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Hvidtfeldt M, Sverrild A, Pulga A, Frøssing L, Silberbrandt A, Hostrup M, Thomassen M, Sanden C, Clausson CM, Siddhuraj P, Bornesund D, Nieto-Fontarigo JJ, Uller L, Erjefält J, Porsbjerg C. Airway hyperresponsiveness reflects corticosteroid-sensitive mast cell involvement across asthma phenotypes. J Allergy Clin Immunol 2023; 152:107-116.e4. [PMID: 36907566 DOI: 10.1016/j.jaci.2023.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/27/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Airway hyperresponsiveness is a hallmark of asthma across asthma phenotypes. Airway hyperresponsiveness to mannitol specifically relates to mast cell infiltration of the airways, suggesting inhaled corticosteroids to be effective in reducing the response to mannitol, despite low levels of type 2 inflammation. OBJECTIVE We sought to investigate the relationship between airway hyperresponsiveness and infiltrating mast cells, and the response to inhaled corticosteroid treatment. METHODS In 50 corticosteroid-free patients with airway hyperresponsiveness to mannitol, mucosal cryobiopsies were obtained before and after 6 weeks of daily treatment with 1600 μg of budesonide. Patients were stratified according to baseline fractional exhaled nitric oxide (Feno) with a cutoff of 25 parts per billion. RESULTS Airway hyperresponsiveness was comparable at baseline and improved equally with treatment in both patients with Feno-high and Feno-low asthma: doubling dose, 3.98 (95% CI, 2.49-6.38; P < .001) and 3.85 (95% CI, 2.51-5.91; P < .001), respectively. However, phenotypes and distribution of mast cells differed between the 2 groups. In patients with Feno-high asthma, airway hyperresponsiveness correlated with the density of chymase-high mast cells infiltrating the epithelial layer (ρ, -0.42; P = .04), and in those with Feno-low asthma, it correlated with the density in the airway smooth muscle (ρ, -0.51; P = .02). The improvement in airway hyperresponsiveness after inhaled corticosteroid treatment correlated with a reduction in mast cells, as well as in airway thymic stromal lymphopoietin and IL-33. CONCLUSIONS Airway hyperresponsiveness to mannitol is related to mast cell infiltration across asthma phenotypes, correlating with epithelial mast cells in patients with Feno-high asthma and with airway smooth muscle mast cells in patients with Feno-low asthma. Treatment with inhaled corticosteroids was effective in reducing airway hyperresponsiveness in both groups.
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Affiliation(s)
- Morten Hvidtfeldt
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark.
| | - Asger Sverrild
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark; Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Alexis Pulga
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Laurits Frøssing
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Morten Hostrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Martin Thomassen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | | | | | - Lena Uller
- Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Jonas Erjefält
- Unit of Airway Inflammation, Lund University, Lund, Sweden
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark; Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
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Ricciardolo FL, Bertolini F, Carriero V, Sprio AE. Asthma phenotypes and endotypes: a systematic review. Minerva Med 2021; 112:547-563. [PMID: 33969960 DOI: 10.23736/s0026-4806.21.07498-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Asthma is a complex disorder characterized by expiratory airflow limitation, wheeze, shortness of breath, chest tightness and cough, which can vary over time and in intensity. Being highly heterogeneous, asthma was characterized and classified in several asthma phenotypes and endotypes from 1947 until today. The present systematic review aims to summarize and describe evidence that was published in the last ten years in the field of asthma phenotyping and endotyping. EVIDENCE ACQUISITION The systematic review resumed high-quality evidence (clinical trials and randomized control trials) retrieved on MEDLINE and EMBASE databanks and involving adult asthmatic populations. Analyses of literature were conducted according to PRISMA and CASP guidelines. EVIDENCE SYNTHESIS Querying MEDLINE and EMBASE databanks, 5019 and 12261 entries were retrieved, respectively. Applying limitations for year of publication, age of participants, and type of publication, the search results were reduced to 98 and 132 articles, respectively. After data abstraction and resolution of duplications, only 50 articles were further evaluated. The research products were then classified first in macro-areas of interest (phenotypes or endotypes) and then in detailed micro-areas. CONCLUSIONS This systematic review overviews the principal findings available from high-quality literature in the last decade concerning asthma phenotypes and endotypes. Asthma has been described from different points of view, characterizing symptoms, microbiota composition, comorbidities, viral infections, and airway and/or systemic inflammatory status. The comprehension of precise mechanisms underlying asthma pathogenesis is thereby the basis for the development of novel therapeutic strategies, likely essential to the development of precision medicine.
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Affiliation(s)
- Fabio L Ricciardolo
- Department of Clinical and Biological Sciences, Rare Lung Disease Unit and Severe Asthma Centre, San Luigi Gonzaga University Hospital, University of Turin, Turin, Italy -
| | - Francesca Bertolini
- Department of Clinical and Biological Sciences, Rare Lung Disease Unit and Severe Asthma Centre, San Luigi Gonzaga University Hospital, University of Turin, Turin, Italy
| | - Vitina Carriero
- Department of Clinical and Biological Sciences, Rare Lung Disease Unit and Severe Asthma Centre, San Luigi Gonzaga University Hospital, University of Turin, Turin, Italy
| | - Andrea E Sprio
- Department of Clinical and Biological Sciences, Rare Lung Disease Unit and Severe Asthma Centre, San Luigi Gonzaga University Hospital, University of Turin, Turin, Italy.,Department of Research, ASOMI College of Sciences, Marsa, Malta
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Hvidtfeldt M, Sverrild A, Backer V, Porsbjerg C. Airway hyperresponsiveness to mannitol improves in both type 2 high and type 2 low asthma after specialist management. J Asthma 2020; 58:1221-1228. [PMID: 32519918 DOI: 10.1080/02770903.2020.1780255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Type 2 low (T2-low) asthma is reported to respond less to anti-inflammatory treatment compared with Type 2 high (T2-high) asthma. Airway hyperresponsiveness (AHR) to mannitol, a marker of airway mast cell activation, may be indicative of response to treatment in patients with T2-low disease. We investigated whether AHR to mannitol improves in patients with T2-low asthma after specialist management. METHODS Patients with asthma or suspected asthma, referred to our specialist outpatient clinic, were enrolled consecutively and assessed with FeNO, asthma control, blood eosinophils, mannitol and methacholine tests and induced sputum. T2-low asthma was defined in patients with FeNO < 25ppb and sputum eosinophils < 3% and blood eosinophils < 300µl-1 at inclusion. Patients with asthma and AHR to mannitol (PD15 ≤ 635 mg) were followed and reassessed after 12 months of specialist management. RESULTS Thirty-two patients (Females: 56%, age: 22 years (15-59)) were followed. Fourteen (44%) with T2-high and 18 (56%) with T2-low asthma. Baseline AHR to mannitol was comparable: Gmean PD15: 150 mg (95% CI 61-368) and 214 mg (95% CI 106-432) for T2-high and T2-low asthma respectively (P = 0.51). Both groups improved equally: Gmean PD15: 488 mg (95% CI 311-767) and 507 mg (95% CI 345-746); corresponding to a doubling-dose of: 3.00 (95% CI 1.58-5.74, P = 0.003) and 2.28 (95% CI 1.47-3.53, P = 0.001) respectively. There were no concomitant improvements in AHR to methacholine. CONCLUSION Patients with asthma and AHR to mannitol improve similarly in responsiveness to mannitol after 12 months of specialist management regardless of Type 2 inflammatory biomarker levels. Mechanisms driving AHR in T2-low asthma need to be further elucidated.
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Affiliation(s)
| | - Asger Sverrild
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Vibeke Backer
- Center for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
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Demarche S, Schleich F, Henket M, Paulus V, Louis R, Van Hees T. Step-down of inhaled corticosteroids in non-eosinophilic asthma: A prospective trial in real life. Clin Exp Allergy 2018; 48:525-535. [DOI: 10.1111/cea.13106] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/29/2017] [Accepted: 01/09/2018] [Indexed: 12/01/2022]
Affiliation(s)
- S. Demarche
- Department of Respiratory Medicine; CHU Liege; GIGA I Research Group; University of Liege; Liege Belgium
- Department of Clinical Pharmacy; CIRM (Center for Interdisciplinary Research on Medicines); University of Liege; Liege Belgium
| | - F. Schleich
- Department of Respiratory Medicine; CHU Liege; GIGA I Research Group; University of Liege; Liege Belgium
| | - M. Henket
- Department of Respiratory Medicine; CHU Liege; GIGA I Research Group; University of Liege; Liege Belgium
| | - V. Paulus
- Department of Respiratory Medicine; CHU Liege; GIGA I Research Group; University of Liege; Liege Belgium
| | - R. Louis
- Department of Respiratory Medicine; CHU Liege; GIGA I Research Group; University of Liege; Liege Belgium
| | - T. Van Hees
- Department of Clinical Pharmacy; CIRM (Center for Interdisciplinary Research on Medicines); University of Liege; Liege Belgium
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Demarche SF, Schleich FN, Henket MA, Paulus VA, Van Hees TJ, Louis RE. Effectiveness of inhaled corticosteroids in real life on clinical outcomes, sputum cells and systemic inflammation in asthmatics: a retrospective cohort study in a secondary care centre. BMJ Open 2017; 7:e018186. [PMID: 29183929 PMCID: PMC5719334 DOI: 10.1136/bmjopen-2017-018186] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The impact of inhaled corticosteroids (ICS) on eosinophilic inflammation in asthma is well established, but their effect in a real-life setting has not been extensively studied. Our purpose was to investigate the effect of ICS on airway and systemic inflammation as well as on clinical outcomes in patients with asthma from clinical practice. DESIGN, SETTING AND PARTICIPANTS We conducted a retrospective analysis on asthmatics from a secondary care centre in whom ICS were initiated/increased (n=101), stopped/decreased (n=60) or remained stable (n=63, used as a control group) between two visits with available sputum and blood cell counts. RESULTS The median time between both visits ranged from 1 to 2 years. Initiating or increasing ICS (median variation (IQR): 800 (400-1200) µg beclomethasone equivalent dose per day) reduced sputum eosinophils and fractional exhaled nitric oxide (P<0.0001) and to a lesser extent blood eosinophils (P<0.0001), while withdrawing or decreasing ICS (median variation (IQR): 900 (500-1200) µg beclomethasone equivalentdose per day) resulted in increased sputum eosinophils (P=0.008). No change was found in patients with a stable dose. The effectiveness of ICS in improving asthma control, quality of life, forced expiratory volume in 1 s (FEV1), bronchial hyper-responsiveness and exacerbation rate was only observed in the eosinophilic phenotype (sputum eosinophils ≥3%, n=79). In non-eosinophilic asthmatics, stepping-down ICS resulted in an improvement in asthma control and quality of life, without any significant change in FEV1 (n=38). CONCLUSIONS Our results confirm the effectiveness of ICS on eosinophilic inflammation in real life and demonstrate that their clinical benefit seems to be restricted to eosinophilic asthmatics. Our data also support a try for stepping-down ICS in non-eosinophilic asthmatics.
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Affiliation(s)
- Sophie F Demarche
- Department of Respiratory Medicine, CHU Liege, GIGA I³ Research Group, University of Liege, Liège, Belgium
- Department of Clinical Pharmacy, Center for Interdisciplinary Research on Medicines (CIRM), University of Liege, Liege, Belgium
| | - Florence N Schleich
- Department of Respiratory Medicine, CHU Liege, GIGA I³ Research Group, University of Liege, Liège, Belgium
| | - Monique A Henket
- Department of Respiratory Medicine, CHU Liege, GIGA I³ Research Group, University of Liege, Liège, Belgium
| | - Virginie A Paulus
- Department of Respiratory Medicine, CHU Liege, GIGA I³ Research Group, University of Liege, Liège, Belgium
| | - Thierry J Van Hees
- Department of Clinical Pharmacy, Center for Interdisciplinary Research on Medicines (CIRM), University of Liege, Liege, Belgium
| | - Renaud E Louis
- Department of Respiratory Medicine, CHU Liege, GIGA I³ Research Group, University of Liege, Liège, Belgium
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Abstract
Noneosinophilic airway inflammation occurs in approximately 50% of patients with asthma. It is subdivided into neutrophilic or paucigranulocytic inflammation, although the proportion of each subtype is uncertain because of variable cut-off points used to define neutrophilia. This article reviews the evidence for noneosinophilic inflammation being a target for therapy in asthma and assesses clinical trials of licensed drugs, novel small molecules and biologics agents in noneosinophilic inflammation. Current symptoms, rate of exacerbations and decline in lung function are generally less in noneosinophilic asthma than eosinophilic asthma. Noneosinophilic inflammation is associated with corticosteroid insensitivity. Neutrophil activation in the airways and systemic inflammation is reported in neutrophilic asthma. Neutrophilia in asthma may be due to corticosteroids, associated chronic pulmonary infection, altered airway microbiome or delayed neutrophil apoptosis. The cause of poorly controlled noneosinophilic asthma may differ between patients and involve several mechanism including neutrophilic inflammation, T helper 2 (Th2)-low or other subtypes of airway inflammation or corticosteroid insensitivity as well as noninflammatory pathways such as airway hyperreactivity and remodelling. Smoking cessation in asthmatic smokers and removal from exposure to some occupational agents reduces neutrophilic inflammation. Preliminary studies of 'off-label' use of licensed drugs suggest that macrolides show efficacy in nonsmokers with noneosinophilic severe asthma and statins, low-dose theophylline and peroxisome proliferator-activated receptor gamma (PPARγ) agonists may benefit asthmatic smokers with noneosinophilic inflammation. Novel small molecules targeting neutrophilic inflammation, such as chemokine (CXC) receptor 2 (CXCR2) antagonists reduce neutrophils, but do not improve clinical outcomes in studies to date. Inhaled phosphodiesterase (PDE)4 inhibitors, dual PDE3 and PDE4 inhibitors, p38MAPK (mitogen-activated protein kinase) inhibitors, tyrosine kinase inhibitors and PI (phosphoinositide) 3kinase inhibitors are under development and these compounds may be of benefit in noneosinophilic inflammation. The results of clinical trials of biological agents targeting mediators associated with noneosinophilic inflammation, such as interleukin (IL)-17 and tumor necrosis factor (TNF)-α are disappointing. Greater understanding of the mechanisms of noneosinophilic inflammation in asthma should lead to improved therapies.
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Affiliation(s)
- Neil C Thomson
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 0YN, UK
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Porsbjerg C, Sverrild A, Backer V. Combining the Mannitol Test and FeNO in the Assessment of Poorly Controlled Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:553-9. [PMID: 25824441 DOI: 10.1016/j.jaip.2015.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/01/2015] [Accepted: 02/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND International guidelines recommend up-titration of anti-inflammatory treatment in asthmatic patients with poor symptom control, but patients without eosinophilic airway inflammation are less likely to benefit from this. The mannitol bronchoprovocation test and fractional exhaled nitric oxide (FeNO) are increasingly used in the diagnostic assessment of asthma, but the utility of combining these tests has not been evaluated. AIM The aim of this study was to determine the value of combining FeNO and the mannitol test to assess patients with asthma referred for specialist assessment because of poor symptom control. METHODS All patients referred consecutively over a 12-month period for the assessment of asthma at the Respiratory Outpatient Clinic at Bispebjerg Hospital in Copenhagen were examined with bronchial provocation to mannitol, FeNO, and induced sputum. RESULTS Among asthmatic patients with partly controlled or uncontrolled symptoms according to Global Initiative for Asthma criteria, only 23% had sputum eosinophilia (eosinophils >2.99%). A positive mannitol test did not increase the likelihood of airway eosinophilia significantly (positive test: 32% vs negative test: 18%, P = .12). However, a positive mannitol test combined with a FeNO > 25 ppb indicated a high likelihood of airway eosinophilia (73%), compared with FeNO > 25 ppb and a negative mannitol test (29%) (P < .05). In contrast, in patients with FeNO < 25 ppb, a positive mannitol test was not associated with airway eosinophilia (sputum eosinophils > 2.99%: positive mannitol test: 0%, negative test: 11%, ns). CONCLUSION Combining the mannitol test and FeNO may aid in the differentiation between eosinophilic and noneosinophilic asthma in patients referred for specialist management because of poorly controlled asthma symptoms.
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Affiliation(s)
- Celeste Porsbjerg
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark.
| | - Asger Sverrild
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Vibeke Backer
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW Induced sputum provides a noninvasive way of assessing airway disease. This has led to the identification of different phenotypes of asthma and the potential for individualized treatment targeted at specific pathological processes. However, practical issues limit the frequent use of this technique. This review assesses the extent to which induced sputum can distinguish between asthma phenotypes and guide treatment. RECENT FINDINGS Although the short-term repeatability of sputum analysis is good, recent research has shown a great deal of variability in sputum inflammatory profiles over follow-up periods of several months to a few years. In particular, the distinction between eosinophilic and noneosinophilic asthma is not consistent in many individuals. These findings suggest that persistent asthma phenotypes cannot be determined using a single sputum sample. Recent studies have also cast doubt on previous findings that noneosinophilic asthma is unresponsive to corticosteroid treatment. SUMMARY Sputum inflammatory profiles are not consistent over time and a persistent asthma phenotype cannot be reliably determined using a single induced sputum. Because time and cost issues prohibit frequent induced sputum analyses in most clinical settings, these findings limit the diagnostic and therapeutic value of sputum analysis for clincal practice.
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