Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma Control study

Tollip deficiency exaggerates airway type 2 inflammation in mice exposed to allergen and influenza A virus: role of the ATP/IL-33 signaling axis

Toll-interacting protein (Tollip) is a negative regulator of the pro-inflammatory response to viruses, including influenza A virus (IAV). Genetic variation of Tollip has been associated with reduced airway epithelial Tollip expression and poor lung function in patients with asthma. Whether Tollip deficiency exaggerates type 2 inflammation (e.g., eosinophils) and viral infection in asthma remains unclear. We sought to address this critical, but unanswered question by using a Tollip deficient mouse asthma model with IAV infection. Further, we determined the underlying mechanisms by focusing on the role of the ATP/IL-33 signaling axis. Wild-type and Tollip KO mice were intranasally exposed to house dust mite (HDM) and IAV with or without inhibitors for IL-33 (i.e., soluble ST2, an IL-33 decoy receptor) and ATP signaling (i.e., an antagonist of the ATP receptor P2Y13). Tollip deficiency amplified airway type 2 inflammation (eosinophils, IL-5, IL-13 and mucins), and the release of ATP and IL-33. Blocking ATP receptor P2Y13 decreased IL-33 release during IAV infection in HDM-challenged Tollip KO mice. Furthermore, soluble ST2 attenuated airway eosinophilic inflammation in Tollip KO mice treated with HDM and IAV. HDM challenges decreased lung viral load in wild-type mice, but Tollip deficiency reduced the protective effects of HDM challenges on viral load. Our data suggests that during IAV infection, Tollip deficiency amplified type 2 inflammation and delayed viral clearance, in part by promoting ATP signaling and subsequent IL-33 release. Our findings may provide several therapeutic targets, including ATP and IL-33 signaling inhibition for attenuating excessive airway type 2 inflammation in human subjects with Tollip deficiency and IAV infection.

Budesonide/Formoterol Anti-Inflammatory Reliever and Maintenance or Fluticasone Propionate/Salmeterol Plus As-Needed, Short-Acting β2 Agonist: Real-World Effectiveness in pAtients without Optimally Controlled asThma (REACT) Study

Introduction

In the prospective, observational, 16-week REACT study conducted between October 21, 2008 and May 12, 2011, we compared the real-world effectiveness of anti-inflammatory reliever and maintenance therapy with budesonide/formoterol (Symbicort^® Turbuhaler) and maintenance therapy with fixed-dose fluticasone/salmeterol (Seretide^®) plus as-needed, short-acting β₂ agonists (SABAs) in Taiwanese patients with inadequate asthma control.

Methods

Asthma control was assessed using the five-item Asthma Control Questionnaire (ACQ-5) and standardized pulmonary function testing. Assessments were performed at baseline and at weeks 4–5 and 12–16. Overall, we enrolled 842 patients at 11 clinics, 723 of whom were included in analyses (budesonide/formoterol, 563.3±1.3 μg/d, n=551; fluticasone/salmeterol, 1013.8±1.4 μg/d, n=172).

Results

At baseline, 72.5% and 27.5% of all patients had “partly” and “uncontrolled” asthma, respectively. Mean±SD ACQ-5 scores were 1.54±1.06 and 1.46±1.28 in the budesonide/formoterol and fluticasone/salmeterol groups, respectively. ACQ-5 scores significantly improved from baseline (ie, decreased) in both groups at weeks 4 and 16. ACQ-5 difference scores were significantly lower in the budesonide/formoterol group (−0.91±1.11) than the fluticasone/salmeterol group (−0.69±1.27) at the end of the study (p=0.027). Peak expiratory flow rate significantly improved from baseline in the budesonide/formoterol but not the fluticasone/salmeterol group at the end of the study. Severe exacerbation rates and medical resource utilization were comparable between the budesonide/formoterol and fluticasone/salmeterol groups.

Conclusion

Collectively, results indicate the real-world effectiveness of budesonide/formoterol anti-inflammatory reliever and maintenance therapy is better than fixed-dose fluticasone/salmeterol plus as-needed SABA.

Trial Registration

ClinicalTrials.gov registration number: NCT00784953.

Serum Eosinophil-Derived Neurotoxin Better Reflect Asthma Control Status Than Blood Eosinophil Counts

BACKGROUND

Although several biomarkers have been proposed for eosinophilic asthma, biomarkers for reflecting asthma control status remain controversial. Eosinophil-derived neurotoxin (EDN), a degranulated eosinophil protein, is an emerging biomarker in asthmatic patients.

OBJECTIVE

This study analyzed serum EDN concentrations in asthmatics and compared its performance with that of blood eosinophil count as an indicator of asthma control status.

METHODS

We enrolled 75 uncontrolled asthmatics, 56 controlled asthmatics, and 43 healthy controls from Asan Medical Center. Serum EDN levels (ng/mL) were measured using an enzyme-linked immunosorbent assay kit. The predictability of EDN for asthma control status was analyzed by univariate and multivariable logistic regression analyses. A receiver operating characteristic (ROC) curve analysis was conducted to compare the performances of a serum EDN level and blood eosinophil count as indicators of uncontrolled asthma status.

RESULTS

The mean serum EDN level in the uncontrolled asthma group was higher than that in the controlled asthma and healthy groups (103.2 ± 60.2 vs 60.8 ± 49.7 vs 49.6 ± 28.3 ng/mL, P < .001). Serum EDN level was the significant parameter related to asthma control status in univariate and multivariable analysis (both P < .001). Serum EDN levels correlated with blood eosinophil counts (r = 0.510, P < .001). However, in the ROC analysis, serum EDN level showed a significantly better performance for predicting uncontrolled asthma status (area under the curve, 0.726 vs 0.628, P = .024).

CONCLUSIONS

Serum EDN levels significantly differed between patients with controlled and uncontrolled status in adult asthmatics. To our knowledge, this is the first study to identify EDN as a better indicator of asthma control status than blood eosinophil count.

Paracetamol inhibits Ca2+ permeant ion channels and Ca2+ sensitization resulting in relaxation of precontracted airway smooth muscle

The purpose of this study was to screen a bronchodilator from old drugs and elucidate the underlying mechanism. Paracetamol (acetaminophen) is a widely used analgesic and antipyretic drug. It has been reported that it inhibits the generation of prostaglandin and histamine, which play roles in asthma. These findings led us to explore whether paracetamol could be a potential bronchodilator. Paracetamol inhibited high K⁺- and acetylcholine (ACH)-induced precontraction of mouse tracheal and bronchial smooth muscles. Moreover, the ACH-induced contraction was partially inhibited by nifedipine (selective blocker of LVDCCs), YM-58483 (selective inhibitor of store-operated Ca²⁺ entry (SOCE), canonical transient receptor potential 3 (TRPC3) and TRPC5 channels) and Y-27632 (selective blocker of ROCK, a linker of the Ca²⁺ sensitization pathway). In single airway smooth muscle cells, paracetamol blocked the currents sensitive to nifedipine and YM-58483, and inhibited intracellular Ca²⁺ increases. In addition, paracetamol inhibited ACH-induced phosphorylation of myosin phosphatase target subunit 1 (MYPT1, another linker of the Ca²⁺ sensitization pathway). Finally, in vivo paracetamol inhibited ACH-induced increases of mouse respirator system resistance. Collectively, we conclude that paracetamol inhibits ASM contraction through blocking LVDCCs, SOCE and/or TRPC3 and/or TRPC5 channels, and Ca²⁺ sensitization. These results suggest that paracetamol might be a new bronchodilator.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Validation of the Brazilian version of the childhood asthma control test (c-ACT)

BACKGROUND

Children's perception of their symptoms has proved reliable and relevant to disease management and should be considered when assessing their asthma control. The aim of the study is to validate the Brazilian Portuguese version of the Childhood Asthma Control Test (c-ACT) in children aged 4-11 years.

METHODS

This is a cross-sectional study in children diagnosed with asthma undergoing treatment in a pediatric pulmonology outpatient clinic in Porto Alegre, Brazil. The translation and linguistic adaptation of the instrument were performed in accordance with international recommendations for questionnaire validation.

RESULTS

A total of 105 participants were included, aged 4-11 years.

VALIDITY

all correlations between the total score and items on the questionnaire were significant and obtained values of r ≥ 0.3, and c-ACT means showed statistically significant differences between the GINA categories (P < 0.01). The controlled asthma group showed significantly higher c-ACT scores than those of uncontrolled asthma group (controlled 22.0 ± 2.9 vs. uncontrolled 16.3 ± 5.3 P < 0.01); and partially controlled asthma group showed significantly higher c-ACT scores than those of uncontrolled asthma group (partially controlled 20.0 ± 4.0 vs. uncontrolled 16.3 ± 5.3 P = 0.03). Correlations between the c-ACT total score and spirometry and nitric oxide were poor (r = 0.020; P = 0.866 and r = 0.035; P = 0.753, respectively). Reliability: the α-C coefficient for the c-ACT total score was 0.677 (95%CI 0.573-0763). Sensitivity to change had an effect size of 0.8 and an intraclass correlation coefficient of 0.598. No floor or ceiling effects were observed.

CONCLUSION

The Brazilian version of the Childhood Asthma Control Test proved to be valid and reliable in children aged 4-11 years.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

All-trans retinoic acid modulates ORMDL3 expression via transcriptional regulation

All-trans retinoic acid (ATRA) is an active metabolite of Vitamin A, it shows protective effects on asthma, including maintains airway epithelial integrity, inhibits asthma effector cells differentiation, modulates immune response, et al. However, the promoting effect of ATRA on Th2 response has restricted the clinical application of ATRA in asthma treatment. ORMDL3 is a candidate gene of childhood onset asthma, and high-transcript of ORMDL3 is associated with the development of asthma. Here we show that ATRA increases ORMDL3 production in vitro via inducing PKA-dependent CREB phosphorylation which in turn binds to the CRE element in promoter region of ORMDL3 and initiates ORMDL3 transcription. This finding is in consistent with the previous reports that ATRA could regulate target genes without the presence of retinoic acid response element (RARE) in promoter region but through other signals such as PKA/CREB. Nevertheless, in the present study, the traditional signal pathway of ATRA, retinoic acid receptor (RAR) signal transduction pathway, indirectly modulated ORMDL3 expression. RAR-α agonist (Am-80) increased ORMDL3 production even though there was no RARE in ORMDL3 promoter, introns or 3′-downstream region. Besides, the signal of RAR might differ from that of ATRA since Am-80 failed to induce CREB activation. In conclusion, our data indicate that ATRA facilitates ORMDL3 production probable through PKA/CREB, and this may be a starting point for more detailed mechanism researches on ATRA and asthma.

Glucocorticoid-resistant asthma: more than meets the eye

INTRODUCTION

For decades glucocorticoids have been considered as the gold standard for the treatment of asthma. We present a case report of typical glucocorticoid-resistant asthma and current consensus in definitions of "severe refractory", "difficult" and "glucocorticoid-resistant" asthma.

METHODS

Full-text papers and abstracts were identified on the basis of a comprehensive literature search primarily in MEDLINE (1966 to June 2012) but also in the Cochrane Central Register of Controlled Trials database.

RESULTS

Glucocorticoid-resistant asthmatics are a small subset of patients who pose noteworthy diagnostic challenges while contributing disproportionately to health care costs. Recognition of various asthma phenotypes has aided in characterizing groups with severe asthma and given a better understanding of its pathophysiological process. The molecular mechanism of glucocorticoid action is complicated and several pathways have been identified to explain drug resistance, which in turn is crucial for drug development. Tobacco smoking appears to be the single most important contributor of glucocorticoid resistance. We present the emerging and promising concepts in the management of glucocorticoid-resistant asthma, which mainly include drugs targeting specific molecules, receptors, inflammatory cells or immune processes.

CONCLUSION

The challenges in making a diagnosis of glucocorticoid-resistant asthma may contribute to underestimating its prevalence and impact on patient care. Considerable progress has been made in identifying distinct phenotypes and mechanisms of glucocorticoid resistance; therefore the future of new drug development in management of asthma is promising.

The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children

This an updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have updated guidelines, which are simple to understand and easy to use by non-asthma specialists, including primary care and general practice physicians. This new version includes updates of acute and chronic asthma management, with more emphasis on the use of Asthma Control Test in the management of asthma, and a new section on "difficult-to-treat asthma." Further, the section on asthma in children was re-written to cover different aspects in this age group. The SINA panel is a group of Saudi experts with well-respected academic backgrounds and experience in the field of asthma. The guidelines are formatted based on the available evidence, local literature, and the current situation in Saudi Arabia. There was an emphasis on patient-doctor partnership in the management that also includes a self-management plan. The approach adopted by the SINA group is mainly based on disease control as it is the ultimate goal of treatment.

Efficacy of interventions to improve adherence to inhaled corticosteroids in adult asthmatics: impact of using components of the chronic care model

BACKGROUND

Adherence to inhaled corticosteroids (ICS) remains poor among asthmatics, yet little is known about the efficacy of interventions to improve adherence. Implementing the Chronic Care Model (CCM) components among patients with respiratory disorders has been associated with an improvement in outcomes, yet little is known about its effects on ICS adherence in asthmatics.

OBJECTIVE

We conducted a systematic review to assess the efficacy of interventions to improve ICS adherence among adult-asthmatics, and whether the use of CCM components (i.e., teaching self-management skills, providing decision support, delivery system design, and clinical information systems) resulted in greater ICS adherence.

METHODS

All English language articles testing the efficacy of an intervention including ICS medication on outcome from MEDLINE and PsychINFO databases through Aug-2010 were reviewed. Interventions were categorized based on the inclusion of CCM components. We standardized treatment effects to obtain effect-size's (ES's) and we combined the ES's of studies according to the number of CCM components included in their interventions.

RESULTS

Eighteen studies met inclusion criteria. Inclusion of a greater number of CCM components within interventions was associated with stronger effects on ICS adherence outcomes, with interventions featuring one, two, and four CCM components having medium (ES = 0.29; 95%CI, 0.16-0.42), large (0.53; 0.40-0.66), and very-large (0.83; 0.69-0.98) effects respectively.

CONCLUSIONS

Findings provide support for using the CCM as a framework for the design and implementation of interventions to improve adherence among adult-asthmatics.

Controversies regarding long-acting β2-agonists

PURPOSE OF REVIEW

This review examines the literature regarding the efficacy and safety of long-acting β2-agonists as add-on therapy to inhaled corticosteroids.

RECENT FINDINGS

The Global Initiative for Asthma (GINA) 2009 guidelines and the National Heart, Lung, and Blood Institute (NHLBI) 2007 asthma guidelines recommend adding long-acting β2-agonists to patients inadequately controlled on inhaled corticosteroids. These recommendations must be balanced against published data which demonstrate a signal of increased morbidity and mortality with use of long-acting β2-agonists. These conflicting data raise the question of whether or not there may be genotypic or phenotypic discriminators leading to disparate responses to long-acting β2-agonists.

SUMMARY

The combination of long-acting β2-agonists and inhaled corticosteroids demonstrates improvement in asthma control and exacerbation rates; however, long-acting β2-agonists are not recommended for use as monotherapy or without optimization of inhaled corticosteroid dose. Although the majority of asthmatic patients appear to benefit from the addition of long-acting β2-agonists, there are concerns that a small proportion of patients, including steroid-naïve patients and African Americans, may not obtain such benefits. Thus far, studies have not clearly demonstrated genotypic or phenotypic differences explaining the variability in response.

The right tools at the right time

Asthma is underdiagnosed and undertreated or inappropriately treated, even though approximately 300 million people worldwide currently have the disease. While asthma in most patients can be controlled using currently available medications, in practice this rarely happens. Despite the wide availability of treatment guidelines, there are clear discrepancies between recommendations and the reality of treatment. There is excessive use of relief medications, particularly among patients with moderate-to-severe persistent asthma, coupled with a marked underuse of inhaled corticosteroids (ICS). This underuse by patients is likely to be related to anxiety about side effects and a misunderstanding about asthma. Many patients overestimate their degree of control and have a perceived lack of need for medication. Early therapeutic intervention, with optimal antiinflammatory therapy and a stepwise approach, has a positive impact on long-term outcomes, achieving suppression of airway inflammation, prompt symptom control, and restoration of pulmonary function. Even at low doses, ICS rapidly improve clinical symptoms and measures of lung function, while their long-term use markedly reduces the frequency and severity of exacerbations and asthma mortality. Although ICS monotherapy achieves successful control of persistent asthma in a significant proportion of patients, add-on therapy with a long-acting beta2-agonist provides control for most patients with moderate-to-severe persistent asthma. Fixed combination inhalers (ICS plus a long-acting beta2-agonist) have become popular, but these have drawbacks and there is the potential for overuse. In conclusion, ICS are the cornerstone of therapy for persistent asthma of all degrees of severity in adults and children, and early therapeutic intervention is recommended for optimal long-term outcome.