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Gauvreau GM, Davis BE, Scadding G, Boulet LP, Bjermer L, Chaker A, Cockcroft DW, Dahlén B, Fokkens W, Hellings P, Lazarinis N, O'Byrne PM, Tufvesson E, Quirce S, Van Maaren M, de Jongh FH, Diamant Z. Allergen Provocation Tests in Respiratory Research: Building on 50 Years of Experience. Eur Respir J 2022; 60:13993003.02782-2021. [PMID: 35086834 PMCID: PMC9403392 DOI: 10.1183/13993003.02782-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/29/2021] [Indexed: 11/05/2022]
Abstract
Allergen provocation test is an established model of allergic airway diseases, including asthma and allergic rhinitis, allowing the study of allergen-induced changes in respiratory physiology and inflammatory mechanisms in sensitised individuals as well as their associations. In the upper airways, allergen challenge is focused on the clinical and pathophysiological sequelae of the early allergic response and applied both as a diagnostic tool and in research settings. In contrast, the bronchial allergen challenge has almost exclusively served as a research tool in specialised research settings with a focus on the late asthmatic response and the underlying type 2 inflammation. The allergen-induced late asthmatic response is also characterised by prolonged airway narrowing, increased non-specific airway hyperresponsiveness and features of airway remodelling including the small airways, and hence, allows the study of several key mechanisms and features of asthma. In line with these characteristics, the allergen challenge has served as a valued tool to study the crosstalk of the upper and lower airways and in proof of mechanism studies of drug development. In recent years, several new insights into respiratory phenotypes and endotypes including the involvement of the upper and small airways, innovative biomarker sampling methods and detection techniques, refined lung function testing as well as targeted treatment options, further shaped the applicability of the allergen provocation test in precision medicine. These topics, along with descriptions of subject populations and safety, in line with the updated GINA2021, will be addressed in this paper.
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Affiliation(s)
- Gail M Gauvreau
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Beth E Davis
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Guy Scadding
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louis-Philippe Boulet
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec, University of Laval, Laval, Quebec, Canada
| | - Leif Bjermer
- Department of Clinical Sciences Lund, Respiratory medicine and Allergology, Lund University, Lund, Sweden
| | - Adam Chaker
- TUM School of Medicine, Dept. of Otolaryngology and Center of Allergy and Environment, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Donald W Cockcroft
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Barbro Dahlén
- Department of Medicine, Huddinge Karolinska Institutet, Stockholm, Sweden
| | - Wyste Fokkens
- Department of Otorhinolaryngology, Faculty of Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - Peter Hellings
- Department of Otorhinolaryngology, Faculty of Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - Nikolaos Lazarinis
- Department of Medicine, Huddinge Karolinska Institutet, Stockholm, Sweden
| | - Paul M O'Byrne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ellen Tufvesson
- Department of Clinical Sciences Lund, Respiratory medicine and Allergology, Lund University, Lund, Sweden
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, and CIBER de Enfermedades Respiratorias CIBERES, Madrid, Spain
| | | | - Frans H de Jongh
- Faculty of Engineering Technology, University of Twente, Enschede, Netherlands
| | - Zuzana Diamant
- Department of Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium.,Department of Respiratory Medicine & Allergology, Institute for Clinical Science, Skane University Hospital, Lund University, Lund, Sweden.,Department of Pharmacology & Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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2
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Sutherland L, Shaw K, Parrish C, Singleton N, McKeever TM, Stewart I, Shaw D, Martin MJ, Harrison T. A low exhaled nitric oxide level excludes a short-term benefit from inhaled corticosteroids in suspected asthma: A randomized placebo-controlled trial. Respirology 2021; 26:666-672. [PMID: 33939245 DOI: 10.1111/resp.14055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 01/29/2021] [Accepted: 02/23/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Fractional exhaled nitric oxide (FeNO) is a non-invasive biomarker that reflects IL-4/IL-13 production and therefore represents T2 allergic inflammation. FeNO has previously been used to guide inhaled corticosteroid (ICS) treatment in asthma. The purpose of this study was to determine if a low FeNO (≤27 ppb) could be used to reliably identify patients with symptoms suggestive of asthma who would not benefit from initiating treatment with an ICS. METHODS A total of 180 steroid-naïve adults with healthcare professional suspected asthma and an FeNO of ≤27 ppb were randomized to receive either 400 mcg of budesonide or placebo daily for 3 months. The primary outcome was the difference in the Asthma Control Questionnaire 7 (ACQ7) between treatment groups and the study was powered to determine equivalence. Secondary outcomes were the difference in FEV1 , Medical Research Council and Leicester Cough Questionnaire scores. RESULTS One hundred and thirty-four patients (68 budesonide and 66 placebo) completed the study and were included in the analysis. The between-group mean difference in ACQ7 from baseline to the end of the study was -0.25 and the 95% CI around this difference was -0.004 to 0.495 confirming equivalence (p < 0.05). Differences in forced expiratory volume over 1 s and other secondary outcomes were also small and clinically unimportant. CONCLUSION The results of this study suggest that steroid-naïve patients with symptoms suggestive of asthma and an FeNO ≤ 27 ppb are unlikely to benefit from initiating treatment with an ICS over 3 months. However, further research is recommended to confirm these findings before withholding ICS treatment.
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Affiliation(s)
- Lissa Sutherland
- School of Life Sciences, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Karen Shaw
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Clair Parrish
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Nicola Singleton
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Tricia M McKeever
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Iain Stewart
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Dominick Shaw
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Matthew J Martin
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Tim Harrison
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
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Pignatti P, Visca D, Loukides S, Märtson AG, Alffenaar JWC, Migliori GB, Spanevello A. A snapshot of exhaled nitric oxide and asthma characteristics: experience from high to low income countries. Pulmonology 2020; 28:44-58. [PMID: 33358001 DOI: 10.1016/j.pulmoe.2020.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/30/2020] [Accepted: 10/31/2020] [Indexed: 12/30/2022] Open
Abstract
Nitric oxide is a gas produced in the airways of asthmatic subjects and related to T2 inflammation. It can be measured as fractional nitric oxide (FeNO) in the exhaled air and used as a non-invasive, easy to evaluate, rapid marker. It is now widely used in many settings to determine airway inflammation. The aim of this narrative review is to report relationship between FeNO and the physiopathologic characteristics of asthmatic patients. Factors affecting FeNO levels have also been analysed as well as the impact of corticosteroid, target therapies and rehabilitation programs. Considering the availability of the test, spreading this methodology to low income countries has also been considered as a possibility for evaluating airway inflammation and monitoring adherence to inhaled corticosteroid therapy. PubMed data search has been performed restricted to English language papers. Research was limited to studies in adults unless studies in children were the only ones reported for a particular issue. This revision could be useful to summarize the role of FeNO in relation to asthma characteristics and help in the use of FeNO in different clinical settings particularly in low income countries.
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Affiliation(s)
- Patrizia Pignatti
- Allergy and Immunology Unit, Istituti Clinici Scientifici Maugeri IRCCS Pavia, Italy.
| | - Dina Visca
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy and Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia; Westmead Hospital, Sydney, Australia; Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Antonio Spanevello
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy and Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
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4
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Orban NT, Jacobson MR, Nouri-Aria KT, Durham SR, Eifan AO. Repetitive nasal allergen challenge in allergic rhinitis: Priming and Th2-type inflammation but no evidence of remodelling. Clin Exp Allergy 2020; 51:329-338. [PMID: 33141493 DOI: 10.1111/cea.13775] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 10/19/2020] [Accepted: 10/28/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Local tissue eosinophilia and Th2 cytokines are characteristic features of seasonal allergic rhinitis. Airway remodelling is a feature of asthma whereas evidence for remodelling in allergic rhinitis (AR) is conflicting. OBJECTIVE By use of a novel human repetitive nasal allergen challenge (RAC) model, we evaluated the relationship between allergic inflammation and features of remodelling in AR. METHODS Twelve patients with moderate-severe AR underwent 5 alternate day challenges with diluent which after 4 weeks were followed by 5 alternate day challenges with grass pollen extract. Nasal symptoms, Th1/Th2 cytokines in nasal secretion and serum were evaluated. Nasal biopsies were taken 24 hours after the 1st and 5th challenges with diluent and with allergen. Sixteen healthy controls underwent a single challenge with diluent and with allergen. Using immunohistochemistry, epithelial and submucosal inflammatory cells and remodelling markers were evaluated by computed image analysis. RESULTS There was an increase in early and late-phase symptoms after every allergen challenge compared to diluent (both P < .05) with evidence of both clinical and immunological priming. Nasal tissue eosinophils and IL-5 in nasal secretion increased significantly after RAC compared to corresponding diluent challenges (P < .01, P = .01, respectively). There was a correlation between submucosal mast cells and the early-phase clinical response (r = 0.79, P = .007) and an association between epithelial eosinophils and IL-5 concentrations in nasal secretion (r = 0.69, P = .06) in allergic rhinitis. No differences were observed after RAC with regard to epithelial integrity, reticular basement membrane thickness, glandular area, expression of markers of activation of airway remodelling including α-SMA, HSP-47, extracellular matrix (MMP7, 9 and TIMP-1), angiogenesis and lymphangiogenesis for AR compared with healthy controls. CONCLUSION Novel repetitive nasal allergen challenge in participants with severe persistent seasonal allergic rhinitis resulted in tissue eosinophilia and increases in IL-5 but no structural changes. Our data support no link between robust Th2-inflammation and development of airway remodelling in AR.
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Affiliation(s)
- Nara T Orban
- Allergy and Clinical Immunology, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre for Allergic Mechanisms of Asthma, Faculty of Medicine, Imperial College London, London, UK.,Allergy Department, Royal Brompton and Harefield Hospitals NHS Trust, Imperial College London, London, UK
| | - Mikila R Jacobson
- Allergy and Clinical Immunology, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre for Allergic Mechanisms of Asthma, Faculty of Medicine, Imperial College London, London, UK.,Allergy Department, Royal Brompton and Harefield Hospitals NHS Trust, Imperial College London, London, UK
| | - Kayhan T Nouri-Aria
- Allergy and Clinical Immunology, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre for Allergic Mechanisms of Asthma, Faculty of Medicine, Imperial College London, London, UK.,Allergy Department, Royal Brompton and Harefield Hospitals NHS Trust, Imperial College London, London, UK
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre for Allergic Mechanisms of Asthma, Faculty of Medicine, Imperial College London, London, UK.,Allergy Department, Royal Brompton and Harefield Hospitals NHS Trust, Imperial College London, London, UK
| | - Aarif O Eifan
- Allergy and Clinical Immunology, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre for Allergic Mechanisms of Asthma, Faculty of Medicine, Imperial College London, London, UK.,Allergy Department, Royal Brompton and Harefield Hospitals NHS Trust, Imperial College London, London, UK
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5
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Fieten KB, Rijssenbeek‐Nouwens LH, Hashimoto S, Bel EH, Weersink EJ. Less exacerbations and sustained asthma control 12 months after high altitude climate treatment for severe asthma. Allergy 2019; 74:628-630. [PMID: 30428132 DOI: 10.1111/all.13664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Karin B. Fieten
- Dutch Asthma Centre Davos Davos Switzerland
- Swiss Institute of Allergy and Asthma Research SIAF University of Zürich Zürich Switzerland
| | | | - Simone Hashimoto
- Department of Respiratory Medicine Amsterdam UMC Location Academic Medical Center University of Amsterdam AmsterdamThe Netherlands
| | - Elisabeth H. Bel
- Department of Respiratory Medicine Amsterdam UMC Location Academic Medical Center University of Amsterdam AmsterdamThe Netherlands
| | - Els J. Weersink
- Department of Respiratory Medicine Amsterdam UMC Location Academic Medical Center University of Amsterdam AmsterdamThe Netherlands
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6
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Lee WY, Southworth T, Booth S, Singh D. High- and low-dose allergen challenges in asthmatic patients using inhaled corticosteroids. Br J Clin Pharmacol 2015; 79:523-32. [PMID: 25214200 DOI: 10.1111/bcp.12508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 09/05/2014] [Indexed: 02/03/2023] Open
Abstract
AIMS The inhaled allergen challenge model has been used previously to investigate the effects of novel anti-inflammatory drugs in inhaled corticosteroid (ICS)-naïve asthmatics. The aim of this study was to characterize high- and low-dose allergen challenges in asthmatic patients using ICS. METHODS Twenty-eight asthmatic patients taking ICS (beclomethasone equivalent <1000 μg day(-1) ) were recruited for high-dose allergen challenge, of whom 10 subsequently also had a repeat low-dose challenge comprising seven allergen challenges. Induced sputum was collected for measurements of cell counts and supernatant biomarkers. RESULTS The high-dose allergen challenge caused an early and late asthmatic response in 19 of 28 patients; the mean maximal fall in the forced expiratory volume in 1 s (FEV1 ) was 29.1% (SD 6.2%) and 25.1% (SD 9.6%), respectively. There was also an increase in sputum eosinophils of 6.2% (P = 0.0004), as well as supernatant eosinophil cationic protein levels. The low-dose allergen challenge caused an acute fall in FEV1 , but had no effect on FEV1 at 24 h after challenge or sputum measurements. CONCLUSIONS The high-dose allergen challenge in asthmatics using ICS induces a late asthmatic response associated with an increase in eosinophilic airway inflammation. This may be a suitable model for studying the effects of novel anti-inflammatory drugs added to maintenance ICS treatment.
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Affiliation(s)
- Wha-Yong Lee
- Manchester Academic Health Science Centre, Manchester, UK; University Hospital South Manchester NHS Foundation Trust, Manchester, UK; NIHR South Manchester Respiratory and Allergy Clinical Research Facility, Medicines Evaluation Unit, The University of Manchester, Manchester, UK
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7
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Toyran M, Bakirtas A, Dogruman-Al F, Turktas I. Airway inflammation and bronchial hyperreactivity in steroid naive children with intermittent and mild persistent asthma. Pediatr Pulmonol 2014; 49:140-7. [PMID: 23798479 DOI: 10.1002/ppul.22810] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 03/10/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intermittent and mild persistent asthma are defined according to symptom frequency and spirometry and treated differently. To our knowledge, there is no study comparing airway inflammation between intermittent and mild persistent asthmatic children. MATERIALS AND METHODS Children aged 7-16 years, referred to our pediatric allergy clinic for recurrent respiratory complaints underwent a detailed clinical history and spirometry with reversibility. None of the subjects had been using regular anti-inflammatory treatment. After a 2-week run-in period during which asthma symptoms were recorded, exhaled NO measurement, bronchial provocation test with adenosine monophosphate and methacholine and sputum induction were performed. Data of patients with intermittent and mild persistent asthma and a control group were compared. RESULTS Thirty intermittent, 26 mild persistent asthmatic children, and 21 control subjects were studied. Sputum was obtained from 19 of intermittent asthmatics (63.3%), 18 of mild persistent asthmatics (69.2%), and 13 of control subjects (61.9%). Eosinophil count and exhaled nitric oxide were not different between asthmatic groups. Neutrophil count of children with mild persistent asthma was higher than the intermittent asthmatic group (P = 0.003). Geometric mean of PC20 methacoline values were not different between groups (P = 0.058). Geometric mean of PC20 AMP was lower among patients with mild persistent asthma (P = 0.102). CONCLUSION Eosinophilic airway inflammation and direct BHR may not be significantly different in intermittent asthmatic children from their peers with mild persistent disease. Neutrophilic airway inflammation and BHR to an indirect stimuli are more pronounced in the mild persistent group.
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Affiliation(s)
- Muge Toyran
- Department of Pediatric Allergy and Immunology, Ankara Pediatric Health and Disease Hematology Oncology Research and Education Hospital, Ankara, Turkey
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8
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Inhaled allergen bronchoprovocation tests. J Allergy Clin Immunol 2013; 132:1045-1055.e6. [PMID: 24119772 DOI: 10.1016/j.jaci.2013.08.023] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/16/2013] [Accepted: 08/20/2013] [Indexed: 11/23/2022]
Abstract
The allergen bronchoprovocation test is a long-standing exacerbation model of allergic asthma that can induce several clinical and pathophysiologic features of asthma in sensitized subjects. Standardized allergen challenge is primarily a research tool, and when properly conducted by qualified and experienced investigators, it is safe and highly reproducible. In combination with validated airway sampling and sensitive detection techniques, allergen challenge allows the study of several features of the physiology of mainly TH2 cell-driven asthma in relation to the kinetics of the underlying airway pathology occurring during the allergen-induced late response. Furthermore, given the small within-subject variability in allergen-induced airway responses, allergen challenge offers an adequate disease model for the evaluation of new (targeted) controller therapies for asthma in a limited number of subjects. In proof-of-efficacy studies thus far, allergen challenge showed a fair positive predicted value and an excellent negative predictive value for the actual clinical efficacy of new antiasthma therapies, underscoring its important role in early drug development. In this review we provide recommendations on challenge methods, response measurements, sample size, safety, and harmonization for future applications.
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Wan GH, Yan DC, Tung TH, Tang CS, Liu CH. Seasonal Changes in Endotoxin Exposure and Its Relationship to Exhaled Nitric Oxide and Exhaled Breath Condensate pH Levels in Atopic and Healthy Children. PLoS One 2013; 8:e66785. [PMID: 23840530 PMCID: PMC3686731 DOI: 10.1371/journal.pone.0066785] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 05/13/2013] [Indexed: 11/20/2022] Open
Abstract
Endotoxin, a component of the cell walls of gram-negative bacteria, is a contaminant in organic dusts (house dust) and aerosols. In humans, small amounts of endotoxin may cause a local inflammatory response. Exhaled nitric oxide (eNO) levels, an inflammation indicator, are associated with the pH values of exhaled breath condensate (EBC). This study evaluated seasonal changes on indoor endotoxin concentrations in homes and the relationships between endotoxin exposure and eNO/EBC pH levels for healthy children and children with allergy-related respiratory diseases. In total, 34 children with allergy-related respiratory diseases and 24 healthy children were enrolled. Indoor air quality measurements and dust sample analysis for endotoxin were conducted once each season inside 58 surveyed homes. The eNO, EBC pH levels, and pulmonary function of the children were also determined. The highest endotoxin concentrations were on kitchen floors of homes of children with allergy-related respiratory diseases and healthy children, and on bedroom floors of homes of asthmatic children and healthy children. Seasonal changes existed in endotoxin concentrations in dust samples from homes of children with allergic rhinitis, with or without asthma, and in EBC pH values among healthy children and those with allergy-related respiratory diseases. Strong relationships existed between endotoxin exposure and EBC pH values in children with allergic rhinitis.
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Affiliation(s)
- Gwo-Hwa Wan
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
- * E-mail:
| | - Dah-Chin Yan
- Division of Taipei Pediatrics, Department of Pediatrics, Chang Gung Children’s Hospital, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Medicine, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Tao-Hsin Tung
- Department of Medical Research and Education, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Chin-Sheng Tang
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chiu-Hsin Liu
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
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Mushaben EM, Brandt EB, Hershey GKK, Le Cras TD. Differential effects of rapamycin and dexamethasone in mouse models of established allergic asthma. PLoS One 2013; 8:e54426. [PMID: 23349887 PMCID: PMC3547928 DOI: 10.1371/journal.pone.0054426] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 12/11/2012] [Indexed: 12/31/2022] Open
Abstract
The mammalian target of rapamycin (mTOR) plays an important role in cell growth/differentiation, integrating environmental cues, and regulating immune responses. Our lab previously demonstrated that inhibition of mTOR with rapamycin prevented house dust mite (HDM)-induced allergic asthma in mice. Here, we utilized two treatment protocols to investigate whether rapamycin, compared to the steroid, dexamethasone, could inhibit allergic responses during the later stages of the disease process, namely allergen re-exposure and/or during progression of chronic allergic disease. In protocol 1, BALB/c mice were sensitized to HDM (three i.p. injections) and administered two intranasal HDM exposures. After 6 weeks of rest/recovery, mice were re-exposed to HDM while being treated with rapamycin or dexamethasone. In protocol 2, mice were exposed to HDM for 3 or 6 weeks and treated with rapamycin or dexamethasone during weeks 4-6. Characteristic features of allergic asthma, including IgE, goblet cells, airway hyperreactivity (AHR), inflammatory cells, cytokines/chemokines, and T cell responses were assessed. In protocol 1, both rapamycin and dexamethasone suppressed goblet cells and total CD4(+) T cells including activated, effector, and regulatory T cells in the lung tissue, with no effect on AHR or total inflammatory cell numbers in the bronchoalveolar lavage fluid. Rapamycin also suppressed IgE, although IL-4 and eotaxin 1 levels were augmented. In protocol 2, both drugs suppressed total CD4(+) T cells, including activated, effector, and regulatory T cells and IgE levels. IL-4, eotaxin, and inflammatory cell numbers were increased after rapamycin and no effect on AHR was observed. Dexamethasone suppressed inflammatory cell numbers, especially eosinophils, but had limited effects on AHR. We conclude that while mTOR signaling is critical during the early phases of allergic asthma, its role is much more limited once disease is established.
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Affiliation(s)
- Elizabeth M. Mushaben
- Division of Pulmonary Biology, Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States of America
| | - Eric B. Brandt
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States of America
| | - Gurjit K. Khurana Hershey
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States of America
| | - Timothy D. Le Cras
- Division of Pulmonary Biology, Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States of America
- * E-mail:
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11
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Koh YY. Long-term asthma remission during adolescence. ALLERGY ASTHMA & RESPIRATORY DISEASE 2013. [DOI: 10.4168/aard.2013.1.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Young Yull Koh
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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12
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Schulze J, Voss S, Zissler U, Rose MA, Zielen S, Schubert R. Airway responses and inflammation in subjects with asthma after four days of repeated high-single-dose allergen challenge. Respir Res 2012; 13:78. [PMID: 22989372 PMCID: PMC3445853 DOI: 10.1186/1465-9921-13-78] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 06/27/2012] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Both standard and low-dose allergen provocations are an established tool in asthma research to improve our understanding of the pathophysiological mechanism of allergic asthma. However, clinical symptoms are less likely to be induced. Therefore, we designed a protocol for repetitive high-dose bronchial allergen challenges to generate clinical symptoms and airway inflammation. METHODS A total of 27 patients aged 18 to 40 years with positive skin-prick tests and mild asthma underwent repetitive high-dose allergen challenges with household dust mites for four consecutive days. Pulmonary function and exhaled NO were measured at every visit. Induced sputum was analysed before and after the allergen challenges for cell counts, ECP, IL-5, INF-γ, IL-8, and the transcription factor Foxp3. RESULTS We found a significant decrease in pulmonary function, an increased use of salbutamol and the development of a late asthmatic response and bronchial hyperresponsiveness, as well as a significant induction of eNO, eosinophils, and Th-2 cytokines. Repeated provocation was feasible in the majority of patients. Two subjects had severe adverse events requiring prednisolone to cope with nocturnal asthma symptoms. CONCLUSIONS Repeated high-dose bronchial allergen challenges resulted in severe asthma symptoms and marked Th-2-mediated allergic airway inflammation. The high-dose challenge model is suitable only in an attenuated form in diseased volunteers for proof-of-concept studies and in clinical settings to reduce the risk of severe asthma exacerbations. TRIAL REGISTRATION ClinicalTrials.govNCT00677209.
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Affiliation(s)
- Johannes Schulze
- Department of Allergy, Pulmonology, and Cystic Fibrosis, Children's Hospital, Goethe-University, Frankfurt, Germany
| | - Sandra Voss
- Department of Allergy, Pulmonology, and Cystic Fibrosis, Children's Hospital, Goethe-University, Frankfurt, Germany
| | - Ulrich Zissler
- Department of Allergy, Pulmonology, and Cystic Fibrosis, Children's Hospital, Goethe-University, Frankfurt, Germany
| | - Markus A Rose
- Department of Allergy, Pulmonology, and Cystic Fibrosis, Children's Hospital, Goethe-University, Frankfurt, Germany
| | - Stefan Zielen
- Department of Allergy, Pulmonology, and Cystic Fibrosis, Children's Hospital, Goethe-University, Frankfurt, Germany
| | - Ralf Schubert
- Department of Allergy, Pulmonology, and Cystic Fibrosis, Children's Hospital, Goethe-University, Frankfurt, Germany
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Badorrek P, Dick M, Emmert L, Schaumann F, Koch W, Hecker H, Murdoch R, Hohlfeld JM, Krug N. Pollen starch granules in bronchial inflammation. Ann Allergy Asthma Immunol 2012; 109:208-214.e6. [PMID: 22920077 DOI: 10.1016/j.anai.2012.06.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 06/05/2012] [Accepted: 06/24/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pollen grains with a diameter of more than 10 μm preferentially deposit in the upper airways. Their contribution to lower airway inflammation is unclear. One hypothesis is that lower airway inflammation is mainly caused by allergen containing pollen starch granules, which are released from the pollen grains and can easily enter the peripheral airways because of their smaller size. OBJECTIVE To investigate the differential effect of pollen grains and pollen starch granules on nasal symptoms and lower airway inflammation. METHODS In a 2-period crossover design, 30 patients with allergic rhinitis and mild intermittent asthma underwent 2 allergen challenges on consecutive days in an environmental challenge chamber with either a mixture of pollen grains plus starch granules or starch granules only. End points were the total nasal symptom score (TNSS), nasal secretion weight, nasal flow, spirometry, and exhaled nitric oxide (eNO). RESULTS The presence of pollen grains had a significant and considerable effect on increase in TNSS and secretion weight and on decrease in nasal flow. Starch granules alone only had minimal effects on nasal symptoms. Challenges with starch granules significantly increased eNO. Pollen had no effect on eNO. CONCLUSION Pollen grains cause nasal symptoms but do not augment lower airway inflammation, whereas starch granules trigger lower airway inflammation but hardly induce nasal symptoms.
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Affiliation(s)
- Philipp Badorrek
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany.
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14
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Cornell AG, Chillrud SN, Mellins RB, Acosta LM, Miller RL, Quinn JW, Yan B, Divjan A, Olmedo OE, Lopez-Pintado S, Kinney PL, Perera FP, Jacobson JS, Goldstein IF, Rundle AG, Perzanowski MS. Domestic airborne black carbon and exhaled nitric oxide in children in NYC. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2012; 22:258-66. [PMID: 22377682 PMCID: PMC3685864 DOI: 10.1038/jes.2012.3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 09/23/2011] [Indexed: 05/21/2023]
Abstract
Differential exposure to combustion by-products and allergens may partially explain the marked disparity in asthma prevalence (3-18%) among New York City neighborhoods. Subclinical changes in airway inflammation can be measured by fractional exhaled nitric oxide (FeNO). FeNO could be used to test independent effects of these environmental exposures on airway inflammation. Seven- and eight-year-old children from neighborhoods with lower (range 3-9%, n=119) and higher (range 11-18%, n=121) asthma prevalence participated in an asthma case-control study. During home visits, FeNO was measured, and samples of bed dust (allergens) and air (black carbon; BC) were collected. Neighborhood built-environment characteristics were assessed for the 500 m surrounding participants' homes. Airborne BC concentrations in homes correlated with neighborhood asthma prevalence (P<0.001) and neighborhood densities of truck routes (P<0.001) and buildings burning residual oil (P<0.001). FeNO concentrations were higher among asthmatics with than in those without frequent wheeze (≥4 times/year) (P=0.002). FeNO concentrations correlated with domestic BC among children without seroatopy (P=0.012) and with dust mite allergen among children with seroatopy (P=0.020). The association between airborne BC in homes and both neighborhood asthma prevalence and FeNO suggest that further public health interventions on truck emissions standards and residual oil use are warranted.
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Affiliation(s)
- Alexandra G. Cornell
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - Steven N. Chillrud
- Lamont-Doherty Earth Observatory, Columbia University, Palisades, NY
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
| | - Robert B. Mellins
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - Luis M. Acosta
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
| | - Rachel L. Miller
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY
- Division of Pulmonary, Allergy, Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - James W. Quinn
- Institute for Social and Economic Research and Policy, Columbia University, New York, NY
| | - Beizhan Yan
- Lamont-Doherty Earth Observatory, Columbia University, Palisades, NY
| | - Adnan Divjan
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | - Omar E. Olmedo
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
| | - Sara Lopez-Pintado
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Patrick L. Kinney
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | - Frederica P. Perera
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | - Judith S. Jacobson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Inge F. Goldstein
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Andrew G. Rundle
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Matthew S. Perzanowski
- Columbia Center for Children’s Environmental Health, Columbia University, New York, NY
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY
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15
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Choi BS, Kim KW, Lee YJ, Baek J, Park HB, Kim YH, Sohn MH, Kim KE. Exhaled nitric oxide is associated with allergic inflammation in children. J Korean Med Sci 2011; 26:1265-9. [PMID: 22022176 PMCID: PMC3192335 DOI: 10.3346/jkms.2011.26.10.1265] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Accepted: 08/29/2011] [Indexed: 11/21/2022] Open
Abstract
Exhaled nitric oxide (eNO) has been proposed as a noninvasive marker of airway inflammation in asthma. In asthmatic patients, exhaled NO levels have been shown to relate with other markers of eosinophilic recruitment, which are detected in blood, sputum, bronchoalveolar lavage fluid and bronchial biopsy samples. The purpose of this study was to assess the possible relationship between eNO and allergic inflammation or sensitization in childhood asthma and allergic rhinitis. Subjects consisted of 118 asthmatic children, 79 patients with allergic rhinitis, and 74 controls. Their age ranged from 6 to 15 yr old. eNO level, peripheral blood eosinophil count, eosinophil cationic protein (ECP), serum total IgE level and specific IgE levels were measured. Methacholine challenge test and allergic skin prick test for common allergens were performed in all subjects. Atopic group (n = 206, 44.48 ± 30.45 ppb) had higher eNO values than non-atopic group (n = 65, 20.54 ± 16.57 ppb, P < 0.001). eNO level was significantly higher in patients with asthma (42.84 ± 31.92 ppb) and in those with allergic rhinitis (43.59 ± 29.84 ppb) than in healthy controls (27.01 ± 21.34 ppb, P < 0.001) but there was no difference between asthma and allergic rhinitis group. eNO also had significant positive correlations with Dermatophagoides pteronyssinus IgE level (r = 0.348, P < 0.001), Dermatophagoides farinae IgE level (r = 0.376, P < 0.001), and the number of positive allergens in skin prick test (r = 0.329, P = 0.001). eNO had significant positive correlations with peripheral blood eosinophil count (r = 0.356, P < 0.001), serum total IgE level (r = 0.221, P < 0.001), and ECP (r = 0.436, P < 0.001). This study reveals that eNO level is associated with allergic inflammation and the degree of allergic sensitization.
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Affiliation(s)
- Bong Seok Choi
- Department of Pediatrics, Good Gangan Hospital, Busan, Korea
| | - Kyung Won Kim
- Department of Pediatrics and Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Ju Lee
- Department of Pediatrics and Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, Seoul, Korea
| | - Jiyoung Baek
- Department of Pediatrics and Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Bin Park
- Department of Pediatrics and Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Hee Kim
- Department of Pediatrics and Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Hyun Sohn
- Department of Pediatrics and Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Earn Kim
- Department of Pediatrics and Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, Seoul, Korea
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Vatrella A, Perna F, Pelaia G, Parrella R, Maselli R, Marsico SA, Calabrese C. T cell activation state in the induced sputum of asthmatics treated with budesonide. Int J Immunopathol Pharmacol 2010; 23:745-53. [PMID: 20943044 DOI: 10.1177/039463201002300308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Bronchial hyperresponsiveness and airway infiltration with eosinophils and T lymphocytes are key features of asthma. In particular, CD4+ T cells are currently believed to play a pivotal role as initiators and coordinators of the asthmatic inflammatory response and, therefore, they represent a crucial target of corticosteroid treatment. The aim of the present investigation is thus to evaluate, in patients with mild asthma, the effects of inhaled corticosteroid therapy on the following parameters: (i) functional state of CD4+ T cells; (ii) airway eosinophilia; (iii) bronchial hyperresponsiveness to methacholine. The study was completed by twenty asthmatic, atopic subjects, subdivided into two groups of ten and treated for 12 weeks with either inhaled budesonide (200 microg twice daily) or terbutaline alone (500 microg twice daily), respectively. Expression of CD4+ T cell activation markers was measured in induced sputum at baseline and after 1, 4, 8 and 12 weeks of treatment by flow cytometry, which showed a down-regulation of HLA-DR and CD25 surface proteins in the budesonide group, compared with the control group; these differences resulted as being statistically significant through weeks 4-12. Budesonide also induced a quick, sharp reduction in the percentage of eosinophils detectable in induced sputum, as well as a more gradual progressive improvement in airway hyperresponsiveness to methacholine. Therefore, in addition to assessing various indices of bronchial inflammation, flow cytometry can be reliably applied to induced sputum in order to monitor, even in mildly symptomatic patients, the effects of anti-asthma treatments on T cell activation.
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Affiliation(s)
- A Vatrella
- Department of Clinical and Experimental Medicine, Division of Respiratory Disease, University Federico II of Naples, Italy.
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17
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Omega-3 polyunsaturated fatty acids and bronchial inflammation in grass pollen allergy after allergen challenge. Respir Med 2010; 104:1793-8. [PMID: 20637584 DOI: 10.1016/j.rmed.2010.06.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 04/16/2010] [Accepted: 06/25/2010] [Indexed: 12/21/2022]
Abstract
UNLABELLED RATIO: Asthma is a major public health problem, with bronchial inflammation as the therapeutic target. The role of dietary fish oil derived polyunsaturated fatty acids (PUFAs) in allergic inflammation is controversial. Most asthmatics suffer from mild disease and non-pharmacologic interventions are attractive. This study investigates the anti-inflammatory potential of nutritional PUFAs in an experimentally induced bronchial inflammation. METHODS We examined 38 grass pollen allergic asthmatics and 19 controls. History of dietary PUFA intake was compared with levels of PUFAs in erythrocyte membranes, and stratified according to low (25th quartile; Q25) and high (75th quartile; Q75) ratios of omega-3 (n-3) to omega-6 (n-6) PUFAs as a surrogate for anti-inflammatory (Q75) or proinflammatory (Q25) effects. Bronchial inflammation was simulated with one-step inhalation of grass pollen. Bronchial response (exhaled nitric monoxide, eNO as surrogate for inflammation, decrease of FEV(1)) was correlated with levels of PUFAs in erythrocyte membranes. RESULTS Ratios of n-3/n-6 PUFA were significantly lower in asthmatics than in healthy controls. Levels of eNO were significantly higher in Q25 asthmatics than in Q75 asthmatics (p = 0.040). There was a trend of higher bronchial hyperreactivity in Q25 asthmatics (median PD(20) 0.27 vs. 0.14; n.s.), induced by specific bronchial challenge with grass pollen (FEV(1) decrease 16.7 vs. 23.1%; n.s.). CONCLUSION When stratifying for erythrocyte membrane PUFA content as a surrogate for alimentary intake, we found mild effects on bronchial allergic inflammation. Future intervention studies with pharmacological PUFA doses appear suitable to clarify dietary PUFA role as an adjunctive intervention to the established treatment of asthma. ClinicalTrials.gov No. NCT00519740.
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18
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Biomarkers in asthma and allergic rhinitis. Pulm Pharmacol Ther 2010; 23:468-81. [PMID: 20601050 DOI: 10.1016/j.pupt.2010.06.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 06/23/2010] [Indexed: 11/20/2022]
Abstract
A biological marker (biomarker) is a physical sign or laboratory measurement that can serve as an indicator of biological or pathophysiological processes or as a response to a therapeutic intervention. An applicable biomarker possesses the characteristics of clinical relevance (sensitivity and specificity for the disease) and is responsive to treatment effects, in combination with simplicity, reliability and repeatability of the sampling technique. Presently, there are several biomarkers for asthma and allergic rhinitis that can be obtained by non-invasive or semi-invasive airway sampling methods meeting at least some of these criteria. In clinical practice, such biomarkers can provide complementary information to conventional disease markers, including clinical signs, spirometry and PC(20)methacholine or histamine. Consequently, biomarkers can aid to establish the diagnosis, in staging and monitoring of the disease activity/progression or in predicting or monitoring of a treatment response. Especially in (young) children, reliable, non-invasive biomarkers would be valuable. Apart from diagnostic purposes, biomarkers can also be used as (surrogate) markers to predict a (novel) drug's efficacy in target populations. Therefore, biomarkers are increasingly applied in early drug development. When implementing biomarkers in clinical practice or trials of asthma and allergic rhinitis, it is important to consider the heterogeneous nature of the inflammatory response which should direct the selection of adequate biomarkers. Some biomarker sampling techniques await further development and/or validation, and should therefore be applied as a "back up" of established biomarkers or methods. In addition, some biomarkers or sampling techniques are less suitable for (very young) children. Hence, on a case by case basis, a decision needs to be made what biomarker is adequate for the target population or purpose pursued. Future development of more sophisticated sampling methods and quantification techniques, such as--omics and biomedical imaging, will enable detection of adequate biomarkers for both clinical and research applications.
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Gerald LB, McClure LA, Mangan JM, Harrington KF, Gibson L, Erwin S, Atchison J, Grad R. Increasing adherence to inhaled steroid therapy among schoolchildren: randomized, controlled trial of school-based supervised asthma therapy. Pediatrics 2009; 123:466-74. [PMID: 19171611 PMCID: PMC2782792 DOI: 10.1542/peds.2008-0499] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE We aimed to determine the effectiveness of school-based supervised asthma therapy in improving asthma control. The primary hypothesis was that the supervised-therapy group would have a smaller proportion of children experiencing an episode of poor asthma control each month, compared with those in the usual-care group. METHODS Children were eligible if they had physician-diagnosed persistent asthma, the need for daily controller medication, and the ability to use a dry-powder inhaler and a peak flowmeter. The trial used a 2-group, randomized, longitudinal design with a 15-month follow-up period. A total of 290 children from 36 schools were assigned randomly to either school-based, supervised therapy or usual care. Ninety-one percent of the children were black, and 57% were male. The mean age was 11 years (SD: 2.1 years). An episode of poor asthma control was defined as > or =1 of the following each month: (1) an absence from school attributable to respiratory illness/asthma; (2) average use of rescue medication >2 times per week (not including preexercise treatment); or (3) > or =1 red or yellow peak flowmeter reading. RESULTS Two hundred forty children completed the study. There were no differences in the likelihood of an episode of poor asthma control between the baseline period and the follow-up period for the usual-care group. For the supervised-therapy group, however, the odds of experiencing an episode of poor asthma control during the baseline period were 1.57 times the odds of experiencing an episode of poor asthma control during the follow-up period. Generalized estimating equation modeling revealed a marginally significant intervention-time period interaction, indicating that children in the supervised-therapy group showed greater improvement in asthma control. CONCLUSIONS Supervised asthma therapy improves asthma control. Clinicians who have pediatric patients with asthma with poor outcomes that may be attributable to nonadherence should consider supervised therapy.
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Affiliation(s)
- Lynn B. Gerald
- Lung Health Center, School of Medicine, University of Alabama at Birmingham
| | - Leslie A. McClure
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Joan M. Mangan
- Lung Health Center, School of Medicine, University of Alabama at Birmingham
| | | | - Linda Gibson
- School of Nursing, University of Alabama at Birmingham
| | - Sue Erwin
- Lung Health Center, School of Medicine, University of Alabama at Birmingham
| | - Jody Atchison
- Lung Health Center, School of Medicine, University of Alabama at Birmingham
| | - Roni Grad
- Lung Health Center, School of Medicine, University of Alabama at Birmingham,Department of Pediatrics, School of Medicine, University of Alabama at Birmingham
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20
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Hara J, Fujimura M, Myou S, Kita T, Abo M, Katayama N, Furusho S, Nobata K, Oribe Y, Kimura H, Sone T, Waseda Y, Ichikawa Y, Araya T, Ohkura N, Tamori S, Takato H, Tambo Y, Herai Y, Hori A, Yasui M, Kasahara K, Nakao S. Sputum eosinophilia, airway hyperresponsiveness and airway narrowing in young adults with former asthma. Allergol Int 2008; 57:211-7. [PMID: 18566550 DOI: 10.2332/allergolint.o-06-461] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Accepted: 10/15/2007] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND 30-80% of outgrown asthma subjects develop symptoms again later in life. We investigated inflammation and function of lower airway in adolescents with former asthma. METHODS 326 never-smoking young adults (mean age 24.0 years) were interviewed with special emphasis on history of asthma. Diagnosis of asthma was based on GINA guidelines. Former asthma subjects consisted of ones with a history of physician-diagnosed childhood asthma, who had been free of asthma symptoms without the use of medication for at least 10 years prior to the study. Provocative concentration of methacholine causing a 20% fall in forced expiratory volume in 1 second (FEV(1))(PC(20)) and eosinophil percentage in induced sputum were measured. RESULTS 31 subjects were former asthma subjects (FBA), 11 subjects were current asthma subjects (CBA) and 284 subjects had no history of asthma (non-BA). PC(20) and FEV(1)/FVC ratio were significantly lower in the FBA group than in the non-BA group (P < 0.01). Maximal mid-expiratory flow (MMF) was significantly lower in the FBA group than in the non-BA group (P < 0.05). Sputum eosinophil percentage was significantly increased in the FBA group compared with the non-BA group (P < 0.01). PC(20) was significantly lower in the CBA group than in the FBA and non-BA groups (P < 0.01). FEV(1), FEV(1)/FVC ratio and MMF were significantly lower in the CBA group than in the FBA group (P < 0.05, P < 0.05 and P < 0.05, respectively) and the non-BA group (P < 0.01, P < 0.01 and P < 0.05, respectively). Sputum eosinophils were significantly higher in the CBA group than in the FBA and non-BA groups (P < 0.01). CONCLUSIONS This study shows that subjects with long-term outgrown asthma continue to have airway eosinophilic inflammation, airway hyperresponsiveness and airway narrowing.
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Affiliation(s)
- Johsuke Hara
- Respiratory Medicine, Cellular Transplantation Biology, Kanazawa University Graduate School of Medicine, Ishikawa, Japan.
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Barreto M, Rennerova Z, Montesano M, Alterio A, Trubacova D, Ronchetti R, Villa MP. Variations in exhaled nitric oxide in children with asthma during a 1-week stay in a mountain village sanatorium. J Asthma 2008; 45:453-8. [PMID: 18612896 DOI: 10.1080/02770900802040035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Knowing about spontaneous variations in the fractional concentration of exhaled nitric oxide (FE(NO)) could improve monitoring of airway inflammation in asthmatic children. We aimed to assess FE(NO) variations (expiratory flow 50 mL/sec) in subjects maintained in similar environmental conditions. We tested spirometry and FE(NO) in symptom-free asthmatic children (9 corticosteroid-naive, 8 corticosteroid-treated) during a 1-week stay in a countryside sanatorium and in their healthy relatives (n = 12) staying in the immediate neighborhood on summer holiday (total 29 children, M/F:14/15, 5.8-16.8 yrs). Testing sessions were repeated every 12 hours (8:00 am, 8:00 pm) for 2 days and again on day 7. Measurements were defined as reproducible when they agreed with an intraclass correlation coefficient (ICC) above 0.60; deviation from mean differences was assessed by the coefficient of repeatability (CR = 2 SD). Lung function remained constant throughout the week in all groups. Baseline FE(NO) levels in corticosteroid-naive asthmatic children tended to decrease at the end of the week (from 13.9 ppb, 95% CI 12.2-19.1 to 9.2 ppb, 95% CI 5.8-15.9, p = 0.057). No differences were found between nocturnal and diurnal FE(NO). Within-session reproducibility for two FE(NO) measurements was high (ICC 0.99 in all groups and CR, 0.9 to 1.3 ppb). Between-session FE(NO) reproducibility at 12 hours and 24 hours was still high for each group but decreased markedly after 6 days in corticosteroid-naive asthmatic children (ICC 0.79 and CR 9.6 ppb at 24 hours vs. ICC 0.13 and CR 20.8 ppb after 6 days), whereas it decreased slightly in corticosteroid-treated asthmatics (from ICC 0.89 and CR 3.1 ppb to ICC 0.88 and CR 3.0 ppb) and healthy children (from ICC 0.79 and CR 4.8 ppb to ICC 0.65 and CR 5.7 ppb). In conclusion, in healthy subjects and in asthmatic children receiving therapy with inhaled corticosteroids (but not in corticosteroid-naive subjects), FE(NO) measurements are reproducible across a week.
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Affiliation(s)
- Mario Barreto
- Pediatric Department, Sant'Andrea Hospital, University La Sapienza, Rome, Italy.
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22
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Colice GL, Yu AP, Ivanova JI, Hsieh M, Birnbaum HG, Lage MJ, Brewster C. Costs and resource use of mild persistent asthma patients initiated on controller therapy. J Asthma 2008; 45:293-9. [PMID: 18446593 DOI: 10.1080/02770900801911178] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The treatment of mild persistent asthma is controversial. OBJECTIVES A retrospective database approach was used to evaluate different alternatives to treating mild persistent asthma. We hypothesized that treatment with inhaled corticosteroids (ICS) would result in lowest costs than treatment with leukotriene modifiers (LM) and combination therapy with ICS long-acting inhaled beta(2)-agonists (LABA) because it would be associated with fewer acute care visits and hospitalizations than LM and it would have lower drug acquisition costs than both ICS+LABA and LM. METHODS Costs and resource utilization were compared in 1,283 mild persistent asthma patients initiating regular use of either ICS, ICS+LABA, or LM. Mild persistent asthma patients were identified from a privately insured claims database (1999-2005) using an established algorithm. Wilcoxon rank-sum tests and generalized linear models were used to compare costs. RESULTS Of the total patients who met study criteria, 319 patients (24.9%) initiated regular ICS use, 414 (32.3%) ICS+LABA use, and 550 (42.9%) LM use. Over the 1 year after controller therapy initiation, asthma-related direct costs were significantly lower with ICS compared with ICS+LABA or LM ($819 for ICS, $1,094 for ICS+LABA, and $869 for LM, p < 0.001 for all comparisons). There were no significant differences in resource use. CONCLUSION In this analysis, physicians, despite guideline recommendations, chose to treat patients with mild persistent asthma more often with LM and ICS+LABA than with ICS. However, therapy with ICS was less costly than treatment with either LM or ICS+LABA, primarily due to differences in drug costs, and provided similar outcomes.
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Affiliation(s)
- Gene L Colice
- The George Washington University School of Medicine and Washington Hospital Center, Washington, DC, USA
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Hewitt RS, Smith AD, Cowan JO, Schofield JC, Herbison GP, Taylor DR. Serial exhaled nitric oxide measurements in the assessment of laboratory animal allergy. J Asthma 2008; 45:101-7. [PMID: 18350400 DOI: 10.1080/02770900701767696] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Laboratory animal allergy (LAA) may cause eosinophilic airway inflammation, for which exhaled nitric oxide (FE(NO)) measurements are sensitive and specific. Our objective was to assess whether serial FE(NO) measurements might detect exposure-related inflammation in laboratory animal workers. METHODS. Fifty laboratory animal workers participated. Measurements of FE(NO) and spirometry were obtained at baseline (Friday) and twice-daily following a weekend with no animal contact. RESULTS Eleven of 50 subjects had work-related symptoms, and 2 of 11 had positive serology for LAA. Baseline FE(NO) was high (> 150 ppb) in the two seropositive subjects and increased progressively during the working week in one subject, confirming exposure-driven airway inflammation. In seronegative subjects, mean FE(NO) levels were 19.8 (standard deviation [SD], 20.1) and 21.7 (SD, 20.8) in the symptomatic and nonsymptomatic groups, respectively, with no significant changes in FE(NO) over time. CONCLUSION Serial FE(NO) measurements may provide complementary information in the assessment of possible occupational sensitisation. The sensitivity and specificity of this approach to diagnosing occupational asthma requires further evaluation.
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Affiliation(s)
- Richard S Hewitt
- Respiratory Research Unit, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Ravensberg AJ, van Rensen ELJ, Grootendorst DC, de Kluijver J, Diamant Z, Ricciardolo FLM, Sterk PJ. Validated safety predictions of airway responses to house dust mite in asthma. Clin Exp Allergy 2007; 37:100-7. [PMID: 17210047 DOI: 10.1111/j.1365-2222.2006.02617.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND House dust mite (HDM) is the most common aeroallergen causing sensitization in many Western countries and is often used in allergen inhalation challenges. The concentration of inhaled allergen causing an early asthmatic reaction [provocative concentration of inhaled allergen causing a 20% fall of forced expiratory volume in 1 s (FEV(1))(PC(20) allergen)] needs to be predicted for safety reasons to estimate accurately the severity of allergen-induced airway responsiveness. This can be accomplished by using the degree of non-specific airway responsiveness and skin sensitivity to allergen. OBJECTIVE We derived prediction equations for HDM challenges using PC(20) histamine or PC(20) methacholine and skin sensitivity data obtained from patients with mild to moderate persistent asthma and validated these equations in an independent asthma population. METHODS PC(20) histamine or PC(20) methacholine, skin sensitivity, and PC(20) allergen were collected retrospectively from 159 asthmatic patients participating in allergen challenge trials. Both the histamine and methacholine groups (n=75 and n=84, respectively), were divided randomly into a reference group to derive new equations to predict PC(20) allergen, and a validation group to test the new equations. RESULTS Multiple linear regression analysis revealed that PC(20) allergen could be predicted either from PC(20) methacholine only ((10)log PC(20) allergen=-0.902+0.741.(10)log PC(20) methacholine) or from PC(20) histamine and skin sensitivity (SS) ((10)log PC(20) allergen=-0.494+0.231.(10)log SS+0.546.(10)log PC(20) histamine). In the validation study, these new equations accurately predicted PC(20) allergen following inhalation of HDM allergen allowing a safe starting concentration of allergen of three doubling concentrations below predicted PC(20) allergen in all cases. CONCLUSION The early asthmatic response to inhaled HDM extract is predominantly determined by non-specific airway responsiveness to methacholine or histamine, whereas the influence of the cutaneous sensitivity to HDM appears to be rather limited. Our new equations accurately predict PC(20) allergen and hence are suitable for implementation in HDM inhalation studies.
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Affiliation(s)
- A J Ravensberg
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands.
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Gerald LB, McClure LA, Harrington KF, Mangan JM, Gibson L, Atchison J, Grad R. Design of the supervised asthma therapy study: implementing an adherence intervention in urban elementary schools. Contemp Clin Trials 2007; 29:304-10. [PMID: 17804302 PMCID: PMC2271116 DOI: 10.1016/j.cct.2007.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 07/24/2007] [Accepted: 07/28/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inhaled corticosteroids, when properly used, can offer considerable protection against asthma-related morbidity. However, adherence to prescribed inhaled steroids among children is low and rates differ markedly by population. The lowest rates of adherence and highest rates of morbidity are among inner-city and low income populations. PURPOSE To describe the design of a school-based clinical trial in a largely minority population that is examining the efficacy of a school-based intervention intended to increase adherence to daily inhaled corticosteroids. METHODS The supervised asthma therapy study is a two-group randomized longitudinal trial. Children were randomly assigned to either school-based supervised asthma therapy or parent supervised asthma therapy. Children were followed longitudinally for 15 months. The primary outcome of the study is the time-averaged difference between the two groups in the percentage of children experiencing at least one asthma exacerbation each month. RESULTS A web-based data collection system was designed to capture data at school. A total of 295 students, recruited from community and school sites, who attended one of 36 urban elementary schools enrolled in the study and 290 were randomized. The average age of the students was 10.0 years (sd=2.1), 91% were African American, 8% were white, and 1% were of other racial groups. 57% of students were male. The study has been recently completed and results are being analyzed. CONCLUSIONS Intervention studies requiring daily medication supervision and daily data collection can be successfully conducted within the elementary school environment.
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Affiliation(s)
- Lynn B Gerald
- University of Alabama at Birmingham, Birmingham, AL 35249, United States.
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Price DB, Williams AE, Yoxall S. Salmeterol/fluticasone stable-dose treatment compared with formoterol/budesonide adjustable maintenance dosing: impact on health-related quality of life. Respir Res 2007; 8:46. [PMID: 17610727 PMCID: PMC1924504 DOI: 10.1186/1465-9921-8-46] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Accepted: 07/04/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving patients' health-related quality of life (HRQoL) is recognized as a fundamental part of asthma management. The aims of this study were to evaluate the long-term efficacy (including symptom-free days and exacerbations) and impact on HRQoL of a stable-dose regimen of salmeterol/fluticasone propionate (SAL/FP) and an adjustable maintenance dosing (AMD) regimen of formoterol/budesonide (FOR/BUD) where treatment is adjusted based on symptoms [SAM40056]. METHODS A total of 688 outpatients with asthma receiving regular low-dose inhaled corticosteroids (ICS) plus a long-acting beta2-agonist, or medium dose ICS alone participated in this randomized, double-blind, double-dummy, parallel-group, 1-year trial, which was conducted in 91 centers in 15 countries. Patients were randomized to receive 1 inhalation of SAL/FP 50/250 mug BID or 2 inhalations of FOR/BUD 6/200 mug BID during Weeks 1-4. For Weeks 5-52, patients meeting strict continuation criteria for stable asthma at Week 4 received AMD with FOR/BUD or stable-dose SAL/FP. RESULTS The percentage of symptom-free days was significantly greater (58.8% vs 52.1%; p = 0.034) and the annual exacerbation rate was significantly lower (47%; p = 0.008) with stable-dose SAL/FP compared with FOR/BUD AMD. A total of 568 patients completed the Asthma Quality of Life Questionnaire (AQLQ) at least once during the study. The mean change from baseline in AQLQ overall score was numerically greater with SAL/FP than FOR/BUD at week 28 and week 52, but did not reach statistical significance (p = 0.121 at Week 52). However, in a post hoc logistic regression analyses for any AQLQ improvement, significant benefits with SAL/FP were seen at both time points (p = 0.038 and p = 0.009, respectively). The minimally important difference of >/= 0.5-point improvement in AQLQ overall score was achieved by a significantly greater number of patients receiving SAL/FP at Week 28 (68% vs 60%; p = 0.049); a trend for this difference remained at Week 52 (71% vs 65%) (p = 0.205). CONCLUSION In this population of patients with persistent asthma, stable-dose SAL/FP resulted in significantly greater increases in symptom-free days, a reduction in exacerbation rates, and provided greater HRQoL benefits compared with FOR/BUD AMD. TRIAL REGISTRATION Clinical Trials registration number NCT00479739.
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Affiliation(s)
- David B Price
- Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, UK
| | - Angela E Williams
- Research and Development, GlaxoSmithKline, Greenford Road, Greenford, Middlesex UB6 0HE, UK
| | - Sally Yoxall
- Research and Development, GlaxoSmithKline, Greenford Road, Greenford, Middlesex UB6 0HE, UK
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Shek LPC, Goh DYT, Bever HV, Lee BW. Challenges in Paediatric Asthma Today. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2007. [DOI: 10.47102/annals-acadmedsg.v36n6p376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Abstract
Achieving and maintaining optimal asthma control is a major asthma management goal advocated by the Global Initiative for Asthma (GINA). Recent evidence suggests that while asthma control is clearly achievable in most asthmatics, not all asthmatics attain optimal asthma control. The difficulty is compounded further because patients, physicians and regulatory bodies have different perceptions of what is meant by asthma control. The challenge therefore remains as to how best to assess asthma control and define management strategies to ensure that this control is achieved and maintained. Despite the availability of several patient-based tools for assessing asthma control, these are mostly employed in a research setting or in selected specialist clinics. A symptom-based treatment approach also may have its limitations because patients can be poor judges of disease symptoms and severity and under-estimation may lead to inadequate treatment of airway inflammation and airway hyperresponsiveness (AHR) when treatment is administered as on-demand reliever therapy, since the effect of treatment on these underlying features occurs over a longer time course. The clinical benefits of sustained maintenance treatment for at least 3 months has been documented in recent studies of salmeterol/fluticasone propionate combination, which have demonstrated correlations between reduction in airway inflammation/AHR and reduction in exacerbation rates. In view of the putative limitations of a purely symptom-based asthma management plan, we suggest that treatment should be focussed on management of all aspects of the disease rather than management of symptoms alone, with a practical approach being treatment for a minimum of 3 months with an optimal dose to ensure maximal effects are seen on asthma control, airway inflammation, lung function, and remodelling.
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Affiliation(s)
- B Lundback
- Lung and Allergy Research, National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Abstract
In the first National Heart Lung and Blood Institute and Global Initiative for Asthma (GINA) guidelines, the level of symptoms and airflow limitation and its variability allowed asthma to be subdivided by severity into four subcategories (intermittent, mild persistent, moderate persistent, and severe persistent). It is important to recognize, however, that asthma severity involves both the severity of the underlying disease and its responsiveness to treatment. Thus, the first update of the GINA guidelines defined asthma severity depending on the clinical features already proposed as well as the current treatment of the patient. In addition, severity is not a fixed feature of asthma, but may change over months or years, whereas the classification by severity suggests a static feature. Moreover, using severity as an outcome measure has limited value in predicting what treatment will be required and what the response to that treatment might be. Because of these considerations, the classification of asthma severity is no longer recommended as the basis for treatment decisions, a periodic assessment of asthma control being more relevant and useful.
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Affiliation(s)
- M Humbert
- Service de Pneumologie, INSERM U764, Hôpital Antoine-Béclère, Assistance-Publique-Hôpitaux de Paris, Université Paris-Sud 11, Clamart, France
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Fitzpatrick AM, Gaston BM, Erzurum SC, Teague WG. Features of severe asthma in school-age children: Atopy and increased exhaled nitric oxide. J Allergy Clin Immunol 2006; 118:1218-25. [PMID: 17157650 PMCID: PMC2878140 DOI: 10.1016/j.jaci.2006.08.019] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Revised: 08/09/2006] [Accepted: 08/11/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Children with severe asthma have persistent symptoms despite treatment with inhaled corticosteroids (ICSs). The differentiating features of severe asthma in children are poorly defined. OBJECTIVE To identify features of severe versus mild-to-moderate asthma in school-age children using noninvasive assessments of lung function, atopy, and airway inflammation. METHODS A total of 75 children (median age, 10 years) with asthma underwent baseline characterization including spirometry and lung volume testing, methacholine bronchoprovocation, allergy evaluation, and offline measurement of exhaled nitric oxide (F(ENO)). Twenty-eight were followed longitudinally over 6 months. Participants were assigned to the severe asthma subgroup if they required high-dose ICS plus 2 or more minor criteria. RESULTS Children with severe versus mild-to-moderate asthma had more symptoms, greater airway obstruction, more gas trapping, and increased bronchial responsiveness to methacholine. Subjects with severe asthma also had higher concentrations of F(ENO) and significantly greater sensitization to aeroallergens. With long-term study, both the reduction in FEV(1) and increase in F(ENO) persisted in the severe versus mild-to-moderate group. Furthermore, despite adjustments in ICS doses, the frequency of exacerbations was significantly higher in subjects with severe (83%) versus mild-to-moderate asthma (43%). CONCLUSION Severe asthma in childhood is characterized by poor symptom control despite high-dose ICS treatment and can be differentiated from mild-to-moderate asthma by measurement of lung function and F(ENO). CLINICAL IMPLICATIONS Clinicians should suspect severe asthma in children with poor response to ICS, airway obstruction, and high F(ENO).
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Kelly MM, Chakir J, Vethanayagam D, Boulet LP, Laviolette M, Gauldie J, O'Byrne PM. Montelukast treatment attenuates the increase in myofibroblasts following low-dose allergen challenge. Chest 2006; 130:741-53. [PMID: 16963671 DOI: 10.1378/chest.130.3.741] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
RATIONALE Airway remodeling is believed to be important in the pathophysiology of asthma, and myofibroblasts are increased in the airways of asthmatic individuals 24 h after allergen challenge. Leukotriene receptor antagonists exert antiinflammatory activity in asthma, but it is unknown whether they influence indices of airway remodeling. In the present study, we evaluated the effect of montelukast on airway myofibroblasts following low-dose allergen challenge (LDAC). METHODS Stable subjects with mild asthma were included in a two-center, randomized, parallel-group study. A 2-week run-in period was followed by LDAC and endobronchial biopsy. Subjects were then randomized to receive either montelukast, 10 mg/d, or placebo (n = 10 in each group) for 8 weeks in a double-blind manner; at the end of the treatment period, subjects underwent a second LDAC and endobronchial biopsy. The effect of treatment on myofibroblasts, fibroblasts, and inflammatory cells was examined using electron microscopy techniques. RESULTS Treatment with montelukast showed no significant difference by comparison with placebo but did show a significant within-group treatment-related decrease in airway wall myofibroblasts not seen in the placebo group. In addition, the montelukast-treated group also showed a significant within-group reduction in lymphomononuclear cells and increased neutrophils. CONCLUSIONS The results suggest that montelukast has an inhibitory effect on airway structural cells that play a key role in airway remodeling in allergic airway inflammation, and that montelukast may be a useful therapy to attenuate airway remodeling in asthma.
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Affiliation(s)
- Margaret M Kelly
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
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32
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Slats AM, Sont JK, van Klink RHCJ, Bel EHD, Sterk PJ. Improvement in bronchodilation following deep inspiration after a course of high-dose oral prednisone in asthma. Chest 2006; 130:58-65. [PMID: 16840383 DOI: 10.1378/chest.130.1.58] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Bronchodilation following deep inspiration is usually impaired in patients with asthma. This might be due to changes in airway mechanics in the presence of inflammation or structural changes within the airways. Although inhaled corticosteroid treatment has been shown to improve airway responses to deep inspiration in patients with asthma, airway inflammation can persist despite inhaled corticosteroid treatment, and thus could still influence the airway mechanics during deep breaths. We hypothesized that oral steroid treatment further optimizes deep inspiration-induced bronchodilation in clinically stable asthmatic patients who are receiving therapy with inhaled corticosteroids. METHODS Twenty-four atopic patients with mild-to-moderate persistent asthma (FEV1, > 70% predicted; provocative concentration of methacholine causing a 20% fall in FEV1 [PC20], < 8 mg/mL), who were treated with 250 to 2,000 mug of beclomethasone-dipropionate or equivalent, participated in a parallel-design, double-blind study. Before and after treatment with 0.5 mg/kg/d prednisone or placebo for 14 days, a methacholine challenge was performed. Deep inspiration-induced bronchodilation was measured by the ratio of flow at 40% of FVC on the flow-volume curve after maximal inspiration/flow at 40% of FVC on the flow-volume curve after partial (60% of FVC) inspiration (M/P ratio). RESULTS The M/P ratio significantly increased from a mean of 1.31 (range, 1.0 to 1.7) to 1.49 (range, 1.1 to 2.3) in the prednisone group. Interestingly, the improvement in the M/P ratio did not correlate with an accompanying significant increase in PC20 for methacholine (mean change, 1.02; SD doubling dose, 0.97) and a decrease in exhaled nitric oxide (mean change, 14 parts per billion [ppb]; SD, 33.4 ppb). CONCLUSIONS Systemic antiinflammatory treatment in addition to maintenance therapy with inhaled corticosteroids increases bronchodilation by deep inspiration in patients with mild-to-moderate persistent asthma. This suggests that residual inflammation impairs airway mechanics in asthma patients.
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Affiliation(s)
- Annelies M Slats
- Department of Pulmonology (C2-P-62), Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Chlumský J, Striz I, Terl M, Vondracek J. Strategy aimed at reduction of sputum eosinophils decreases exacerbation rate in patients with asthma. J Int Med Res 2006; 34:129-39. [PMID: 16749408 DOI: 10.1177/147323000603400202] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Under Global Initiative for Asthma guidelines, the clinical control of disease activity and the adjustment of treatment in patients with asthma are based on symptoms, use of rescue medication, lung function and peak expiratory flow measurement (standard strategy). We investigated whether a strategy to reduce the number of sputum eosinophils (EOS strategy) gives better clinical control and a lower exacerbation rate compared with the standard strategy. Fifty-five patients with moderate to severe asthma entered this open, randomized, parallel-group study and visited the out-patient department every 3 months for 18 months. The dose of corticosteroids was adjusted according to the standard strategy or the percentage of sputum eosinophils (EOS strategy). During the study period, the EOS strategy led to a significantly lower incidence of asthma exacerbations compared with the standard strategy group (0.22 and 0.78 exacerbations per year per patient, respectively). There were significant differences between the strategies in time to first exacerbation.
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Affiliation(s)
- J Chlumský
- Department of Pneumology, 1st Medical Faculty, Charles University and Thomayer Faculty Hospital, Prague, Czech Republic.
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Peeters D, Peters IR, Clercx C, Day MJ. Real-time RT-PCR quantification of mRNA encoding cytokines, CC chemokines and CCR3 in bronchial biopsies from dogs with eosinophilic bronchopneumopathy. Vet Immunol Immunopathol 2006; 110:65-77. [PMID: 16226318 DOI: 10.1016/j.vetimm.2005.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Revised: 09/05/2005] [Accepted: 09/08/2005] [Indexed: 10/25/2022]
Abstract
Idiopathic canine eosinophilic bronchopneumopathy (EBP) is a disease characterized by eosinophilic infiltration of the pulmonary interstitium and bronchial mucosa, a cause for which has not yet been discovered. A recent study, examining the relative proportion of various lymphocyte cell subsets within bronchoalveolar lavage fluid from dogs with EBP, has shown a selective increase in CD4(+) T-cells and a selective decrease in CD8(+) T-cells, suggesting that a similar Th2 immune response might occur in EBP. The aim of the present study was to determine the profile of cytokine, chemokine and CC chemokine receptor 3 (CCR3) messenger RNA (mRNA) expression in bronchial tissue from dogs with EBP. Real-time RT-PCR assays were used for the quantification of mRNA encoding for a panel of cytokines, CC chemokines and CCR3 in perendoscopic bronchial biopsies from eight dogs with EBP and seven age-matched control dogs. Messenger RNA transcribed from the housekeeping gene glyceraldehyde-3-phosphate dehydrogenase was used for normalisation of the threshold cycle in order to determine the relative copy numbers of the transcripts. No significant difference in the expression of any cytokine, MCP-1, -2, -4 and CCR3 was found between control and EBP dogs. The expression of transcript for MCP-3, eotaxin-2 and -3 was significantly greater in bronchial biopsies from dogs with EBP than in samples from control dogs while there was significantly less mRNA encoding RANTES in the mucosa of dogs with EBP. In conclusion, the cytokine mRNA expression profile in perendoscopic bronchial biopsies is similar in dogs with EBP and dogs without respiratory disease. Further studies on the quantification of mRNA encoding cytokines in isolated T lymphocytes from bronchoalveolar lavage fluid or bronchial biopsies are needed before any conclusion on the cytokine profile in canine EBP can be drawn. Eotaxin-2, -3 and MCP-3 appear to be implicated in the pathogenesis of the disease.
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Affiliation(s)
- D Peeters
- Department of Veterinary Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Sart-Tilman B44, 4000 Liège, Belgium.
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de Kluijver J, Schrumpf JA, Evertse CE, Sont JK, Roughley PJ, Rabe KF, Hiemstra PS, Mauad T, Sterk PJ. Bronchial matrix and inflammation respond to inhaled steroids despite ongoing allergen exposure in asthma. Clin Exp Allergy 2006; 35:1361-9. [PMID: 16238797 DOI: 10.1111/j.1365-2222.2005.02334.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Inflammatory and structural changes of the airway mucosa are chronic features of asthma. The mechanisms underlying these changes and their modulation by steroid prophylaxis have not been clarified. OBJECTIVE We postulated that asymptomatic ongoing allergen exposure could drive airway inflammation as well as changes in the extracellular matrix (ECM), and that inhaled steroids could prevent this. METHODS Therefore, we exposed patients with mild asthma to 2 weeks of repeated low-dose allergen, with concomitant inhaled steroid or placebo treatment. Bronchial biopsies, which were taken before and after this exposure, were stained and digitally analysed. The ECM proteins in asthmatics were also compared with a normal control group. RESULTS Low-dose allergen exposure alone resulted in a significant increase of bronchial epithelial macrophages. Despite ongoing allergen exposure, inhaled steroids reduced the numbers of mucosal eosinophils, neutrophils and T lymphocytes. At baseline, the mean density of the proteoglycans (PGS) biglycan and decorin were, respectively, higher and lower in the bronchial mucosa of asthmatics as compared with normal controls. Steroid treatment, during allergen exposure, increased the mean density of the PGS biglycan and versican. CONCLUSION We conclude that chronic allergen exposure induces inflammatory changes in the bronchial mucosa. Despite ongoing allergen exposure, steroid treatment decreases mucosal inflammatory cells while altering PG density. The latter observation highlights the need to examine steroid-induced changes closely in the airway structure in patients with asthma.
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Affiliation(s)
- J de Kluijver
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
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Diamant Z, Kuperus J, Baan R, Nietzmann K, Millet S, Mendes P, Miller B, Amin D, Rohatagi S, Sterk PJ, Hoogsteden HC, Prins JB. Effect of a very late antigen-4 receptor antagonist on allergen-induced airway responses and inflammation in asthma. Clin Exp Allergy 2006; 35:1080-7. [PMID: 16120091 DOI: 10.1111/j.1365-2222.2005.02296.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Very late antigen-4 (VLA(4)) plays a key role in the recruitment of eosinophils in allergic responses in animal studies. OBJECTIVE We investigated whether pretreatment with multiple doses of a VLA(4) receptor antagonist, HMR 1031, protects against allergen-induced airway responses and airway inflammation in humans. METHODS Fourteen asthmatics (7F/7M), 18-49 years, PC(20) forced expiratory volume in 1 s (FEV(1)) methacholine (M) (<8 mg/mL; FEV(1) 82.3-116.1% predicted) with dual responses to inhaled allergen participated in a double-blind, placebo-controlled, cross-over study. Each treatment period consisted of 9 days, separated by >or=2 weeks. Exhaled nitric oxide (eNO), PC(20)FEV(1)(M) and hypertonic saline-induced sputum was obtained on Days 1, 7 and 9. Subjects inhaled HMR 1031 (20 mg b.i.d.) or placebo (P) on Days 1--8. On Day 8, an allergen bronchoprovocation test was performed, the airway response was measured by FEV(1), and expressed as %fall from baseline. Data from 12 evaluable subjects are presented here. RESULTS Both treatments were well tolerated. There was no significant difference between HMR 1031 and P in the early asthamatic response: mean AUC (0-3 h)+/-SEM (%fall h): 26.01+/-4.26 and 17.41+/-4.26, respectively (P=0.18), nor in the late response: mean AUC (3-9 h)+/-SEM (%fall h): 97.09+/-8.63 and 97.61+/-8.63, respectively, P=0.97. This corresponded to the absence of significant allergen-induced changes in PC(20)FEV(1)(M), eNO, sputum eosinophils and soluble inflammation markers between both treatment periods. CONCLUSIONS Treatment with multiple inhaled doses of the VLA(4) antagonist, HMR 1031, did not result in detectable protection against allergen-induced airway responses or airway inflammation in asthma.
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Affiliation(s)
- Z Diamant
- Erasmus University Medical Centre, Lung Function Lab, Rotterdam, The Netherlands.
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Nieto A, Pamies R, Oliver F, Medina A, Caballero L, Mazon A. Montelukast improves pulmonary function measured by impulse oscillometry in children with asthma (Mio study). Respir Med 2005; 100:1180-5. [PMID: 16330196 DOI: 10.1016/j.rmed.2005.10.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2005] [Revised: 10/23/2005] [Accepted: 10/25/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Systemic drugs-like oral montelukast can reach lower airways, whose inflammation plays a crucial role in the evolution of asthma, while inhaled drugs hardly reach them. The impulse oscillometry (IOS) technique is useful to evaluate both central and peripheral airways function. OBJECTIVE To measure the effect of oral montelukast on airways resistance evaluated by oscillometry in children with asthma. METHODS In an open study, respiratory function in 23 children with mild asthma and a positive bronchodilator response was assessed by spirometry and oscillometry. They took oral montelukast during 4 weeks and were again evaluated. As a control group, 23 similar patients with no preventive treatment underwent the same study. MEASUREMENTS AND MAIN RESULTS Children on oral montelukast showed improvements (measured in kPa s L(-1)) in all oscillometry parameters: mean 0.20 (22.4%) in total respiratory impedance Zrs5, 0.18 (21.8%) in total airway resistance Rrs5, 0.09 (17.8%) in central airway resistance Rrs20, and 0.09 (28.8%) in distal capacitive reactance Xrs5; the frequency of resonance Fres improved 2.3 Hz (8.7%) (P<0.05 in all cases). No changes were found in the control group. Expiratory flows showed no changes except for a small (0.23 L s(-1), 7.4%) but significant worsening of FEF25-75 in the control group. CONCLUSIONS Montelukast improves central and especially peripheral airways function in the first month of treatment, as evaluated by IOS, a technique based on tidal breathing analysis which is more sensitive than conventional forced spirometry.
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Affiliation(s)
- Antonio Nieto
- Pediatric Allergy Unit, Children's Hospital, Av. Campanar 21, Valencia 46009, Spain.
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Almqvist C. High allergen exposure as a risk factor for asthma and allergic disease. Clin Rev Allergy Immunol 2005; 28:25-41. [PMID: 15834167 DOI: 10.1385/criai:28:1:025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The association between pet ownership in childhood and subsequent asthma and sensitization is very controversial. Intriguing, but contradictory, reports have caused considerable uncertainty in parents who wish to avoid asthma and allergic disease in their children. This article argues that high allergen exposure is a risk factor for asthma and allergic disease. It describes dispersal of pet allergens in society and critically assesses epidemiological studies regarding how early exposure to pet allergens affects subsequent immunoglobulin E-sensitization and allergic diseases. Additionally, this article evaluates the effects of allergen exposure in already sensitized subjects with asthma. Cat and dog allergens are ubiquitous in society and may induce sensitization and allergic symptoms in predisposed individuals, regardless of pet ownership. This, in combination with selection mechanisms for pet ownership in families with a history of allergic diseases, makes it difficult to study associations between early exposure to pets and subsequent allergic disease. Nevertheless, exposure to pet allergens worsens asthma in already sensitized children. Thus, it is clear that clinicians should advise sensitized asthmatics that avoidance of exposure to indoor allergens is an important element in the treatment of allergic disease.
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Affiliation(s)
- Catarina Almqvist
- Department of Occupational and Environmental Health, Karolinska Hospital, Stockholm, Sweden.
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Kumar RK, Herbert C, Kasper M. Reversibility of airway inflammation and remodelling following cessation of antigenic challenge in a model of chronic asthma. Clin Exp Allergy 2005; 34:1796-802. [PMID: 15544607 DOI: 10.1111/j.1365-2222.2004.02097.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Asthma is associated with recruitment of eosinophils, accumulation of chronic inflammatory cells in the airway walls, subepithelial fibrosis and other structural changes of airway wall remodelling. The role of ongoing exposure to allergens in their pathogenesis remains unclear. OBJECTIVE To examine whether changes of inflammation and remodelling were reversible following cessation of antigenic challenge in a mouse model of chronic asthma. METHODS BALB/c mice sensitized to ovalbumin (OVA) were chronically challenged by inhalation of a low mass concentration of antigen for 8 weeks, leading to development of acute-on-chronic airway inflammation, subepithelial fibrosis and other changes of airway wall remodelling. Epithelial injury was assessed by immunohistochemistry, while inflammation and remodelling were quantified by appropriate histomorphometric techniques. Regression of lesions was assessed in animals examined at 1, 2 and 4 weeks after exposure to OVA ceased. RESULTS We did not find evidence of airway epithelial injury in this model of low-level chronic inhalational exposure to antigen. Persistence of the recruitment of eosinophils and chronic inflammatory cells in the airway walls was dependent on continuing antigenic challenge, as was persistence of mucous cell hyperplasia/metaplasia. Subepithelial fibrosis and epithelial hypertrophy exhibited delayed reversibility following cessation of exposure to antigen, possibly related to matrix-associated accumulation of transforming growth factor-beta(1). CONCLUSION In chronic asthma, low-level antigenic challenge may be required to maintain the inflammatory response in the airway wall, but airway remodelling may persist in its absence.
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Affiliation(s)
- R K Kumar
- Department of Pathology, University of New South Wales, Sydney, Australia.
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Abstract
PURPOSE OF REVIEW In addition to the acute manifestations of asthma, researchers now understand that asthma is a chronic inflammatory disease of the airways. Knowing the critical time to intervene in asthma is of utmost importance to clinicians and patients alike. This article reviews recent evidence that early intervention improves long-term outcomes in asthma. RECENT FINDINGS The recent published literature demonstrates that early in the course of asthma, changes in structure occur, and that even in very young children, measurable abnormalities of lung function have already occurred. Large studies of inhaled corticosteroids given early in the progression of asthma show, at best, only modest effects on long-term lung function. Though a study on inhaled corticosteroids in very young children is ongoing, there is little evidence to suggest that any other commonly used medications have important effects on underlying lung function. Recent studies have also highlighted the lack of clear understanding of the relation between inflammation and remodeling, and parallel the disappointing results from studies of inhaled corticosteroids on lung function. SUMMARY Current anti-inflammatory medications have modest effects on preventing loss of lung function in asthma. Although inhaled corticosteroids are highly efficacious in controlling the overt clinical manifestations of the disease, their effects on lung function are small. The standard paradigm of inflammation leading to remodeling and remodeling to loss of lung function may be overly simplistic. In the future, novel pharmacologic targets and careful timing of treatments must occur to intervene effectively with remodeling and/or decline in lung function in asthma.
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Affiliation(s)
- Anne E Dixon
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
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van den Toorn LM, Prins JB, de Jongste JC, Leman K, Mulder PGH, Hoogsteden HC, Overbeek SE. Benefit from anti-inflammatory treatment during clinical remission of atopic asthma. Respir Med 2005; 99:779-87. [PMID: 15878496 DOI: 10.1016/j.rmed.2004.11.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2004] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVES Subjects with atopic asthma often experience a disappearance of symptoms around puberty. However, airway inflammation and remodeling may persist. It is unknown whether those findings warrant prolonged anti-inflammatory treatment despite the absence of symptoms. In this study, we investigated whether a short course of combined anti-inflammatory treatment would, also in this specific patient population, diminish airway inflammation and/or remodeling. DESIGN A double-blind, randomized placebo-controlled trial was conducted in 28 asymptomatic subjects with a history of atopic asthma, with established bronchial hyperresponsiveness to methacholine (MCh) as non-invasive indicator of ongoing airway pathology. INTERVENTIONS Intervention consisted of the salmeterol/fluticasone propionate combination (SFC) product (50/250 microg bid via the Diskus inhaler) or placebo for 3 months. MEASUREMENTS The change in lung function (FEV1), bronchial response to MCh and adenosine monophosphate (AMP), the fraction of nitric oxide in exhaled air (FENO) and quality of life (QOL) scores were measured. Also, bronchial biopsies were taken and cryo sections immunostained for eosinophils (major basic protein, MBP) and mast cells (tryptase and chymase) before and after treatment. The change in reticular basement membrane (RBM) thickness, one of the parameters of airway remodeling, was also determined. RESULTS SFC treatment improved hyperresponsiveness to MCh (P = 0.014) as well as AMP (P = 0.011), and reduced FENO (P < 0.001) significantly as compared with placebo. Lung function tended to improve (NS). Furthermore, SFC treatment reduced tryptase in the subepithelium of bronchial biopsy specimens (P = 0.01), and slightly reduced RBM thickness (P = 0.05). However, eosinophils in (sub)epithelium were not significantly affected; neither were chymase levels, blood eosinophils or QOL scores. CONCLUSIONS We found that 3 months of treatment with fluticasone propionate and salmeterol reduced airway hyperresponsiveness, FENO and tryptase density in the airway mucosa as markers of airway inflammation. MBP density in the airway mucosa and QOL were, however, unchanged. The clinical relevance of these findings, especially with respect to the long-term outcome, has not been determined yet.
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Affiliation(s)
- Leon M van den Toorn
- Department of Pulmonary Medicine, Erasmus MC Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
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42
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Abstract
Management of asthma has gradually evolved from the concept of controlling bronchial hyperresponsiveness to focusing on control of inflammation. The awareness of airway remodeling, and the emergence of data suggesting irreversibility of some of these changes, despite standard-of-care pharmacotherapies such as inhaled steroids, has highlighted the need for early detection; effective diagnosis and treatment; monitoring responses and adhering to treatment; and predicting exacerbations. Pre-clinical intervention strategies targeted toward picking up early suggestions of asthma before irreversible airway changes occur may open the door to primary prevention approaches. Although invasive methods, such as bronchial biopsy, remain the gold standard to understanding and treating asthma, there is a preference for noninvasive techniques for reasons of convenience, ease of use, and patient comfort. In this article, recent data that support the use of exhaled nitric oxide as a noninvasive biomarker of inflammation in clinical practice are reviewed.
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Affiliation(s)
- Chitra Dinakar
- Section of Allergy/Asthma/Immunology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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van den Toorn LM. Clinical implications of airway inflammation in mild intermittent asthma. Ann Allergy Asthma Immunol 2004; 92:589-94; quiz 595-7, 658. [PMID: 15237759 DOI: 10.1016/s1081-1206(10)61423-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether inhaled corticosteroids should be prescribed to patients with milder forms of asthma and whether markers of airway inflammation should be considered when making therapy decisions. DATA SOURCES A PubMed search was performed of the English-language literature published in the preceding 10 years (January 1, 1993, through December 31, 2003) concerning epidemiology, pathophysiology, therapy, and prognosis of mild intermittent asthma, with asthma, mild, and intermittent as indexing terms. STUDY SELECTION All relevant studies including author's expert opinions were selected. RESULTS Several studies have addressed the question of a possible benefit of maintenance therapy (ie, inhaled steroids) in patients with mild intermittent asthma. Although a diminishing effect on airway inflammation has been widely demonstrated, even in patients with mild disease, the impact of inhaled steroids on the long-term prognosis is much less clear. For patients with mild disease who are long-term inhaled steroid users, alternative therapy strategies, including low-dose inhaled steroids and leukotriene receptor antagonists, have been advocated. CONCLUSIONS Mild intermittent asthma is a disease characterized not only by infrequent symptoms and normal lung function but also by chronic airway inflammation, possibly resulting in irreversible airflow limitation if left unattended. Therefore, maintenance therapy, such as (low-dose) inhaled steroids or leukotriene receptor antagonists, should be considered in patients with mild disease. Future studies should give more insight into the impact of prolonged anti-inflammatory therapy on the long-term prognosis of mild intermittent asthma patients. Whether results from these studies will justify a more aggressive treatment for these patients remains to be answered.
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Colice GL. Categorizing asthma severity: an overview of national guidelines. Clin Med Res 2004; 2:155-63. [PMID: 15931352 PMCID: PMC1069088 DOI: 10.3121/cmr.2.3.155] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2004] [Accepted: 06/16/2004] [Indexed: 11/18/2022]
Abstract
Asthma is an inflammatory disease of the airways associated with intermittent episodes of bronchospasm. Corticosteroids are the most effective anti-inflammatory class of medication currently available for the treatment of asthma. However, as higher doses of inhaled corticosteroids are used the risks of systemic exposure and side effects will correspondingly increase. Justification of the benefits from higher doses of inhaled corticosteroids can only be made if patients with more severe asthma can be identified. Methods to categorize asthma severity have been introduced in various national asthma management guidelines. Unfortunately, there are substantial conceptual and practical differences among these recommended approaches to asthma severity categorization. Furthermore, these recommended approaches suffer from a focus on features of asthma control, such as symptoms, short-acting beta-agonist use, and lung function rather than actual measures of asthma severity that would encompass markers of airway inflammation. Without the endpoints necessary to assess airway inflammation, current recommendations for asthma severity categorization may lead to systematic under dosing of appropriate anti-inflammatory therapy with subsequent perpetuation of the asthma exacerbation cycle.
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Affiliation(s)
- Gene L Colice
- Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, District of Columbia 20010, USA.
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Jungsuwadee P, Dekan G, Stingl G, Epstein MM. Inhaled dexamethasone differentially attenuates disease relapse and established allergic asthma in mice. Clin Immunol 2004; 110:13-21. [PMID: 14962792 DOI: 10.1016/j.clim.2003.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2002] [Accepted: 09/09/2003] [Indexed: 01/28/2023]
Abstract
Inhaled glucocorticoids are effective in patients with chronic allergic asthma. We examined the effects of inhaled glucocorticoids on relapse (allergen challenge after disease remission) and established/overt allergic asthma (repeated allergen challenge in weekly intervals) in mice to establish a reference standard for novel treatments. BALB/c mice were treated before relapse or during overt disease with 1 h of nebulized PBS or 10 mg% dexamethasone twice daily for 5 days. Dexamethasone eliminated airway hyperresponsiveness before relapse and during overt disease. They more efficiently reduced airway inflammation, mucus production, and OVA-specific IgG1 and IgE during relapse compared to overt disease. However, during overt disease, parenchymal inflammatory infiltrates were more effectively eliminated compared to relapse, suggesting that activated infiltrating leukocytes have increased sensitivity to steroids. These data demonstrate that inhaled corticosteroids attenuate relapse and overt disease differentially and suggest that both airway and parenchymal inflammation need to be evaluated for treatment efficacy.
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Affiliation(s)
- Paiboon Jungsuwadee
- Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, VIRCC, University of Vienna Medical School, Vienna, Austria
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Abstract
PURPOSE Asthma is now defined as a TH2-mediated inflammatory disease involving both large and small airways. However, assessment of airways inflammation is limited by techniques that are time consuming and possibly distressing to the patient. Exhaled nitric oxide, an easily and rapidly obtained noninvasive study, is a potential surrogate for measuring airways inflammation, but its clinical utility remains to be determined. This review examines the role of exhaled nitric oxide in assessing and directing therapy of asthmatic airways inflammation. RECENT FINDINGS It is well established that exhaled nitric oxide is increased in patients with untreated asthma and decreases with corticosteroid treatment. Exhaled nitric oxide also generally correlates with eosinophilic inflammation in asthmatic patients. Recent studies show that this correlation is especially pronounced in atopic subjects with asthma when compared with nonatopic subgroups. Recent studies also show that exhaled nitric oxide may be useful in identifying subclinical inflammation, assessing the antiinflammatory effects of asthma medications other than inhaled or oral corticosteroids, and heralding an asthma exacerbation. A number of new studies assert the utility of exhaled nitric oxide as a diagnostic tool for asthma. SUMMARY Exhaled nitric oxide may be a useful parameter for monitoring asthmatic inflammation, adjusting therapy, and diagnosing asthma, although prospective longitudinal trials investigating the correlation between exhaled nitric oxide and clinical outcomes are necessary to determine its utility.
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Affiliation(s)
- Michelle R Zeidler
- David Geffen School of Medicine at University of California, Los Angeles, USA.
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Abstract
PURPOSE OF REVIEW Inhaled corticosteroids (ICS) are the mainstay of asthma therapy. Although compliance to this type of medication is often suboptimal and once-daily dosing can help to improve adherence to the treatment, the clinical implications of such a mode of administration should be determined. RECENT FINDINGS This review summarizes the recent studies on comparative efficacy of once-versus twice-daily administration of ICS, in light of previous reports. SUMMARY Although twice-daily administration of ICS is often better to optimize asthma parameters, in many patients, asthma can be sufficiently controlled by a once-daily regimen of most ICS. An increased frequency of dosing seems preferable if asthma becomes uncontrolled or is severe, although this requires further study. A therapeutic trial should, however, be done to ensure that asthma control is adequate. Comparative long-term effects of such a strategy on inflammatory and remodeling parameters remain to be determined, as does the proportion of patients who can adequately control their asthma with once-daily administration of the various ICS available.
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Affiliation(s)
- Louis-Philippe Boulet
- Institut de cardiologie et de pneumologie de l'Université Laval, Hôpital Laval, Quebec City, QC, Canada.
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Abstract
Many people with allergies monitor daily pollen and spore counts with the belief that they can act on that information to improve their health. Because many factors can affect personal exposure, the value of community-wide counts for an individual is questionable. These factors include the presence of local pollen and spore sources, diurnal variations, weather effects, air pollution, and a particle-free bioaerosol. To take advantage of bioparticulate counts, the public needs to be informed about their meaning and factors that can influence personal exposure.
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Affiliation(s)
- Jay Portnoy
- Section of Allergy, Asthma and Immunology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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49
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Abstract
The social and economic impact of asthma is substantial worldwide. Although current therapies targeting both airway inflammation and airway hyperreactivity effectively relieve and prevent symptoms in the majority of patients, some patients experience persistent symptoms and a progressive decline in lung function, described as irreversible or refractory asthma. Indeed, there are many unanswered questions about the role of airway remodeling in asthma. This review addresses several topics of controversy, including whether all patients with asthma demonstrate airway remodeling; the contribution of distinct airway resident cells to the development of remodeling; the role of biomarkers or noninvasive measurements in predicting airway remodeling; and the effectiveness of current therapies on airway remodeling and disease progression.
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Affiliation(s)
- Aili L Lazaar
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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50
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de Kluijver J, Evertse CE, Sont JK, Schrumpf JA, van Zeijl-van der Ham CJG, Dick CR, Rabe KF, Hiemstra PS, Sterk PJ. Are rhinovirus-induced airway responses in asthma aggravated by chronic allergen exposure? Am J Respir Crit Care Med 2003; 168:1174-80. [PMID: 12893645 DOI: 10.1164/rccm.200212-1520oc] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Airway inflammation in asthma may represent a favorable environment for respiratory viral infections, augmenting virus-induced exacerbations in asthma. We postulated that repeated low-dose allergen exposure preceding experimental rhinovirus 16 (RV16) infection increases the severity of RV-induced airway obstruction and inflammation. Thirty-six house dust mite-allergic patients with mild to moderate asthma participated in a three-arm, parallel, placebo-controlled, double-blind study. Patients inhaled a low dose of house dust mite allergen for 10 subsequent working days (Days 1-5 and 8-12) and/or were subsequently infected with RV16 (Days 15 and 16). Allergen exposure resulted in a significant fall in FEV1 (p < 0.001) and provocative concentration of histamine causing a 20% fall in FEV1 (p < 0.001) and an increase in exhaled nitric oxide (p < 0.001) and percentage of sputum eosinophils (p < 0.001). RV16 infection led to a fall in FEV1 (p = 0.02) and increases in the percentage of sputum neutrophils (p = 0.01), sputum interleukin-8 (p = 0.04), and neutrophil elastase (p = 0.04). Successive allergen exposure and RV16 infection had no synergistic or additive effect on any of the clinical or inflammatory outcomes. In conclusion, repeated low-dose allergen exposure and RV16 infection induce distinct inflammatory profiles within the airways in asthma without apparent interaction between these two environmental triggers. This suggests that preceding allergen exposure, at the used dose and duration, is not a determinant of the severity of RV-induced exacerbations in patients with mild to moderate asthma.
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Affiliation(s)
- Josephine de Kluijver
- Lung Function Laboratory, Department of Pulmonology, Leiden University Medical Center, P.O. Box 9600, NL-2300 RC Leiden, The Netherlands
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