteristic symptoms and/or the use of several different diagnostic tests. However, there is currently no gold standard for making a diagnosis, and some degree of misclassification and inter-observer variation can be expected. This may lead to local and regional differences in the treatment, monitoring, and follow-up of the patients. The Danish National Database for Asthma (DNDA) is slated to be established with the overall aim of collecting data on all patients treated for asthma in Denmark and systematically monitoring the treatment quality and disease management in both primary and secondary care facilities across the country. The DNDA links information from population-based disease registers in Denmark, including the National Patient Register, the National Prescription Registry, and the National Health Insurance Services register, and potentially includes all asthma patients in Denmark. The following quality indicators have been selected to monitor trends: first, conduction of annual asthma control visits, appropriate pharmacological treatment, measurement of lung function, and asthma challenge testing; second, tools used for diagnosis in new cases; and third, annual assessment of smoking status, height, and weight measurements, and the proportion of patients with acute hospital treatment. The DNDA will be launched in 2016 and will initially include patients treated in secondary care facilities in Denmark. In the nearby future, the database aims to include asthma diagnosis codes and clinical data registered by general practitioners and specialised practitioners as well.

Corticosteroid insensitivity in smokers with asthma : clinical evidence, mechanisms, and management

Corticosteroids are the most effective treatment for asthma, but the therapeutic response varies considerably between individuals. Several clinical studies have found that smokers with asthma are insensitive to the beneficial effects of short- to medium-term inhaled corticosteroid treatment compared with non-smokers with asthma. It is estimated that 25% of adults in most industrialized countries smoke cigarettes, and similar surveys amongst asthmatic individuals suggest that the prevalence of smoking in this grouping mirrors that found in the general population. Therefore, cigarette smoking is probably the most common cause of corticosteroid insensitivity in asthma. Cigarette smoking and asthma are also associated with poor symptom control and an accelerated rate of decline in lung function. The mechanism of corticosteroid insensitivity in smokers with asthma is currently unexplained but could be due to alterations in airway inflammatory cell phenotypes, changes in glucocorticoid receptor alpha/beta ratio, and/or reduced histone deacetylase activity. Smoking cessation should be encouraged in all smokers with asthma. Short-term benefits include improvements in lung function and asthma control. However, the numbers of sustained quitters is disappointingly small. Additional or alternative drugs need to be identified to treat those individuals who are unable to stop smoking or who have persistent symptoms following smoking cessation.

Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT)

Health professionals tasked with advising patients with asthma and chronic obstructive pulmonary disease (COPD) how to use inhaler devices properly and what to do about unwanted effects will be aware of a variety of commonly held precepts. The evidence for many of these is, however, lacking or old and therefore in need of re-examination. Few would disagree that facilitating and encouraging regular and proper use of inhaler devices for the treatment of asthma and COPD is critical for successful outcomes. It seems logical that the abandonment of unnecessary or ill-founded practices forms an integral part of this process: the use of inhalers is bewildering enough, particularly with regular introduction of new drugs, devices and ancillary equipment, without unnecessary and pointless adages. We review the evidence, or lack thereof, underlying ten items of inhaler ‘lore’ commonly passed on by health professionals to each other and thence to patients. The exercise is intended as a pragmatic, evidence-informed review by a group of clinicians with appropriate experience. It is not intended to be an exhaustive review of the literature; rather, we aim to stimulate debate, and to encourage researchers to challenge some of these ideas and to provide new, updated evidence on which to base relevant, meaningful advice in the future. The discussion on each item is followed by a formal, expert opinion by members of the ADMIT Working Group.

Are Asthma and COPD a Continuum of the Same Disease?

Asthma and chronic obstructive pulmonary disease (COPD) are common heterogeneous diseases with significant impact on morbidity, mortality, and health care costs. In most of the cases, the main features and pathophysiology differ substantially between both asthma and COPD, which allows differentiating both entities and providing appropriate treatment. The recognition of a subgroup of patients who present clinically with features of both conditions, asthma chronic obstructive pulmonary disease overlap syndrome, has reignited the question of whether asthma and COPD are different manifestations of the same disease or unique processes, the so-called Dutch hypothesis versus British hypothesis controversy. There is enough heterogeneity in the clinical and mechanistic profiles of these 3 diseases, and subsets of these 3 diseases, to suggest that a new approach relying on the concept of endotypes of obstructive airways disease may be more useful. This characterization has provided the basis for opening new areas of research that may eventually lead to the development of new targeted drugs. This review focuses on the current knowledge of asthma, COPD, and asthma chronic obstructive pulmonary disease overlap syndrome phenotypes with emphasis on mechanisms of disease and how these may define endotypes, providing a more rational approach to research and clinical care.

Long-term prognosis of asthma, chronic obstructive pulmonary disease, and asthma-chronic obstructive pulmonary disease overlap in the Copenhagen City Heart study: a prospective population-based analysis

BACKGROUND

Long-term prognosis of patients with characteristics of both chronic obstructive pulmonary disease (COPD) and asthma, named asthma-COPD overlap, is poorly described. We investigated the long-term prognosis of individuals with different types of chronic airway disease, with a special focus on individuals with asthma-COPD overlap.

METHODS

We assigned participants from the Copenhagen City Heart Study into six subgroups: healthy never-smokers, ever-smokers without asthma and COPD, those with asthma with low cumulated smoking exposure and no airflow limitation, those with COPD, those with asthma-COPD overlap with asthma onset before the age of 40 years, and those with asthma-COPD overlap with asthma onset after the age of 40 years. We defined asthma-COPD overlap as current self-reported asthma and a postbronchodilatatory forced expiratory volume in 1 s (FEV1) to forced vital capacity ratio of less than 0·7, without any restrictions regarding smoking. We investigated the course of FEV1 decline for 18 years and risk of admission to hospital due to exacerbations or pneumonias and respiratory and all-cause mortality for 22 years. We analysed FEV1 decline in the six groups using a linear mixed-effects model.

FINDINGS

We included 8382 participants from the Copenhagen City Heart Study in our study: 2199 never-smokers, 5435 ever-smokers, 158 with asthma, 320 with COPD, 68 with asthma-COPD overlap with early-onset asthma, and 202 with asthma-COPD overlap with late-onset asthma. The multivariable-adjusted decline in FEV1 in asthma-COPD overlap with early-onset asthma was 27·3 mL (standard error 5·0) per year, which did not differ significantly from the decline of 20·9 mL (1·2) per year in healthy never-smokers (p=0·19). FEV1 decline in individuals with asthma-COPD overlap with late-onset asthma was 49·6 mL (3·0) per year, higher than the decline in asthma-COPD overlap with early-onset asthma (p=0·0001), the decline of 39·5 mL (2·5) per year in COPD (p=0·003), and the decline in healthy never-smokers (p<0·0001). Hazard ratios for hospital admissions due to exacerbations of asthma or COPD were 39·48 (95% CI 25·93-60·11) in asthma-COPD overlap with early-onset asthma, 83·47 (61·67-112·98) in asthma-COPD overlap with late-onset asthma, 23·80 (17·43-33·50) in COPD, and 14·74 (10·06-21·59) in asthma compared with never-smokers without lung disease (all p<0·0001). Life expectancy was 9·3 years (5·4-13·1) shorter in participants with asthma-COPD overlap with early-onset asthma, 12·8 years (11·1-14·6) shorter in those with asthma-COPD overlap with late-onset asthma, 10·1 years (8·6-11·5) shorter in those with COPD (all p<0·0001), and 3·3 years (1·0-5·5) shorter in those with asthma (p=0·004) than in healthy never-smokers.

INTERPRETATION

Prognosis of individuals with asthma-COPD overlap is poor and seems to be affected by the age of recognition of asthma, being worst in those with late asthma onset (after 40 years of age). Such patients should be followed up closely to prevent fast lung function decline and exacerbations.

FUNDING

Capital Region of Copenhagen, Danish Heart Foundation, Danish Lung Foundation, Velux Foundation, AstraZeneca.

Majority of never-smokers with airflow limitation do not have asthma: the Copenhagen General Population Study

BACKGROUND

A substantial proportion of individuals with airflow limitation are never-smokers. However, whether never-smokers with airflow limitation have undiagnosed asthma is unknown. We hypothesised that the majority of never-smokers with respiratory symptoms and airflow limitation but without known asthma have undiagnosed asthma by comparing characteristics and prognosis in never-smokers with airflow limitation and asthma (NS+AFL+A) with never-smokers with airflow limitation but without asthma (NS+AFL-A).

METHODS

Among 94 079 participants aged 20-100 years from the general population, 39 102 (42%) were never-smokers. In this group, 13 719 (35%) reported to have respiratory symptoms of whom 1610 (12%) had airflow limitation. We investigated characteristics and risk of complications (asthma or COPD exacerbations, pneumonias and all-cause mortality) and comorbidities (lung cancer, ischaemic heart disease, myocardial infarction, deep venous thrombosis and PE) during 4.5 years median follow-up.

RESULTS

NS+AFL-A compared with NS+AFL+A reported less allergy and respiratory symptoms, and had higher FEV1 and lower levels of eosinophils and IgE in peripheral blood. NS+AFL+A had increased risk of asthma and COPD exacerbations, but not of pneumonias; adjusted HRs in NS+AFL+A compared with NS+AFL-A were 16 (95% CI 3.7 to 73) for asthma exacerbations and 15 (2.8 to 80) for COPD exacerbations. Still, NS+AFL-A had increased risk of COPD exacerbations and pneumonias, but not of asthma exacerbations; adjusted HRs in NS+AFL-A compared with never-smokers without airflow limitation or asthma (NS-AFL-A) were 7.7 (2.8 to 21) for COPD exacerbations and 1.7 (1.3 to 2.3) for pneumonias. Risk of comorbidities or all-cause mortality was not increased in NS+AFL-A or NS+AFL+A compared with NS-AFL-A.

CONCLUSIONS

Majority of NS+AFL-A do not seem to have undiagnosed asthma and may instead have airflow limitation caused by other risk factors.

Addressing corticosteroid insensitivity in adults with asthma

Corticosteroids are the most effective treatment for asthma, but the therapeutic response varies markedly between individuals, with up to one third of patients showing evidence of insensitivity to corticosteroids. This article summarizes information on genetic, environmental and asthma-related factors as well as demographic and pharmacokinetic variables associated with corticosteroid insensitivity in asthma. Molecular mechanisms proposed to explain corticosteroid insensitivity are reviewed including alterations in glucocorticoid receptor subtype, binding and nuclear translocation, increased proinflammatory transcription factors and defective histone acetylation. Current therapies and future interventions that may restore corticosteroid sensitivity in asthma are discussed, including small molecule drugs and biological agents. In the future, biomarkers may be used in the clinic to predict corticosteroid sensitivity in patients with poorly controlled asthma.

Use of asthma control indicators in measuring inhaled corticosteroid effectiveness in asthmatic smokers: a systematic review

OBJECTIVE

The objective of this review is to explore how current research measures the effectiveness of inhaled corticosteroids (ICS) in smokers with asthma.

DATA SOURCES

PubMed, CINAHL and PsycINFO databases were searched for combinations of terms relating to asthma, tobacco use and ICS effectiveness.

STUDY SELECTIONS

The search was limited to articles published between 2004 and 2015, in English language. Studies met inclusion criteria if reporting the use of guideline-based asthma control indicators to measure the therapeutic effects of ICS or ICS combination therapies. This review did not exclude articles based on study design. Data were extracted and summarized to describe how indicators were measured across studies in order to characterize and describe the effects of ICS in smokers.

RESULTS

Thirteen studies were included in this review. Six of these 13 studies used only one indicator to measure asthma control in smokers and ICS was found to improve asthma in only one of six of these studies. Of studies evaluating combination therapy, three of four studies reported a therapeutic benefit to smokers. In these studies of combination therapy multiple indicators of control were measured to assess drug effects.

CONCLUSIONS

To assess the therapeutic benefit of ICS drugs in smokers, multiple indicators should be measured to determine if current therapy is improving asthma control. Asthma therapy should then be adjusted based on the patient's current asthma status. The development of clinical treatment guidelines for asthmatic smokers may help clinicians make best-practice, evidence-based recommendations in order to optimize care for these patients.

Asthma in a university campus: a survey of students and staff of Obafemi Awolowo University, Ile-Ife, Nigeria

BACKGROUND

Asthma continues to be an important cause of morbidity and mortality in developing countries. But, its burden among adult populations in university campuses is not well described.

METHOD

Through a multistage cluster sampling of students and staff of the Obafemi Awolowo University, Ile-Ife, Nigeria, we obtained a representative sample, each for students and staff. We administered the European Community Respiratory Health Survey (ECRHS) screening questionnaire to all the respondents. A subgroup did a spirometry test and completed a detailed questionnaire. Asthma was considered "possible", if a respondent provided affirmative response to symptoms of "wheezing or whistling", "attack of shortness of breath", "diagnosed attack of asthma" in the last 12 months or "currently taking medicines for asthma".

RESULTS

From population of 13,750 students and 1428 staff of the university, we systematically sampled 2750 (20%) students and all the staff. Amongst these, 2372 students and 455 staff completed the screening questionnaire. The mean age (SD) of the responders was 21.9 (3.2) and 46.1 (8.9) for students and staff and most of them were men; 58.6% and 65.9%, respectively. While an estimated 2.6% (95% CI: 1.7-3.5) of students had an asthma attack in the preceding 12 months, 14.5% (95% CI: 12.5-16.5) and 25.2% (95% CI: 22.8-27.7) reported shortness of breath and nocturnal cough, respectively. The staff population reported fewer symptoms. The proportion with "possible asthma" was 18.2% (95% CI: 16.0-20.4) for students and 8.0% (95% CI: 5.4-10.7) for staff.

CONCLUSION

The prevalence of asthma is high among students and staff of Obafemi Awolowo University, Nigeria.

Natural history of COPD: Focusing on change in FEV1

The natural history of chronic obstructive pulmonary disease (COPD) is usually described with a focus on change in forced expiratory volume in 1 s (FEV1 ) over time as this allows for exploration of risk factors for an accelerated decline-and thus of developing COPD. From epidemiological studies we have recognized important risk factors such as smoking, exposure to biomass and occupational exposures, but we have also learnt about features such as chronic bronchitis, airway hyper-responsiveness and asthma that seem to accelerate decline in FEV1 independent of exposures. In addition we are gradually beginning to better link early life events to subsequent risk of disease in adulthood. Although more complicated, our current understanding of COPD has come a long way from being a simple image of smoking leading to poor lungs.

Emerging corticosteroid agonists for the treatment of asthma

INTRODUCTION

Asthma is one of the most frequent chronic diseases worldwide. For decades, asthma has been treated with bronchodilators and inhaled corticosteroids (ICS). However, adverse effects of ICS and disease heterogeneity necessitate improvements in the existing treatment regimes. Recently approved ICS show improved pharmocodynamic properties. Nevertheless, emerging drugs acting on the same receptor as the ICS, glucocorticoid receptor agonists (GRAs), are under current research. These drugs exhibit selective action on the glucocorticoid receptor (GR), which may improve their adverse effect profile, compared to the currently approved ICS that act unselectively on the GR.

AREAS COVERED

The present article reviews emerging GRAs for the treatment of asthma. Furthermore, the more recently approved ICS with improved safety profiles are reviewed.

EXPERT OPINION

Compared with drugs acting on other pathological pathways, research in GRAs for asthma is sparse. However, a few promising agents acting selectively on the GR are currently under investigation and may reach approval for asthma treatment. These drugs exhibit improved pharmacodynamic properties due to selectivity in the mechanism of action, including promotion of transrepression and reduction of transactivation. However, competition from already approved ICS and other emerging treatment options may lead to cessation of development of the new GRAs.

Revisiting early intervention in adult asthma

The term "early intervention" with inhaled corticosteroids (ICS) in asthma is used in different ways, thereby causing confusion and misinterpretation of data. We propose that the term should be reserved for start of ICS therapy in patients with a diagnosis of asthma but within a short period of time after the first symptoms, not from the date of diagnosis. Prospective clinical studies suggest a time frame of 2 years for the term "early" from the onset of symptoms to starting anti-inflammatory treatment with ICS. The current literature supports early intervention with ICS for all patients with asthma including patients with mild disease, who often have normal or near-normal lung function. This approach reduces symptoms rapidly and allows patients to achieve early asthma control. Later introduction of ICS therapy may not reduce effectiveness in terms of lung function but delays asthma control and exposes patients to unnecessary morbidity. Results of nationwide intervention programmes support the early use of ICS, as it significantly minimises the disease burden. Acute asthma exacerbations are usually preceded by progressing symptoms and lung function decline over a period of 1-2 weeks. Treatment with an increased dose of ICS together with a rapid- and long-acting inhaled β2-agonist during this phase has reduced the risk of severe exacerbations.

Lung function impairment increases with age of diagnosis in adult onset asthma

BACKGROUND

Asthma-onset in older individuals has been associated with an accelerated decline in lung function, but direct comparisons with younger adults have not been reported.

METHODS

In a random population sample comprising 4983 individuals from the Copenhagen City Heart Study without asthma at baseline, we compared young (<35 years), middle-aged (35-64 years) and older (>64 years) adults with newly diagnosed asthma during a 10-year follow-up.

RESULTS

The proportion of cases with newly diagnosed asthma during follow-up was similar across age groups (Older adults: 7% (84/1168), middle-aged adults: 7% (223/3147), and young adults: 6% (42/668) (p = ns)). In all three age groups, lung function was reduced at baseline in subjects who were subsequently diagnosed with asthma, but most pronounced in those >35 years. (Mean FEV1%: Young 90.2% (±13.9), middle-aged 80.8% (±20.8), and older adults 80.8% (±24.2), p < 0.001). Furthermore, incident asthma was associated with an accelerated decline in lung function in older adults (young adults 11.0 mL/year, middle-aged adults 18.2 mL/year, and older adults 30.8 mL/year). These differences were independent of FEV1 at baseline and smoking status, and were not explained by undiagnosed asthma in older adults, as the frequency of respiratory symptoms, including wheeze, was similar in all three age groups at baseline.

CONCLUSIONS

Asthma was diagnosed as frequently in older as in younger adults. Preexisting symptoms were equally common, but lung function was more reduced pre-diagnosis, and declined more rapidly in older adults. This emphasizes the need for a high level of therapeutic attention in patients with asthma diagnosed late in life.

Effects of the recombinant allergen rDer f 2 on neuro-endocrino-immune network in asthmatic mice

Severe and life-threatening side effects can occur in patients receiving allergen-specific immunotherapy (SIT), and recombinant allergens made from cDNA have been used in clinical trials for ten years and appear promising for SIT. The aim of this study is to explore the effects of the recombinant allergen Der f 2 (the group 2 allergen from Dermatophagoides farinae) on the neuro-endocrino-immune network in asthmatic mice. Twenty-eight mice were divided into four groups – A, B, C and D. To induce asthma, a crude extract of D. farinae was injected intraperitoneally into the mice in groups B, C and D. Later, the crude extract or recombinant allergen rDer f 2 was given to groups C and D, respectively. Normal saline was given to groups A and B. Serum corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), corticosterone (CORT), interleukin 4 (IL-4), and interferon γ (IFN-γ) were detected by immunoassay and the pathological change of lung tissue was observed by hematoxylin and eosin (HE) staining. Serum CRH, ACTH, CORT, and IFN-γ were highest in healthy group A but lowest in asthma group B. Treatment with the crude extract or recombinant allergen rDer f 2 significantly attenuated this response in asthmatic mice, but there was no difference between the two treatments (p > 0.05). Serum IL-4 was elevated in asthma group B but lowest in healthy group A. Treatment with the crude extract or recombinant allergen rDer f 2 significantly attenuated this response in asthmatic mice, but there was no significant difference between the two treatments (p > 0.05). However, lung pathology as measured histologically (Underwood Score) showed that rDer f 2-treatment was significantly better than crude extract treatment (p < 0.05). In brief, recombinant allergen Der f 2 can strengthen the function of hypothalamus-pituitary-adrenal (HPA) axis, affect the balance of Th1 and Th2 cytokines, and reduce pulmonary inflammation in asthmatic mice.

The relation of airway obstruction to asthma, chronic rhinosinusitis and age: results from a population survey of adults

RATIONALE

There is conflicting evidence on whether patients with asthma experience an accelerated decline in lung function with age. We examined the association between postbronchodilator lung function, asthma, chronic rhinosinusitis (CRS), and atopy with age using a large European sample.

METHODS

In 17 centers in 11 European countries, case-control studies were nested within representative cross-sectional surveys of adults aged less than 75 years. Representative samples of participants with asthma, CRS or both and controls were assessed for postbronchodilator ventilatory function, smoking history, atopy, and treatment. Multiple regression was used to assess the interactive effects of age and diagnostic group on decline in postbronchodilator ventilatory function.

RESULTS

A total of 3337 participants provided adequate data (778 with asthma, 399 with CRS, 244 with both asthma and CRS and 1916 controls who had neither asthma nor CRS). Participants with asthma had lower FEV1 /FVC (-4.09% (95% CI: -5.02, -3.15, P < 0.001) and a steeper slope of FEV1 /FVC against age (-0.14%/annum [95%CI: -0.19, -0.08]) equivalent to smoking 1-2 packs of cigarettes per day. Those with atopy had a slope equivalent to controls.

CONCLUSIONS

People with asthma have a steeper decline in postbronchodilator lung function with age, but neither CRS nor atopy alone were associated with such decline.

Longitudinal changes in airway remodeling and air trapping in severe asthma

RATIONALE AND OBJECTIVES

Previous cross-sectional studies have demonstrated that airway wall thickness and air trapping are greater in subjects with severe asthma than in those with mild-to-moderate asthma. However, a better understanding of how airway remodeling and lung density change over time is needed. This study aimed to evaluate predictors of airway wall remodeling and change in lung function and lung density over time in severe asthma.

MATERIALS AND METHODS

Phenotypic characterization and quantitative multidetector-row computed tomography (MDCT) of the chest were performed at baseline and ∼2.6 years later in 38 participants with asthma (severe n = 24 and mild-to-moderate n = 14) and nine normal controls from the Severe Asthma Research Program.

RESULTS

Subjects with severe asthma had a significant decline in postbronchodilator forced expiratory volume in 1 second percent (FEV1%) predicted over time (P < .001). Airway wall thickness measured by MDCT was increased at multiple airway generations in severe asthma compared to mild-to-moderate asthma (wall area percent [WA%]: P < .05) and normals (P < .05) at baseline and year 2. Over time, there was an increase in WA% and wall thickness percent (WT%) in all subjects (P = .030 and .009, respectively) with no change in emphysema-like lung or air trapping. Baseline prebronchodilator FEV1% inversely correlated with WA% and WT% (both P < .05). In a multivariable regression model, baseline WA%, race, and health care utilization were predictors of subsequent airway remodeling.

CONCLUSIONS

Severe asthma subjects have a greater decline in lung function over time than normal subjects or those with mild-to-moderate asthma. MDCT provides a noninvasive measure of airway wall thickness that may predict subsequent airway remodeling.

The prevalence of severe asthma and low asthma control among Danish adults

BACKGROUND

The prevalence of severe asthma is unknown. However, international expert statements estimate that severe asthma represents 5% to 10 % of the entire asthma population.

OBJECTIVE

Based on register data from a nationwide population, we wanted to investigate the prevalence of severe asthma, the extent of asthma control, and contact with specialist care.

METHODS

A descriptive cross-sectional register study was performed. By using a nationwide prescription database, we identified current patients with asthma (age, 18-44 years) in 2010. Severity was classified as severe versus mild-moderate asthma according to the level of antiasthma treatment. We investigated prescription drug use, hospitalizations, emergency department visits, and outpatient clinic visits according to severity.

RESULTS

Among a nationwide population, we identified 61,583 current patients with asthma. Based on the level of antiasthma treatment, 8.1% of identified patients was classified as having severe asthma. Low asthma control (dispensed prescriptions of prednisolone, emergency department visits, hospitalization, or excessive short-acting β₂-agonist use) was more frequent in subjects with severe asthma (36.4% vs 25.2%, P < .0001); 63.8% with severe asthma and low asthma control were not managed by specialist care. Patients with severe asthma with specialist contact more frequently had impaired asthma control compared with subjects not treated by a specialist (44.4% vs 33.1%, P < .0001).

CONCLUSION

Based on the level of treatment, 8.1% of a nationwide population of current patients with asthma was classified as having severe asthma. Low asthma control was more frequent among subjects with severe asthma, and only a minority had access to specialist care. There is room for optimizing asthma management, particularly among patients with severe disease.

Long-term benefits of inhaled corticosteroids in asthma: the propensity score method

PURPOSE

The aim of this study was to apply a propensity score approach to assess the long-term benefits of inhaled corticosteroids (ICS) on respiratory health in asthma.

METHODS

This analysis was conducted on adults with persistent asthma from the Epidemiological study on the Genetics and Environment of Asthma, a 12-year follow-up study. ICS exposure was assessed by questionnaire. Change in lung function over the follow-up period, asthma control, and health-related quality of life (asthma quality of life questionnaire) were assessed by standardized and validated methods.

RESULTS

Among 245 adults with persistent asthma, 78 (31.8%) were regularly/continuously exposed to ICS (≥6 months/year, ICS++ ) and 167 never/irregularly exposed to ICS (<6 months/year, ICS+/- ) over the follow-up period. Compared with ICS+/- subjects, a nonsignificant trend for a slower lung function decline (mL/year) was observed in ICS++ subjects (β [95%CI] = -11.4 [-24.9; 2.0]). The ICS++ subjects did not have better controlled asthma and higher health-related quality of life as compared with ICS+/- subjects.

CONCLUSIONS

Applying a propensity score method did not offer evidence of a statistical significant long-term benefit of ICS on respiratory health in adults with persistent asthma regularly or continuously exposed to ICS over a long period.

Factors contributing to an accelerated decline in pulmonary function in asthma

Patients with asthma show a steeper age-related decline in pulmonary function than healthy subjects, which is often alleviated after the initiation of treatment with inhaled corticosteroids (ICS). However, there still are patients who develop irreversible airflow limitations despite receiving adequate ICS treatment. The identification of the characteristics of such patients and biomarkers of progression for airflow limitation, a functional consequence of airway remodeling, is considered important in the management of asthma. A variety of biomarkers are associated with the forced expiratory volume in 1s (FEV1) in asthma in a cross-sectional fashion. However, few biomarkers are known to reflect the decline in pulmonary function, particularly in patients with asthma who receive ICS treatment. Recently periostin, a matricellular protein that prolongs Th2/eosinophilic inflammation and reflects airway remodeling, was reported to be detected in serum. In a Kinki Hokuriku Airway disease Conference multicenter cohort study, we demonstrated that among several serum markers, high serum periostin level, particularly ≥95ng/mL, was the only marker associated with a greater annual decline in FEV1 and a decline in FEV1 of ≥30mL·yr-1. A variant (rs9603226) of the POSTN gene that encodes periostin was also involved in the frequency of a decline in FEV1 of ≥30mL·yr-1. Our results suggest that the serum periostin level is a useful marker reflecting pulmonary function decline in patients with asthma receiving ICS.

Changes in forced expiratory volume in 1 second over time in patients with controlled asthma at baseline

BACKGROUND

A predominant feature of asthma is an accelerated rate of decline in forced expiratory volume in 1 s (FEV1), but data on the variability and factors associated with this change in patients with controlled asthma are largely unknown.

METHODS

140 patients with controlled asthma were enrolled based on the Global Initiative for Asthma guidelines. We examined the data of a prospective analysis of the association between asthma control and change in FEV1 over time.

RESULTS

A 3-year follow-up assessment was completed in 128 patients. The mean rate of change in FEV1 was a decline of 22.2 mL yr(-1), with significant variation in the levels of change. The between patient standard deviation for the rate of decline was 34.1 mL yr(-1). We next classified the subjects of less than the 25th percentile as rapid decliners, and greater than the 25th percentile as non-rapid decliners. The decrease in the Asthma Control Test score over a 3-year period was higher for rapid decliners than that for non-rapid decliners (p < 0.001). The rapid decliner was more likely to be older, to have higher levels of FeNO, and to have had severe exacerbations during the study. Patients with severe exacerbations had a greater annual decline in FEV1 compared to patients with no exacerbations (-13.6 vs. -53.2 mL yr(-1), p < 0.0001).

CONCLUSIONS

Among patients with controlled asthma at baseline, the rate of change in FEV1 is highly variable. Severe exacerbations are strongly associated with a rapid loss of lung function.

Impact of inhaled corticosteroid treatment on 15-year longitudinal respiratory function changes in adult patients with bronchial asthma

BACKGROUND

Bronchial asthma is mainly controlled by inhaled corticosteroid (ICS) treatment, and discontinuation of ICS treatment can worsen asthma symptoms and reduce respiratory function. However, the longitudinal impact of ICS on lung function in adult patients is unknown.

METHODS

To determine whether regular ICS treatment can prevent long-term lung function deterioration in adults with bronchial asthma, we recruited 167 adult asthma patients who first visited Fukuoka National Hospital in 1995 and underwent lung function tests in 1995, 1996 and 2010. Regular ICS treatment was continued in 102 patients (regular group), while 39 patients received irregular ICS treatment (irregular group). Changes in lung function were compared retrospectively between the groups. The influences of smoking, disease severity and disease duration were also analyzed.

RESULTS

The forced expiratory volume in 1 s (FEV₁) values increased in the regular group 1 year after the initiation of therapy, but they decreased in the irregular group. At year 15, the predicted FEV₁% had decreased significantly more in the irregular group than in the regular group (p < 0.05); FEV₁ decreased by 28.2 ml/year (SD 24.5) in the regular group and by 44.6 ml/year (32.5) in the irregular group (p < 0.05). The decrease in FEV₁ was greater in smokers than in nonsmokers, despite regular ICS treatment, and it was significantly greater in patients with severe asthma than in those with mild or intermittent disease. Delay in ICS initiation also affected the annual FEV₁ decrease.

CONCLUSIONS

Regular ICS, introduced early when symptoms are mild, could prevent lung function from worsening significantly. Smoking should be strongly discouraged in asthma patients.

Could FEV₁ decline have a role in daily clinical practice for asthma monitoring?

OBJECTIVE

The aim of this review was to understand whether FEV1 decline measured during the follow-up of asthmatic subjects (FEV1 variation between two different measurements at a distance of at least 5 years) may have a role in their management.

METHODS

Articles, commentaries and reviews relating to the topic were searched in PubMed.

RESULTS

Patients with an accelerated FEV1 decline (>30 ml/year) may be either steroid-resistant/difficult-to-treat asthmatics or not adequately treated because they are either under-perceivers or poorly adherent to their therapy. Sometimes they may be unable to use devices correctly. Untreated rhinitis and incorrect lifestyle (obesity status, a high-fat diet and lack of exercise) must be considered when facing a pulmonary function decline. Identifying asthmatics with an accelerated FEV1 decline, even with well controlled symptoms, may allow us to make possible treatment adjustments or to remove potentially harmful environmental exposure and suggest a correct lifestyle. Depending on FEV1 decline severity, we may detect different asthma phenotypes. One type is characterized by no/low lung function reduction. Among moderate/severe 'declining' subjects, there may be a group that might be responsive to treatment and a second one with a quicker loss in lung function that may be unresponsive to therapy.

CONCLUSION

FEV1 decline calculation should be assessed early in clinical practice over the course of time in order to make all possible variations in treatment, environmental exposure and lifestyle more efficacious overall for declining subjects responsive to anti-inflammatory therapy. Further studies are necessary to validate this approach to asthma.