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Hussain M, Liu G. Eosinophilic Asthma: Pathophysiology and Therapeutic Horizons. Cells 2024; 13:384. [PMID: 38474348 PMCID: PMC10931088 DOI: 10.3390/cells13050384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
Asthma is a prevalent chronic non-communicable disease, affecting approximately 300 million people worldwide. It is characterized by significant airway inflammation, hyperresponsiveness, obstruction, and remodeling. Eosinophilic asthma, a subtype of asthma, involves the accumulation of eosinophils in the airways. These eosinophils release mediators and cytokines, contributing to severe airway inflammation and tissue damage. Emerging evidence suggests that targeting eosinophils could reduce airway remodeling and slow the progression of asthma. To achieve this, it is essential to understand the immunopathology of asthma, identify specific eosinophil-associated biomarkers, and categorize patients more accurately based on the clinical characteristics (phenotypes) and underlying pathobiological mechanisms (endotypes). This review delves into the role of eosinophils in exacerbating severe asthma, exploring various phenotypes and endotypes, as well as biomarkers. It also examines the current and emerging biological agents that target eosinophils in eosinophilic asthma. By focusing on these aspects, both researchers and clinicians can advance the development of targeted therapies to combat eosinophilic pathology in severe asthma.
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Affiliation(s)
- Musaddique Hussain
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Gang Liu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Kankaanranta H, Viinanen A, Ilmarinen P, Hisinger-Mölkänen H, Mehtälä J, Ylisaukko-Oja T, Idänpään-Heikkilä JJ, Lehtimäki L. Comorbidity Burden in Severe and Nonsevere Asthma: A Nationwide Observational Study (FINASTHMA). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:135-145.e9. [PMID: 37797715 DOI: 10.1016/j.jaip.2023.09.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Asthma, affecting more than 330 million people worldwide, is associated with a high level of morbidity, mortality, and socioeconomic costs. OBJECTIVE In this cross-sectional study, we analyzed the comorbidity burden in patients with severe asthma compared with nonsevere asthma and investigated the role of corticosteroid use on the risk of comorbidities. METHODS All adults (≥18 y) with a diagnosis of asthma (International Classification of Diseases-10th revision code J45.x) between 2014 and 2017 were identified and data were collected until 2018 from Finnish nationwide registers. Asthma was defined as continuously or transiently severe or nonsevere based on annual dispensed inhaled corticosteroids (ICS), oral corticosteroids (OCS), and hospitalizations. RESULTS Of 193,730 adult identified patients diagnosed with asthma, 86.3% had nonsevere, 8.1% transiently severe, and 5.6% continuously severe asthma. Excess prevalence of pneumonia was observed in continuously (22%) and transiently severe (14%) compared with nonsevere patients after adjusting for age and sex. Cataract, osteoporosis, obesity, heart failure, and atrial fibrillation were also more frequent in severe asthma patients. The ICS and/or OCS use contributed to the risk of several comorbidities in a dose-dependent manner, particularly pneumonia, osteoporosis, obesity, heart failure, and atrial fibrillation. High OCS use and the presence of comorbidities were associated with increased health care resource use. CONCLUSIONS Patients with severe asthma have a high burden of comorbidities, especially pneumonia. Many of the comorbidities have a strong dose-dependent association with ICS and OCS treatment, suggesting that corticosteroid doses should be carefully evaluated in clinical practice.
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Affiliation(s)
- Hannu Kankaanranta
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Arja Viinanen
- Pulmonary Diseases and Clinical Allergology, Turku University Hospital, Turku, Finland; Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland
| | | | | | | | | | | | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Allergy Centre, Tampere University Hospital, Tampere, Finland
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Lo CWH, Pathadka S, Qin SX, Fung LWY, Yan VKC, Yiu HHE, Bloom CI, Wong ICK, Chan EWY. Neuropsychiatric events associated with montelukast in patients with asthma: a systematic review. Eur Respir Rev 2023; 32:230079. [PMID: 37758273 PMCID: PMC10523155 DOI: 10.1183/16000617.0079-2023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/13/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND The United States Food and Drug Administration issued a black box warning on the mental health adverse effects of montelukast in 2020. Age-related effects on the risk of developing specific neuropsychiatric events in montelukast users remain largely unknown. OBJECTIVE To describe the risk of neuropsychiatric events associated with montelukast in adults and children with asthma. METHODS A systematic search of all studies investigating neuropsychiatric events in montelukast users was performed in PubMed, the Cochrane Library and Embase from inception to 7 September 2022. Animal studies and conference abstracts were excluded. RESULTS 59 studies (21 pharmacovigilance studies, four reviews from 172 randomised controlled trials, 20 observational studies, 10 case reports and four case series) evaluating neuropsychiatric events in patients with asthma on montelukast were reviewed. No significant association was shown between montelukast and suicide-related events in six of the observational studies. No association was found for depression as defined by the International Classification of Diseases 10th revision codes in three observational studies and a review of randomised clinical trials. However, findings from four studies using antidepressant prescriptions as the outcome identified significant associations. Consistent with nine pharmacovigilance studies, two large-scale observational studies revealed possible associations of montelukast with anxiety and sleeping disorders in adult patients with asthma, respectively. However, the results were not replicated in two observational studies on children. CONCLUSION Montelukast is not associated with suicide- and depression-related events in asthma patients. Older adults may be particularly susceptible to anxiety and sleeping disorders.
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Affiliation(s)
- Chris Wai Hang Lo
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Swathi Pathadka
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
- LCCI - Value, Evidence, Outcomes Division, Eli Lilly Services India Private Limited, Bengaluru, India
| | - Simon Xiwen Qin
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong SAR, China
| | - Lydia W Y Fung
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong SAR, China
| | - Vincent Ka Chun Yan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
| | - Hei Hang Edmund Yiu
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
| | - Chloe I Bloom
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ian Chi Kei Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong SAR, China
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Esther Wai Yin Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong SAR, China
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Cai X, Rong R, Huang Y, Pu X, Ge N. Effects of theophylline combined with inhaled corticosteroids on patients with moderate and severe asthma and changes of T lymphocyte subsets in peripheral blood. Cent Eur J Immunol 2023; 48:135-143. [PMID: 37692023 PMCID: PMC10485692 DOI: 10.5114/ceji.2023.127843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/29/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction Asthma is a common respiratory disease. Theophylline combined with inhaled corticosteroids (ICS) is a promising therapy for asthma. This study explored the therapeutic effects of ICS combined with theophylline on moderate and severe asthma patients and T lymphocyte subsets (CD3+CD8+ T cells) in peripheral blood. Material and methods A total of 202 moderate and severe asthma patients were selected, with 101 treated with theophylline combined with ICS and 101 treated with ICS alone as controls. Lung function [forced expiratory volume within 1 second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF)] were tested using a spirometer. Asthma symptom control was evaluated by asthma control tests (ACT). The life quality was evaluated using the Asthma Quality of Life Questionnaire (AQLQ). The number and percentage of CD3+ T, CD3+CD4+ T and CD3+CD8+ T cells in peripheral blood mononuclear cells were assessed by flow cytometry. The correlation between CD3+CD8+ T cells and lung function and asthma control of patients after combination therapy was analyzed by Pearson correlation analysis. Results Compared with moderate and severe patients treated with ICS alone, theophylline improved the efficacy of ICS. Theophylline combined with ICS decreased IL-4 and IL-6 levels, and CD3+ T and CD3+CD8+ T cell number and percentage. After combined treatment, CD3+ CD8+ T cells in peripheral blood of patients were positively correlated with lung function and negatively correlated with asthma control. Conclusions The additional use of theophylline improved the efficacy of corticosteroids in asthma patient treatment and reduced inflammation level and CD3+ T and CD3+CD8+ T cell contents in peripheral blood.
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Affiliation(s)
- Xiaozhen Cai
- Department of Respiratory and Critical Care Medicine, Houjie Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong, China
| | - Rong Rong
- Department of Respiratory and Critical Care Medicine, Houjie Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong, China
| | - Yidan Huang
- Department of Respiratory and Critical Care Medicine, Houjie Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong, China
| | - Xiaowen Pu
- Department of Respiratory and Critical Care Medicine, Houjie Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong, China
| | - Nanhai Ge
- Department of Respiratory and Critical Care Medicine, Houjie Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong, China
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Beasley R, Kankaanranta H. Inhaled Corticosteroids in Asthma: When Less Is More. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:544-545. [PMID: 36759081 DOI: 10.1016/j.jaip.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 02/10/2023]
Affiliation(s)
- Richard Beasley
- Department of Medicine, Medical Research Institute of New Zealand, Wellington, New Zealand; School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Hannu Kankaanranta
- Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland; Faculty of Medicine and Health technology, Tampere University, Tampere, Finland.
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Pavord ID, Tran TN, Jones RC, Nuevo J, van den Berge M, Brusselle GG, Menzies-Gow AN, Skinner D, Carter V, Kocks JWH, Price DB. Effect of Stepping Up to High-Dose Inhaled Corticosteroids in Patients With Asthma: UK Database Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:532-543. [PMID: 36371063 DOI: 10.1016/j.jaip.2022.10.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND It is unclear whether patients with asthma benefit from stepping up to high-dose inhaled corticosteroids (ICSs). OBJECTIVE To determine the effectiveness of stepping up to high-dose ICSs. METHODS A historic cohort study of patients with asthma (≥13 years old), identified from 2 large UK electronic medical record databases, was conducted. Patients who remained on medium-dose ICSs were compared with those who stepped up from medium- to high-dose ICSs, whereas patients who stepped up from low- to medium-dose ICSs were compared with those who stepped up from low- to high-dose ICSs. Time to first severe exacerbation (primary outcome) between treatment groups was compared using multivariable Cox proportional hazards models, and the number of exacerbations and antibiotics courses was analyzed using negative binomial regression. Inverse probability of treatment weighting was used to handle confounding. RESULTS The mean follow-up time to first exacerbation was 2.7 ± 2.7 years for those who remained on stable medium-dose ICSs and 2.0 ± 2.2 years for those who stepped up from medium- to high-dose ICSs. A similar pattern was noted for those who stepped up from low- to medium-dose ICSs (2.6 ± 2.5 years) and from low- to high-dose ICSs (2.3 ± 2.5 years). Patients who stepped up from medium- to high-dose ICSs (n = 6879) had a higher risk of exacerbations during follow-up compared with those who remained on medium-dose ICSs (n = 51,737; hazard ratio, 1.17; 95% CI, 1.12-1.22). This was similar in patients stepping up from low- to high-dose (n = 3232) compared with low- to medium-dose (n = 12,659) ICSs (hazard ratio, 1.10; 95% CI, 1.04-1.17). A step-up to high-dose ICSs was also associated with a higher number of asthma exacerbations and antibiotics courses. No significant difference in associations was found across subgroups of patients with different blood eosinophil counts. CONCLUSIONS We found no evidence that a step-up to high-dose ICSs is effective in preventing future asthma exacerbations.
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Affiliation(s)
- Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Oxford, United Kingdom; Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Rupert C Jones
- Research and Knowledge Exchange, Plymouth Marjon University, Plymouth, United Kingdom
| | | | - Maarten van den Berge
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Guy G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium; Department of Epidemiology and Respiratory Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Derek Skinner
- Optimum Patient Care, Cambridge, United Kingdom; Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - Victoria Carter
- Optimum Patient Care, Cambridge, United Kingdom; Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - Janwillem W H Kocks
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore; General Practitioners Research Institute, Groningen, The Netherlands; Groningen Research Institute Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - David B Price
- Optimum Patient Care, Cambridge, United Kingdom; Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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Saukkosalmi P, Kankaanranta H, Vähätalo I, Sillanmäki L, Sumanen M. Defined daily dose definition in medication adherence assessment in asthma. Eur Clin Respir J 2023; 10:2207335. [PMID: 37139181 PMCID: PMC10150619 DOI: 10.1080/20018525.2023.2207335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Adherence to inhaled corticosteroids (ICS) has been described as poor. In adherence studies, if the actual prescribed dosing is not available, generic defined daily doses (DDD) are applied instead when assessing adherence. We evaluated asthma patients' adherence in a large prospective follow-up survey. We also analysed whether World Health Organization (WHO) and Global Initiative for Asthma (GINA) reference doses give different results. The current study was cross-sectional and included respondents attending to HeSSup follow-up questionnaire in 2012. Altogether 1,141 of 12,854 adult participants answered positively to the question about having asthma. According to the Finnish Social Insurance Institutions' medication register, 686 of them had purchased ICS medication during 2011. DDDs for ICS by WHO as well as medium doses from GINA report were used as reference doses to evaluate adherence. To estimate adherence to ICS, the proportion of days covered (PDC) over one year was calculated for every patient. If the lower limit of GINA medium ICS dose was used as a reference, 65% of the patients were adherent (PDC ≥ 80%). Use of WHO's DDD as reference halved the proportion of adherent patients. Adherence was higher among those using a combination inhaler of corticosteroid and long-acting β2-agonist compared to those using steroid only inhalers. Use of WHO's daily defined doses as reference values may lead to underestimation of adherence to inhaled corticosteroids. Thus, attention should be paid when choosing the reference doses for the evaluation of adherence to inhaled corticosteroids in asthma.
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Affiliation(s)
- Päivi Saukkosalmi
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Regional State Administrative Agency for Southern Finland, Hämeenlinna, Finland
| | - Hannu Kankaanranta
- Faculty of Medicine and Health Technology, Tampere University Respiratory Research Group, Tampere, Finland
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Department of Internal Medicine, Krefting Research Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Iida Vähätalo
- Faculty of Medicine and Health Technology, Tampere University Respiratory Research Group, Tampere, Finland
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Lauri Sillanmäki
- Department of Public Health, University of Turku and Turku University Hospital, Turku, Finland
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Markku Sumanen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- CONTACT Markku Sumanen Faculty of Medicine and Health Technology, Tampere University, TampereFIN-33014, Finland
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Damiański P, Kardas G, Panek M, Kuna P, Kupczyk M. Improving the risk-to-benefit ratio of inhaled corticosteroids through delivery and dose: current progress and future directions. Expert Opin Drug Saf 2021; 21:499-515. [PMID: 34720035 DOI: 10.1080/14740338.2022.1999926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) are known to increase the risk of systemic and local adverse effects, especially with high doses and long-term use. Hence, considerable resources are invested to improve pharmacokinetic/pharmacodynamic (PK/PD) properties of ICS, effective delivery systems and novel combination therapies to enhance the risk-to-benefit ratio of ICS. AREAS COVERED There is an unmet need for new solutions to achieve optimal clinical outcomes with minimal dose of ICS. This paper gives an overview of novel treatment strategies regarding the safety of ICS therapy on the basis of the three most recent molecules introduced to our everyday clinical practice - ciclesonide, mometasone furoate, and fluticasone furoate. Advances in aerosol devices and new areas of inhalation therapy are also discussed. EXPERT OPINION Current progress in improving the risk-to-benefit ratio of ICS through dose and delivery probably established pathways for further developments. This applies both to the improvement of the PK/PD properties of ICS molecules but also includes technical aspects that lead to simplified applicability of the device with simultaneous optimal drug deposition in the lungs. Indubitably, the future of medicine lies not only in the development of new molecules but also in technology and digital revolution.
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Affiliation(s)
- Piotr Damiański
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Grzegorz Kardas
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Michał Panek
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Piotr Kuna
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Maciej Kupczyk
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
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Shafiek H, Verdú J, Iglesias A, Ramon-Clar L, Toledo-Pons N, Lopez-Causape C, Juan C, Fraile-Ribot P, Oliver A, Cosio BG. Inhaled corticosteroid dose is associated with Pseudomonas aeruginosa infection in severe COPD. BMJ Open Respir Res 2021; 8:e001067. [PMID: 34615691 PMCID: PMC8496398 DOI: 10.1136/bmjresp-2021-001067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/23/2021] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Patients with chronic obstructive pulmonary disease (COPD) with frequent exacerbations (ExCOPD) are commonly treated with inhaled corticosteroids (ICS) and are at risk of infections caused by potential pathogenic bacteria (PPB) including Pseudomonas aeruginosa (PsA). OBJECTIVES To investigate the association between the use of ICS and PsA infection among ExCOPD. METHODS Case-control study with longitudinal follow-up that recruited ExCOPD after a hospitalisation due to exacerbation between 2012 and 2020. Patients with isolation of PsA (COPD-PsA) in sputum either during admission or follow-up were compared with those with other or no PPB. Clinical, functional characteristics, DDD, use of ICS and survival were evaluated. Cox regression analysis was performed to evaluate the risk factors associated to PsA infection and mortality. RESULTS 358 patients (78% male, mean age 73±9 years) were enrolled and followed up for a median of 4 years (IQR=3-8). 173 patients (48.3%) had at least a positive culture for PsA. COPD-PsA had more frequent exacerbations, more severe airflow limitation and higher mortality (69.4% vs 46.5%, p<0.001). There were no differences in the use of ICS between groups but the dose of ICS was significantly higher among COPD-PsA (median of 500 µg fluticasone propionate equivalents (IQR=250-1000) vs 400 µg (IQR=200-1000), p=0.007). Blood eosinophil count (BEC) was not different between ICS users and non-users. In multivariate analysis, the dose of ICS was an independent risk factor for PsA infection and mortality but not ICS use. CONCLUSIONS ICS dose, but not its use, could be a risk factor for PsA infection in patients with severe COPD regardless of BEC.
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Affiliation(s)
- Hanaa Shafiek
- Department of Chest Diseases, Alexandria University Faculty of Medicine, Alexandria, Egypt
- Department of Respiratory Medicine, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Javier Verdú
- Department of Respiratory Medicine, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Amanda Iglesias
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, Spain
| | - Lluisa Ramon-Clar
- Department of Respiratory Medicine, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Nuria Toledo-Pons
- Department of Respiratory Medicine, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Carla Lopez-Causape
- Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, Spain
- Department of Clinical Microbiology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Carlos Juan
- Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, Spain
- Department of Clinical Microbiology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Pablo Fraile-Ribot
- Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, Spain
- Department of Clinical Microbiology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Antonio Oliver
- Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, Spain
- Department of Clinical Microbiology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Borja G Cosio
- Department of Respiratory Medicine, Hospital Universitario Son Espases, Palma de Mallorca, Spain
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Rönnebjerg L, Axelsson M, Kankaanranta H, Backman H, Rådinger M, Lundbäck B, Ekerljung L. Severe Asthma in a General Population Study: Prevalence and Clinical Characteristics. J Asthma Allergy 2021; 14:1105-1115. [PMID: 34556999 PMCID: PMC8454418 DOI: 10.2147/jaa.s327659] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Current guidelines primarily use medication levels to distinguish severe asthma from other types of asthma. In addition, severe asthma must also be uncontrolled at high-intensity treatment or become uncontrolled if treatment level is decreased. To date, only a few studies have used this definition to investigate the prevalence and clinical characteristics of severe asthma in population-based samples. Therefore, the aim of this study was to evaluate the prevalence and clinical characteristics of individuals with severe asthma in the population-representative West Sweden Asthma Study. MATERIALS AND METHODS In this cross-sectional population-based study, a randomly selected sample (n=1172) and a separate asthma sample (n=744) underwent clinical examinations, completed a structured interview and responded to questionnaires. Severe asthma was defined as at least one feature of uncontrolled asthma despite treatment in line with the Global Initiative for Asthma (GINA) steps 4/5. This treatment level required a minimum medium dose of inhaled corticosteroids (ICS) plus a second controller or oral corticosteroids. RESULTS The prevalence of severe asthma was 1.1% in the adult random sample and 9.5% within the asthma sample. Individuals with severe asthma were older and had more symptoms, activity limitations, heart disease and blood neutrophils compared to those with other asthma. They also had lower lung function and despite these impairments, 32% did not have annual contact with a healthcare provider. CONCLUSION The prevalence of severe asthma was higher compared to previous studies, and many individuals with severe asthma did not have regular contact with healthcare providers. Due to the high burden of symptoms and impairments for individuals with severe asthma, it is important that the healthcare system implement strategies to improve follow-up and evaluate these patients according to existing guidelines.
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Affiliation(s)
- Lina Rönnebjerg
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Malin Axelsson
- Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
| | - Hannu Kankaanranta
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Tampere University Respiratory Research Group, Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Helena Backman
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Madeleine Rådinger
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Bo Lundbäck
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Linda Ekerljung
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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11
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Choi Y, Sim S, Park HS. Distinct functions of eosinophils in severe asthma with type 2 phenotype: clinical implications. Korean J Intern Med 2020; 35:823-833. [PMID: 32460456 PMCID: PMC7373972 DOI: 10.3904/kjim.2020.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/06/2020] [Indexed: 12/16/2022] Open
Abstract
Asthma is commonly recognized as a heterogeneous condition with a complex pathophysiology. With advances in the development of multiple medications for patients with asthma, most asthma symptoms are well managed. Nevertheless, 5% to 10% of adult asthmatic patients (called severe asthma) are in uncontrolled or partially controlled status despite intensive treatment. Especially, severe eosinophilic asthma is one of the severe asthma phenotypes characterized by eosinophilia in sputum/blood driven by type 2 immune responses. Eosinophils have been widely accepted as a central effector cell in the lungs. Some evidence has demonstrated that persistent eosinophilia in upper and lower airway mucosa contributes to asthma severity by producing various mediators including cytokines, chemokines and granule proteins. Moreover, extracellular traps released from eosinophils have been revealed to enhance type 2 inflammation in patients with severe asthma. These novel molecules have the ability to induce airway inf lammation and hyperresponsiveness through enhancing innate and type 2 immune responses. In this review, we highlight recent insight into the function of eosinophil extracellular traps in patients with severe asthma. In addition, the role of eosinophil extracellular vesicles in severe asthma is also proposed. Finally, current biologics are suggested as a potential strategy for effective management of severe eosinophilic asthma.
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Affiliation(s)
- Youngwoo Choi
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Soyoon Sim
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
- Correspondence to Hae-Sim Park, M.D. Department of Allergy and Clinical Immunology, Ajou University School of Medicine, 164 World cup-ro, Yeongtonggu, Suwon 16499, Korea Tel: +82-31-219-5196, Fax: +82-31-219-5154, E-mail:
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12
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Fleming L, Heaney L. Severe Asthma-Perspectives From Adult and Pediatric Pulmonology. Front Pediatr 2019; 7:389. [PMID: 31649906 PMCID: PMC6794347 DOI: 10.3389/fped.2019.00389] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022] Open
Abstract
Both adults and children with severe asthma represent a small proportion of the asthma population; however, they consume disproportionate resources. For both groups it is important to confirm the diagnosis of severe asthma and ensure that modifiable factors such as adherence have, as far as possible, been addressed. Most children can be controlled on inhaled corticosteroids and long term oral corticosteroid use is rare, in contrast to adults where steroid related morbidity accounts for a large proportion of the costs of severe asthma. Atopic sensitization is very common in children with severe asthma as are other atopic conditions such as allergic rhinitis and hay fever which can impact on asthma control. In adults, the role of allergic driven disease, even in those with co-existent evidence of sensitization, is unclear. There is currently an exciting pipeline of novel biologicals, particularly directed at Type 2 inflammation, which afford the possibility of improved asthma control and reduced treatment side effects for people with asthma. However, not all drugs will work for all patients and accurate phenotyping is essential. In adults the terms T2 high and T2 low asthma have been coined to describe groups of patients based on the presence/absence of eosinophilic inflammation and T-helper 2 (TH2) cytokines. Bronchoscopic studies in children with severe asthma have demonstrated that these children are predominantly eosinophilic but the cytokine patterns do not fit the T2 high paradigm suggesting other steroid resistant pathways are driving the eosinophilic inflammation. It remains to be seen whether treatments developed for adult severe asthma will be effective in children and which biomarkers will predict response.
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Affiliation(s)
- Louise Fleming
- National Heart and Lung Institute, Imperial College, London and Royal Brompton Hospital, London, United Kingdom
| | - Liam Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Institute for Health Sciences, Queens University Belfast, Belfast, United Kingdom
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13
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Al-Moamary MS, Alhaider SA, Alangari AA, Al Ghobain MO, Zeitouni MO, Idrees MM, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2019; 14:3-48. [PMID: 30745934 PMCID: PMC6341863 DOI: 10.4103/atm.atm_327_18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mohamed S Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed O Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Respiratory Division, Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah F Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S Al-Hajjaj
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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14
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Izquierdo JL, Cosio BG. The dose of inhaled corticosteroids in patients with COPD: when less is better. Int J Chron Obstruct Pulmon Dis 2018; 13:3539-3547. [PMID: 30498343 PMCID: PMC6207269 DOI: 10.2147/copd.s175047] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background The use of inhaled corticosteroids (ICS) in combination with bronchodilators in patients with COPD has been shown to decrease the rate of disease exacerbations and to improve the lung function and patients’ quality of life. However, their use has also been associated with an increased risk of pneumonia. Materials and methods We have reviewed existing clinical evidence on the risks and benefits of ICS in COPD, including large randomized clinical trials, meta-analyses, and clinical reviews. Results A large body of evidence supports the clinical benefits of ICS in patients with COPD in terms of exacerbations, symptoms, lung function, and quality of life. The incidence of adverse events related to ICS, including pneumonia, varies strongly among the studies and seems to be dose dependent, with recent well-designed, large studies on low-dose ICS reporting similar safety profiles in ICS and non-ICS groups. Conclusion The benefits of ICS in COPD continue to outweigh the risks, especially when lower ICS doses are employed. Given that the data on ICS withdrawal in COPD are scarce and conflicting, we argue that using reduced doses of ICS could be an optimal strategy to manage patients with COPD.
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Affiliation(s)
- José Luis Izquierdo
- Department of Pneumology and Medicine, Hospital Universitario, Universidad de Alcalá, Guadalajara, Spain,
| | - Borja G Cosio
- Department of Respiratory Medicine, Hospital Son Espases-IdISBa, Palma de Mallorca, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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15
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Vähätalo I, Ilmarinen P, Tuomisto LE, Niemelä O, Kankaanranta H. Inhaled corticosteroids and asthma control in adult-onset asthma: 12-year follow-up study. Respir Med 2018; 137:70-76. [PMID: 29605216 DOI: 10.1016/j.rmed.2018.02.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/26/2018] [Accepted: 02/28/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prescribed inhaled corticosteroid (ICS) doses in asthma have been studied in cross-sectional settings whereas long-term follow-up studies have not been carried out. OBJECTIVE To evaluate prescribed medication longitudinally by calculating cumulative ICS doses and dose changes in a cohort of new-onset adult asthma during 12 years and in different groups of asthma control. METHODS A total of 203 patients were followed for 12 years as part of Seinäjoki Adult Asthma Study (SAAS). All asthma-related visits and prescribed medication over the study period were collected from medical records. RESULTS Total cumulative ICS dose for the 12-year follow-up period was 3.4g (±SEM 0.1) per patient. Both respiratory specialists and GPs prescribed step-ups and step-downs in ICS treatment and in total 649 dose changes were noted during the follow-up (median 3(1-5) per patient). Patients with uncontrolled asthma received higher ICS doses throughout the follow-up period, and therefore, cumulative 12-year ICS dose (3.8g ± SEM 0.2) in this group was higher than that in those with partially controlled (3.4g ± SEM 0.2) or controlled disease (2.9g ± SEM 0.2) (p = 0.0001). Patients with uncontrolled asthma were also prescribed a higher number of ICS dose changes than patients with controlled disease. CONCLUSION Despite frequent dose changes and high ICS doses during the 12-year follow-up, the level of asthma control remained poor in patients with uncontrolled asthma. This suggests that high ICS doses may not be effective enough for management of disease in patients with uncontrolled adult-onset asthma and novel targeted treatments are required.
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Affiliation(s)
- Iida Vähätalo
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Pinja Ilmarinen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Leena E Tuomisto
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Onni Niemelä
- Department of Laboratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland; University of Tampere, Tampere, Finland.
| | - Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland; Department of Respiratory Medicine, University of Tampere, Tampere, Finland.
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16
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Sonnappa S, McQueen B, Postma DS, Martin RJ, Roche N, Grigg J, Guilbert T, Gouder C, Pizzichini E, Niimi A, Phipatanakul W, Chisholm A, Dandurand RJ, Kaplan A, Israel E, Papi A, van Aalderen WMC, Usmani OS, Price DB. Extrafine Versus Fine Inhaled Corticosteroids in Relation to Asthma Control: A Systematic Review and Meta-Analysis of Observational Real-Life Studies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:907-915.e7. [PMID: 28941668 DOI: 10.1016/j.jaip.2017.07.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The particle size of inhaled corticosteroids (ICSs) may affect airway drug deposition and effectiveness. OBJECTIVE To compare the effectiveness of extrafine ICSs (mass median aerodynamic diameter, <2 μm) versus fine-particle ICSs administered as ICS monotherapy or ICS-long-acting β-agonist combination therapy by conducting a meta-analysis of observational real-life asthma studies to estimate the treatment effect of extrafine ICSs. METHODS MEDLINE and EMBASE databases were reviewed for asthma observational comparative effectiveness studies from January 2004 to June 2016. Studies were included if they reported odds and relative risk ratios and met all inclusion criteria (Respiratory Effectiveness Group/European Academy of Allergy and Clinical Immunology quality standards, comparison of extrafine ICSs with same or different ICS molecule, ≥12-month follow-up). End-point data (asthma control, exacerbations, prescribed ICS dose) were pooled. Random-effects meta-analysis modeling was used. The study protocol is published in the PROSPERO register CRD42016039137. RESULTS Seven studies with 33,453 subjects aged 5 to 80 years met eligibility criteria for inclusion. Six studies used extrafine beclometasone propionate and 1 study used both extrafine beclometasone propionate and extrafine ciclesonide as comparators with fine-particle ICSs. The overall odds of achieving asthma control were significantly higher for extrafine ICSs compared with fine-particle ICSs (odds ratio, 1.34; 95% CI, 1.22-1.46). Overall exacerbation rate ratios (0.84; 95% CI, 0.73-0.97) and ICS dose (weighted mean difference, -170 μg; 95% CI, -222 to -118 μg) were significantly lower for extrafine ICSs compared with fine-particle ICSs. CONCLUSIONS This meta-analysis demonstrates that extrafine ICSs have significantly higher odds of achieving asthma control with lower exacerbation rates at significantly lower prescribed doses than fine-particle ICSs.
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Affiliation(s)
- Samatha Sonnappa
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Department of Respiratory Paediatrics, Rainbow Children's Hospital, Bengaluru, India
| | - Brett McQueen
- University of Colorado Denver, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Denver, Colo
| | - Dirkje S Postma
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Richard J Martin
- National Jewish Health and the University of Colorado Denver, Denver, Colo
| | - Nicolas Roche
- Respiratory and Intensive Care Medicine, Cochin Hospital (APHP), University Paris Descartes (EA2511), Paris, France
| | - Jonathan Grigg
- Blizard Institute, Queen Mary University London, London, United Kingdom
| | - Theresa Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Cincinnati, Ohio
| | - Caroline Gouder
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Emilio Pizzichini
- Department of Medicine, Federal University of Santa Catarina, Santa Catarina, Brazil
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Alison Chisholm
- Respiratory Effectiveness Group, Oakington, Cambridge, United Kingdom
| | - Ronald J Dandurand
- Montreal Chest Institute, Meakins-Christie Laboratories and the McGill University Health Centre Research Institute, McGill University, Montreal, Canada
| | - Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada
| | - Elliot Israel
- Pulmonary and Critical Care Division, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alberto Papi
- Department of Respiratory Medicine, University Hospital S. Anna, Ferrara, Italy
| | - Willem M C van Aalderen
- Department of Pediatric Respiratory Diseases, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, London, United Kingdom
| | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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Keränen T, Moilanen E, Korhonen R. Suppression of cytokine production by glucocorticoids is mediated by MKP-1 in human lung epithelial cells. Inflamm Res 2017; 66:441-449. [PMID: 28299397 DOI: 10.1007/s00011-017-1028-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 01/12/2017] [Accepted: 02/15/2017] [Indexed: 11/30/2022] Open
Abstract
Mitogen-activated protein kinase phosphatase 1 (MKP-1) expression is induced by inflammatory factors and serves as an endogenous p38 MAPK suppressor to limit inflammatory response. Glucocorticoids are very effective anti-inflammatory drugs and they are used for the treatment of many inflammatory diseases, such as asthma and COPD. We investigated the role of MKP-1 in the inhibition of cytokine production by dexamethasone in human A549 bronchial epithelial cells. We found that dexamethasone increased MKP-1 expression, inhibited p38 MAPK phosphorylation, and suppressed TNF and MIP-3α production in A549 cells. Interestingly, the suppression of p38 MAPK phosphorylation and the inhibition of TNF expression by dexamethasone were attenuated in cells, where MKP-1 expression was silenced by siRNA. In conclusion, these data suggest that dexamethasone increases MKP-1 expression and this results in the suppression of p38 MAPK signaling leading to the inhibition of cytokine production in human bronchial epithelial cells. These results point to the role of MKP-1 as an important factor in the therapeutic effects of glucocorticoids in the treatment of inflammatory lung diseases.
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Affiliation(s)
- Tiina Keränen
- The Immunopharmacology Research Group, University of Tampere School of Medicine, and Tampere University Hospital, University of Tampere, FI-33014, Tampere, Finland
| | - Eeva Moilanen
- The Immunopharmacology Research Group, University of Tampere School of Medicine, and Tampere University Hospital, University of Tampere, FI-33014, Tampere, Finland
| | - Riku Korhonen
- The Immunopharmacology Research Group, University of Tampere School of Medicine, and Tampere University Hospital, University of Tampere, FI-33014, Tampere, Finland.
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18
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Varsano S, Segev D, Shitrit D. Severe and non-severe asthma in the community: A large electronic database analysis. Respir Med 2016; 123:131-139. [PMID: 28137489 DOI: 10.1016/j.rmed.2016.12.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 11/09/2016] [Accepted: 12/26/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND A large electronic database analysis was conducted in a community of 351,799 people, ages 20-70 years to determine the prevalence and clinical characteristics of severe asthma, according to 2014 international guidelines and healthcare utilization. METHODS Severe asthmatics were grouped into controlled severe-asthma and uncontrolled severe-asthma and additional subgroups of uncontrolled severe asthma on the basis of medications dispensed. Non-asthmatic population at the same ages served as controls. RESULTS A total of 19,991 (5.68%) were diagnosed as asthmatic, of which 4.65% had severe asthma. Of these, one-third was uncontrolled severe-asthma. Controlled severe-asthma group was similar to non-severe asthma and non-asthmatics in the rate of emergency room visits (21.5%, 22%, and 20%, respectively) and to all cause hospitalizations (7.4%, 7.4%, and 6.4%, respectively). Uncontrolled severe-asthmatics had significantly more hospitalizations (RR = 2.9) than controlled severe-asthmatics. Only 19.2% of uncontrolled-severe asthmatics had IgE testing and 3.6% were dispensed omalizumab. CONCLUSIONS The prevalence of severe asthma is slightly less than 5% of all asthmatics. Controlling severe asthma is crucial to reducing healthcare utilization. A simple electronic database analysis, based on dispensed medications, can help healthcare providers identify subgroups of uncontrolled severe asthmatics that require focused efforts. CLINICAL TRIAL REGISTRATION NCT01961258. Ethics Committee approval: 032/2013C.
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Affiliation(s)
- Shabtai Varsano
- Department of Pulmonary Medicine, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Asthma Care & Education Unit, Meir Medical Center, Kfar Saba, Israel.
| | - David Segev
- Clalit Health Services, Sharon-Shomron Medical District Headquarters, Tel Aviv, Israel
| | - David Shitrit
- Department of Pulmonary Medicine, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Chang V, Gray EL, Thomas PS. Phamacology of fluticasone furoate and vilanterol trifenatate combination therapy for asthma. Expert Rev Respir Med 2016; 10:1069-78. [PMID: 27599692 DOI: 10.1080/17476348.2016.1227245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Fluticasone furoate (FF) is a novel inhaled corticosteroid (ICS). Vilanterol trifenate (VI) is a new inhaled, selective, long - acting β2 adrenergic agonist (LABA). It is now also marketed as a novel once daily combined ICS/LABA indicated for treatment of moderate and severe asthma. AREAS COVERED FF has a highly specific, fast association and slow dissociation from the glucocorticoid receptor, with a 24 hr duration of action. This, combined with a slow transport out of respiratory cells, creates a long tissue retention period. Vilanterol trifenate (VI) is a new inhaled, selective, long - acting β2 adrenergic agonist, also with a rapid onset of action with a maximal effect within 6 mins and prolonged lung retention with effects on lung function over 24 hours. Expert commentary: Multiple Phase I-III efficacy studies performed on FF and VI have shown an improvement in spirometry as well as symptom control in asthma. The development of once daily ICS/LABA combinations may potentially improve adherence to asthma therapy, but this has yet to be demonstrated.
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Affiliation(s)
- Vicky Chang
- a Department of Respiratory Medicine , Prince of Wales Hospital , Randwick , Australia
| | - Emma L Gray
- a Department of Respiratory Medicine , Prince of Wales Hospital , Randwick , Australia
| | - Paul S Thomas
- a Department of Respiratory Medicine , Prince of Wales Hospital , Randwick , Australia.,b Inflammation and Infection Research Centre, School of Medical Sciences, and Prince of Wales Clinical School , University of New South Wales , Randwick , Australia
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20
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Tuomisto LE, Ilmarinen P, Niemelä O, Haanpää J, Kankaanranta T, Kankaanranta H. A 12-year prognosis of adult-onset asthma: Seinäjoki Adult Asthma Study. Respir Med 2016; 117:223-9. [PMID: 27492535 DOI: 10.1016/j.rmed.2016.06.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 12/11/2022]
Abstract
RATIONALE Long-term prognosis of adult-onset asthma is poorly known. OBJECTIVE To evaluate 12-year prognosis of adult-onset asthma and the factors associated with disease prognosis. METHODS Seinäjoki Adult-onset Asthma Study (SAAS) is a 12-year real-life single-center follow-up study of new-onset asthma diagnosed at adult age and treated in primary and specialized care. Remission was defined by no symptoms and no asthma medication use for 6 months. Asthma control was evaluated according to Global Initiative for Asthma 2010. Factors associated with current asthma control were analyzed by multinomial multivariate logistic regression. MAIN RESULTS A total of 203 patients (79% of the baseline population) were followed for 12 years. Remission occurred in 6 (3%) patients. In 34% asthma was controlled, in 36% it was partially controlled and in 30% uncontrolled. Uncontrolled asthma was predicted by elevated body-mass index at baseline, smoking (pack-years) and current allergic or persistent rhinitis. Elevated blood eosinophils and good lung function (FEV1) at baseline protected from uncontrolled asthma. In contrast, gender, age at the onset or baseline symptoms (Airways Questionnaire 20) were not significant predictors of uncontrolled disease. CONCLUSIONS During a 12-year follow-up, remission of adult-onset asthma was rare occurring in only 3% of patients. The majority of patients (66%) presented either with uncontrolled or partially controlled asthma. This study is registered at ClinicalTrials.gov with identifier number NCT02733016.
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Affiliation(s)
- Leena E Tuomisto
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Pinja Ilmarinen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Onni Niemelä
- Department of Laboratory Medicine and Medical Research Unit, Seinäjoki Central Hospital and University of Tampere, Finland
| | - Jussi Haanpää
- Department of Clinical Physiology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | | | - Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland; Department of Respiratory Medicine, University of Tampere, Tampere, Finland
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21
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Gray EL, Chang V, Thomas PS. Fluticasone furoate and vilanterol trifenatate combination therapy for the treatment of asthma. Expert Rev Respir Med 2016; 10:839-47. [PMID: 27221165 DOI: 10.1080/17476348.2016.1192465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Combination inhaled corticosteroids (ICS) and long acting β2-adrenergic agonists (LABA) are used in a stepwise fashion for patients whose asthma is not controlled by low dose ICS alone. Adherence is one of the main issues facing clinicians in the control of asthma symptoms with currently available combination inhalers requiring twice-daily (BD) inhalation. Fluticasone furoate (FF) and vilanterol trifenatate (VI) both have prolonged retention in the lung with effects on lung function over 24-hours and as such the combination has been proposed for once-daily (OD) dosing. AREAS COVERED The stepwise pharmacologic approach to asthma management is addressed, followed by a detailed assessment of the literature pertaining to the efficacy, tolerability and safety of FF/VI combination therapy for the treatment of asthma. Expert commentary: Doses of 100/25µg and 200/25µg inhaled OD, have similar improvements in lung function, asthma control as well as rates of side effects to one of the currently available BD ICS/LABA combinations, fluticasone propionate and salmeterol (FP/SAL) but have not been compared with other commonly used combinations. It is hoped that OD dosage of FF/VI can improve adherence and hence asthma control in these patients, however evidence to support this has yet to become available.
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Affiliation(s)
- Emma L Gray
- a Department of Respiratory Medicine , Prince of Wales Hospital , Randwick , Australia
| | - Vicky Chang
- a Department of Respiratory Medicine , Prince of Wales Hospital , Randwick , Australia
| | - Paul S Thomas
- a Department of Respiratory Medicine , Prince of Wales Hospital , Randwick , Australia.,b Inflammation and Infection Research Centre, School of Medical Sciences , University of New South Wales , Randwick , Australia
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22
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Kankaanranta H, Kauppi P, Tuomisto LE, Ilmarinen P. Emerging Comorbidities in Adult Asthma: Risks, Clinical Associations, and Mechanisms. Mediators Inflamm 2016; 2016:3690628. [PMID: 27212806 PMCID: PMC4861800 DOI: 10.1155/2016/3690628] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 01/07/2023] Open
Abstract
Asthma is a heterogeneous disease with many phenotypes, and age at disease onset is an important factor in separating the phenotypes. Most studies with asthma have been performed in patients being otherwise healthy. However, in real life, comorbid diseases are very common in adult patients. We review here the emerging comorbid conditions to asthma such as obesity, metabolic syndrome, diabetes mellitus type 2 (DM2), and cardiac and psychiatric diseases. Their role as risk factors for incident asthma and whether they affect clinical asthma are evaluated. Obesity, independently or as a part of metabolic syndrome, DM2, and depression are risk factors for incident asthma. In contrast, the effects of comorbidities on clinical asthma are less well-known and mostly studies are lacking. Cross-sectional studies in obese asthmatics suggest that they may have less well controlled asthma and worse lung function. However, no long-term clinical follow-up studies with these comorbidities and asthma were identified. These emerging comorbidities often occur in the same multimorbid adult patient and may have in common metabolic pathways and inflammatory or other alterations such as early life exposures, systemic inflammation, inflammasome, adipokines, hyperglycemia, hyperinsulinemia, lung mechanics, mitochondrial dysfunction, disturbed nitric oxide metabolism, and leukotrienes.
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Affiliation(s)
- Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central Hospital, 60220 Seinäjoki, Finland
- Department of Respiratory Medicine, University of Tampere, 33521 Tampere, Finland
| | - Paula Kauppi
- Department of Respiratory Medicine and Allergology, Skin and Allergy Hospital, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland
| | - Leena E. Tuomisto
- Department of Respiratory Medicine, Seinäjoki Central Hospital, 60220 Seinäjoki, Finland
| | - Pinja Ilmarinen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, 60220 Seinäjoki, Finland
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Al-Moamary MS, Alhaider SA, Idrees MM, Al Ghobain MO, Zeitouni MO, Al-Harbi AS, Yousef AA, Al-Matar H, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2016; 11:3-42. [PMID: 26933455 PMCID: PMC4748613 DOI: 10.4103/1817-1737.173196] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Mohamed S. Al-Moamary
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Pulmonary Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, University of Dammam, Dammam, Saudi Arabia
| | - Hussain Al-Matar
- Department of Medicine, Imam Abdulrahman Al Faisal Hospital, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Medicine, Respiratory Division, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Abstract
PURPOSE OF REVIEW To review the pharmacological considerations and rationale for treating small-airway disease in asthma via the inhaled and systemic route, and to also directly address the comparison between small vs. large aerosol particles in the management of asthmatic patients. RECENT FINDINGS Airway inflammation in patients with asthma is predominantly present within the small airways and this region is the main contributor to airflow limitation. Assessing small-airway dysfunction has advanced in the last decade, allowing us to compare this region in disease to health and also in response to treatment. Recent pharmaceutical developments have led to inhaler devices with smaller aerosols and systemic biologic treatments, enabling therapeutic drug delivery to the distal lung regions. The question therefore is does targeting the small airways directly translate into health benefits for asthmatic patients with respect to an improvement in their disease control and quality of life? SUMMARY Studies now show that treating the peripheral airways with smaller drug particle aerosols certainly achieve comparable efficacy (and some studies show superiority) compared with large particles, a reduction in the daily inhaled corticosteroid dose, and greater asthma control and quality of life in real-life studies. Hence, the small airways should not be neglected when choosing the optimal asthma therapy.
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Seinäjoki Adult Asthma Study (SAAS): a protocol for a 12-year real-life follow-up study of new-onset asthma diagnosed at adult age and treated in primary and specialised care. NPJ Prim Care Respir Med 2015; 25:15042. [PMID: 26110580 PMCID: PMC4480212 DOI: 10.1038/npjpcrm.2015.42] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 04/29/2015] [Accepted: 05/12/2015] [Indexed: 12/25/2022] Open
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Tuomisto LE, Ilmarinen P, Kankaanranta H. Prognosis of new-onset asthma diagnosed at adult age. Respir Med 2015; 109:944-54. [PMID: 26052036 DOI: 10.1016/j.rmed.2015.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 04/24/2015] [Accepted: 05/05/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Asthma is a common chronic disease, which can affect patients at any age. Recently, cluster analyses have suggested that patients with asthma can be divided into different phenotypes and that the age at the onset of the disease is a critical defining factor. The prognosis of allergic childhood-onset asthma is relatively well known, whereas the prognosis of adult-onset asthma remains unclear. METHODS We undertook a systematic review to identify studies that evaluated the long-term prognosis of new-onset asthma diagnosed at adult age. Criteria used (set 1) were: 1. adult-onset asthma, 2. physician diagnosed asthma (including objective lung-functions) < 1 year before the first visit, 3. follow-up time of at least 5 years, 4. objective lung function measurements used at follow-up and 5. not a comparative trial. Another set of studies (set 2) with less strict criteria were gathered. RESULTS The main result of this systematic review is that the amount of evidence on the prognosis of new-onset asthma diagnosed at adult age is very limited. Only one study (n = 250) fulfilled the criteria (set 1) and it suggests that the five-year prognosis of new-onset asthma diagnosed at adult age may not be favorable, the proportion of patients being in remission was less than 5%. Furthermore, six additional follow-up studies (n = 964) were identified including mainly patients with adult-onset asthma (set 2). These studies had variable endpoints and the results could not be combined. CONCLUSION Further follow-up studies that recruit patients with new-onset adult asthma are needed to understand the prognostic factors in adult-onset asthma.
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Affiliation(s)
- Leena E Tuomisto
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Pinja Ilmarinen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland; Department of Respiratory Medicine, University of Tampere, Tampere, Finland
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Kankaanranta H, Harju T, Kilpeläinen M, Mazur W, Lehto JT, Katajisto M, Peisa T, Meinander T, Lehtimäki L. Diagnosis and pharmacotherapy of stable chronic obstructive pulmonary disease: the finnish guidelines. Basic Clin Pharmacol Toxicol 2015; 116:291-307. [PMID: 25515181 PMCID: PMC4409821 DOI: 10.1111/bcpt.12366] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 12/07/2014] [Indexed: 12/18/2022]
Abstract
The Finnish Medical Society Duodecim initiated and managed the update of the Finnish national guideline for chronic obstructive pulmonary disease (COPD). The Finnish COPD guideline was revised to acknowledge the progress in diagnosis and management of COPD. This Finnish COPD guideline in English language is a part of the original guideline and focuses on the diagnosis, assessment and pharmacotherapy of stable COPD. It is intended to be used mainly in primary health care but not forgetting respiratory specialists and other healthcare workers. The new recommendations and statements are based on the best evidence available from the medical literature, other published national guidelines and the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. This guideline introduces the diagnostic approach, differential diagnostics towards asthma, assessment and treatment strategy to control symptoms and to prevent exacerbations. The pharmacotherapy is based on the symptoms and a clinical phenotype of the individual patient. The guideline defines three clinically relevant phenotypes including the low and high exacerbation risk phenotypes and the neglected asthma-COPD overlap syndrome (ACOS). These clinical phenotypes can help clinicians to identify patients that respond to specific pharmacological interventions. For the low exacerbation risk phenotype, pharmacotherapy with short-acting β2 -agonists (salbutamol, terbutaline) or anticholinergics (ipratropium) or their combination (fenoterol-ipratropium) is recommended in patients with less symptoms. If short-acting bronchodilators are not enough to control symptoms, a long-acting β2 -agonist (formoterol, indacaterol, olodaterol or salmeterol) or a long-acting anticholinergic (muscarinic receptor antagonists; aclidinium, glycopyrronium, tiotropium, umeclidinium) or their combination is recommended. For the high exacerbation risk phenotype, pharmacotherapy with a long-acting anticholinergic or a fixed combination of an inhaled glucocorticoid and a long-acting β2 -agonist (budesonide-formoterol, beclomethasone dipropionate-formoterol, fluticasone propionate-salmeterol or fluticasone furoate-vilanterol) is recommended as a first choice. Other treatment options for this phenotype include combination of long-acting bronchodilators given from separate inhalers or as a fixed combination (glycopyrronium-indacaterol or umeclidinium-vilanterol) or a triple combination of an inhaled glucocorticoid, a long-acting β2 -agonist and a long-acting anticholinergic. If the patient has severe-to-very severe COPD (FEV1 < 50% predicted), chronic bronchitis and frequent exacerbations despite long-acting bronchodilators, the pharmacotherapy may include also roflumilast. ACOS is a phenotype of COPD in which there are features that comply with both asthma and COPD. Patients belonging to this phenotype have usually been excluded from studies evaluating the effects of drugs both in asthma and in COPD. Thus, evidence-based recommendation of treatment cannot be given. The treatment should cover both diseases. Generally, the therapy should include at least inhaled glucocorticoids (beclomethasone dipropionate, budesonide, ciclesonide, fluticasone furoate, fluticasone propionate or mometasone) combined with a long-acting bronchodilator (β2 -agonist or anticholinergic or both).
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Affiliation(s)
- Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central HospitalSeinäjoki, Finland
- Department of Respiratory Medicine, University of TampereTampere, Finland
| | - Terttu Harju
- Department of Internal Medicine, Unit of Respiratory Medicine, Medical Research Center, Oulu University HospitalOulu, Finland
| | | | - Witold Mazur
- Heart and Lung Center, University of Helsinki and Helsinki University Central HospitalHelsinki, Finland
| | - Juho T Lehto
- Department of Palliative Medicine, University of TampereTampere, Finland
- Department of Oncology, Tampere University HospitalTampere, Finland
| | - Milla Katajisto
- Heart and Lung Center, University of Helsinki and Helsinki University Central HospitalHelsinki, Finland
| | | | - Tuula Meinander
- Finnish Medical Society DuodecimHelsinki, Finland
- Department of Internal Medicine, Tampere University HospitalTampere, Finland
| | - Lauri Lehtimäki
- Department of Respiratory Medicine, University of TampereTampere, Finland
- Allergy Centre, Tampere University HospitalTampere, Finland
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Fogli S, Stefanelli F, Martelli A, Daniele S, Testai L, Calderone V, Trincavelli ML, Martini C, Breschi MC. Protective effect of high-dose montelukast on salbutamol-induced homologous desensitisation in airway smooth muscle. Pulm Pharmacol Ther 2013; 26:693-9. [PMID: 23810957 DOI: 10.1016/j.pupt.2013.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 05/28/2013] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Abstract
Montelukast (MK) is a potent cysteinyl-leukotriene receptor antagonist that causes dose-related improvements in chronic asthma. We sought to determine whether MK was able to prevent salbutamol-induced tolerance in airway smooth muscle. Homologous β2-adrenoceptor desensitisation models were established in guinea-pigs and in human bronchial smooth muscle cells (BSMC) by chronic salbutamol administration. Characterisation tools included measurement of the response of tracheal smooth muscle tissues to salbutamol, analysis of gene expression and receptor trafficking, evaluation of intracellular cAMP levels and phosphodiesterase (PDE) activity in human bronchial smooth muscle cells. Salbutamol-induced β2-adrenoceptor desensitisation was characterised by β2-agonist hyporesponsiveness (-30%, p < 0.001) in desensitised tracheal smooth muscle, as compared to controls. MK, given intraperitoneally at 5 mg/kg/day for 6 consecutive days, completely restored tissue responsiveness to salbutamol. Prolonged salbutamol treatment significantly decreased cAMP synthesis, induced a complete removal of the β2-adrenoceptor from plasma membrane with a parallel increase in the cytosol and increased PDE4D5 gene transcription and PDE activity in human bronchial smooth muscle cells. In homologously desensitised BSMC, MK 30 μM for 24 h was able to prevent salbutamol subsensitivity and such an effect was associated with inhibition of salbutamol-induced PDE4 activity and restoration of membrane β2-adrenoceptor expression and function. These findings suggest the presence of a favourable interaction between MK and β2-adrenoceptor agonists that might improve the therapeutic index of bronchodilators in patients with chronic respiratory diseases.
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Affiliation(s)
- Stefano Fogli
- Department of Pharmacy, University of Pisa, 56126 Pisa, Italy.
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Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, Al-Matar H, Alorainy HS. The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2012; 7:175-204. [PMID: 23189095 PMCID: PMC3506098 DOI: 10.4103/1817-1737.102166] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 09/19/2012] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Mohamed S. Al-Moamary
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Respiratory Division, Department of Medicine, Medical College, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed O. Al-Ghobain
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Pulmonary Division, Department of Medicine, Military Hospital, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Military Hospital, Riyadh, Saudi Arabia
| | - Maha M. Al Dabbagh
- Department of Pediatrics, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Hussain Al-Matar
- Department of Medicine, Imam Abdulrahman Al Faisal, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Riemersma RA, Postma D, van der Molen T. Budesonide/formoterol maintenance and reliever therapy in primary care asthma management: effects on bronchial hyperresponsiveness and asthma control. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2012; 21:50-6. [PMID: 22015542 DOI: 10.4104/pcrj.2011.00090] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The management of asthma has changed since the introduction of budesonide/formoterol (Symbicort®) as both maintenance and reliever therapy (SMART). SMART and its effects on bronchial hyperresponsiveness (BHR) have not been studied in primary care. AIMS To compare the effects of SMART and guideline-driven usual care (UC) on BHR and clinical asthma severity in primary care practice. METHODS Patients with mild-to-moderate stable asthma were randomised to receive SMART treatment (n=54) (budesonide/formoterol 80/4.5 μg Turbuhaler®, two puffs once daily and extra inhalations as needed) or UC treatment (n=48) for 12 months. Diary data, Asthma Control Questionnaire scores, forced expiratory volume in 1 second (FEV1), and peak expiratory flow (PEF) measurements were collected during run-in and after 1, 3, 6, and 12 months of treatment. BHR, measured as the dose of histamine provoking a fall in FEV1 of 20% (PD20-histamine), was determined at randomisation and after 12 months. RESULTS One hundred and two patients with asthma participated in the study. The change in PD20-histamine during the study was not significantly different between the SMART and UC groups (p=0.26). The mean inhaled corticosteroid (ICS) dose was 326 μg beclomethasone dipropionate (BDP) equivalents/day (95% CI 254 to 399) with SMART, which was significantly lower (p<0.0001) than the mean ICS dose with UC treatment (798 μg BDP equivalents/day (95% CI 721 to 875). Morning and evening PEF values increased significantly with SMART treatment compared with UC; FEV1, symptoms and asthma control did not differ. CONCLUSIONS Despite a 59% lower dose of ICS, BHR and other clinical outcomes remained stable during SMART treatment while PEF values improved.
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Affiliation(s)
- Roland A Riemersma
- Department of General Practice, University Medical Center Groningen, Groningen, The Netherlands.
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Bellecoste V, Devouassoux G, Pacheco Y. [Montelukast in the treatment of mild to moderate persistent asthma]. Rev Mal Respir 2011; 28:706-29. [PMID: 21742233 DOI: 10.1016/j.rmr.2010.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 11/19/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Anti-inflammatory preventive treatment is recommended in cases of persistent asthma. Besides inhaled corticosteroids (ICS), which represent the mainstay of treatment, other therapeutic options are available, of which only antileukotrienes are approved for all age groups. BACKGROUND Given as a substitute of low-dose ICS, montelukast prevents exacerbations as efficiently and for a longer period than long-acting β2-agonists. Montelukast is as efficient as doubling the dose of ICS on asthma symptoms in cases of inadequate control with low-dose ICS. Combined with ICS, it can lead to better control of asthma and potentially to ICS sparing. CONCLUSIONS Given the efficacy, tolerance and long-term treatment compliance of montelukast in mild persistent asthma in adults and children, montelukast, given as a substitute or combined with ICS, could contribute to enhanced control of asthma, especially in children.
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Affiliation(s)
- V Bellecoste
- Service de pneumologie, centre hospitalier Lyon-Sud, HCL, pavillon médical, Pierre-Bénite cedex, France
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Cukic V, Lovre V, Dragisic D. Sleep disorders in patients with bronchial asthma. Mater Sociomed 2011; 23:235-7. [PMID: 23678304 PMCID: PMC3633408 DOI: 10.5455/msm.2011.23.235-237] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Accepted: 09/05/2011] [Indexed: 01/03/2023] Open
Abstract
Respiratory disturbances during sleep are recognized as extremely common disorders with important clinical consequences. Breathing disorders during sleep can result in broad range of clinical manifestations, the most prevalent of which are unrefreshing sleep, daytime sleepiness and fatigue, and cognitive impairmant. There is also evidence that respiratory-related sleep disturbances can contribute to several common cardiovascular and metabolic disorders, including systemic hypertension, cardiac dysfunction, and insulin-resistance. Correlations are found between asthma-related symptoms and sleep disturbances. Difficulties inducing sleep, sleep fragmentation on polysomnography, early morning awakenings and daytime sleepiness are more common in asthmatics compared with subjects without asthma. The "morning deep" in asthma is relevant for the characterization of asthma severity, and impact drugs' choices. Sleep and night control of asthma could be relevant to evaluate disease's control. Appropriate asthma control recovering is guarantor for better sleep quality in these patients and less clinical consequences of respiratory disturbances during sleep.
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Affiliation(s)
- Vesna Cukic
- Clinic for pulmonary diseases and tuberculosis "Podhrastovi", Clinical center, University of Sarajevo, Bosnia and Herzegovina
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Harada M, Hirota T, Jodo AI, Hitomi Y, Sakashita M, Tsunoda T, Miyagawa T, Doi S, Kameda M, Fujita K, Miyatake A, Enomoto T, Noguchi E, Masuko H, Sakamoto T, Hizawa N, Suzuki Y, Yoshihara S, Adachi M, Ebisawa M, Saito H, Matsumoto K, Nakajima T, Mathias RA, Rafaels N, Barnes KC, Himes BE, Duan QL, Tantisira KG, Weiss ST, Nakamura Y, Ziegler SF, Tamari M. Thymic stromal lymphopoietin gene promoter polymorphisms are associated with susceptibility to bronchial asthma. Am J Respir Cell Mol Biol 2010; 44:787-93. [PMID: 20656951 DOI: 10.1165/rcmb.2009-0418oc] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Thymic stromal lymphopoietin (TSLP) triggers dendritic cell--mediated T helper (Th) 2 inflammatory responses. A single-nucleotide polymorphism (SNP), rs3806933, in the promoter region of the TSLP gene creates a binding site for the transcription factor activating protein (AP)-1. The variant enhances AP-1 binding to the regulatory element, and increases the promoter--reporter activity of TSLP in response to polyinosinic-polycytidylic acid (poly[I:C]) stimulation in normal human bronchial epithelium (NHBE). We investigated whether polymorphisms including the SNP rs3806933 could affect the susceptibility to and clinical phenotypes of bronchial asthma. We selected three representative (i.e., Tag) SNPs and conducted association studies of the TSLP gene, using two independent populations (639 patients with childhood atopic asthma and 838 control subjects, and 641 patients with adult asthma and 376 control subjects, respectively). We further examined the effects of corticosteroids and a long-acting β(2)-agonist (salmeterol) on the expression levels of the TSLP gene in response to poly(I:C) in NHBE. We found that the promoter polymorphisms rs3806933 and rs2289276 were significantly associated with disease susceptibility in both childhood atopic and adult asthma. The functional SNP rs3806933 was associated with asthma (meta-analysis, P = 0.000056; odds ratio, 1.29; 95% confidence interval, 1.14-1.47). A genotype of rs2289278 was correlated with pulmonary function. Moreover, the induction of TSLP mRNA and protein expression induced by poly(I:C) in NHBE was synergistically impaired by a corticosteroid and salmeterol. TSLP variants are significantly associated with bronchial asthma and pulmonary function. Thus, TSLP may serve as a therapeutic target molecule for combination therapy.
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Affiliation(s)
- Michishige Harada
- Laboratory for Respiratory Diseases, Center for Genomic Medicine, Institute of Physical and Chemical Research, Kanagawa, Japan
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Barnes PJ. Inhaled Corticosteroids. Pharmaceuticals (Basel) 2010; 3:514-540. [PMID: 27713266 PMCID: PMC4033967 DOI: 10.3390/ph3030514] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 03/02/2010] [Indexed: 11/16/2022] Open
Abstract
Inhaled corticosteroids (ICS) are the most effective controllers of asthma. They suppress inflammation mainly by switching off multiple activated inflammatory genes through reversing histone acetylation via the recruitment of histone deacetylase 2 (HDAC2). Through suppression of airway inflammation ICS reduce airway hyperresponsiveness and control asthma symptoms. ICS are now first-line therapy for all patients with persistent asthma, controlling asthma symptoms and preventing exacerbations. Inhaled long-acting β₂-agonists added to ICS further improve asthma control and are commonly given as combination inhalers, which improve compliance and control asthma at lower doses of corticosteroids. By contrast, ICS provide much less clinical benefit in COPD and the inflammation is resistant to the action of corticosteroids. This appears to be due to a reduction in HDAC2 activity and expression as a result of oxidative stress. ICS are added to bronchodilators in patients with severe COPD to reduce exacerbations. ICS, which are absorbed from the lungs into the systemic circulation, have negligible systemic side effects at the doses most patients require, although the high doses used in COPD has some systemic side effects and increases the risk of developing pneumonia.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College, London, UK.
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Al-Moamary MS, Al-Hajjaj MS, Idrees MM, Zeitouni MO, Alanezi MO, Al-Jahdali HH, Al Dabbagh M. The Saudi Initiative for Asthma. Ann Thorac Med 2009; 4:216-33. [PMID: 19881170 PMCID: PMC2801049 DOI: 10.4103/1817-1737.56001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 09/02/2009] [Indexed: 12/04/2022] Open
Abstract
The Saudi Initiative for Asthma (SINA) provides up-to-date guidelines for healthcare workers managing patients with asthma. SINA was developed by a panel of Saudi experts with respectable academic backgrounds and long-standing experience in the field. SINA is founded on the latest available evidence, local literature, and knowledge of the current setting in Saudi Arabia. Emphasis is placed on understanding the epidemiology, pathophysiology, medications, and clinical presentation. SINA elaborates on the development of patient-doctor partnership, self-management, and control of precipitating factors. Approaches to asthma treatment in SINA are based on disease control by the utilization of Asthma Control Test for the initiation and adjustment of asthma treatment. This guideline is established for the treatment of asthma in both children and adults, with special attention to children 5 years and younger. It is expected that the implementation of these guidelines for treating asthma will lead to better asthma control and decrease patient utilization of the health care system.
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Affiliation(s)
- Mohamed S Al-Moamary
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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Harada M, Obara K, Hirota T, Yoshimoto T, Hitomi Y, Sakashita M, Doi S, Miyatake A, Fujita K, Enomoto T, Taniguchi M, Higashi N, Fukutomi Y, Nakanishi K, Nakamura Y, Tamari M. A functional polymorphism in IL-18 is associated with severity of bronchial asthma. Am J Respir Crit Care Med 2009; 180:1048-55. [PMID: 19745201 DOI: 10.1164/rccm.200905-0652oc] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE IL-18 is a unique cytokine that enhances innate immunity and both Th1- and Th2-driven immune responses. Recent murine and human genetic studies have shown its role in the pathogenesis of asthma. OBJECTIVES We conducted an association study in a Japanese population to discover variants of IL-18 that might have an effect on asthma susceptibility and/or progression and conducted functional analyses of the related variants. METHODS The IL-18 gene locus was resequenced in 48 human chromosomes. Asthma severity was determined according to the 2002 Global Initiative for Asthma Guidelines. Association and haplotype analyses were performed using 1,172 subjects. MEASUREMENTS AND MAIN RESULTS Although no polymorphisms differed significantly in frequency between the control and adult asthma groups, rs5744247 C>G was significantly associated with the severity of adult asthma (steps 1, 2 vs. steps 3, 4; P = 0.0034). We also found a positive association with a haplotype (P = 0.0026). By in vitro functional analyses, the rs5744247 variant was found to increase enhancer-reporter activity of the IL-18 gene in bronchial epithelial cells. Expression levels of IL-18 in response to LPS stimulation in monocytes were significantly greater in subjects homozygous for the susceptibility G allele at rs5744247 C>G. Furthermore, we found a significant correlation between the serum IL-18 level and the genotype of rs5744247 (P = 0.031). CONCLUSIONS Although the association results need to be replicated by other studies, IL-18 variants are significantly associated with asthma severity, and the rs5744247 variant reflects higher transcriptional activity and higher expression of IL-18 in LPS-stimulated monocytes and a higher serum IL-18 level.
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Affiliation(s)
- Michishige Harada
- Laboratory for Respiratory Diseases, Center for Genomic Medicine, Institute of Physical and Chemical Research (RIKEN, Tsurumi-ku, Yokohama, Kanagawa 230-0045, Japan
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Tamminen K, Laine J, Soini E, Martikainen J, Kankaanranta H. Cost-effectiveness analysis of budesonide/formoterol maintenance and reliever therapy versus fixed combination treatments for asthma in Finland*. Curr Med Res Opin 2008; 24:3453-61. [PMID: 19032127 DOI: 10.1185/03007990802567566] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Budesonide/formoterol maintenance and reliever therapy has shown its effectiveness as a treatment for moderate-to-severe asthma. OBJECTIVE To explore the cost-effectiveness of budesonide/formoterol maintenance and reliever therapy as compared to fixed combination therapies (budesonide/formoterol and salmeterol/fluticasone) with terbutaline as needed in the treatment of asthma in Finland. METHODS Patients without asthma exacerbations during a 6-month period were used as the effectiveness variable in the within-trial economic analysis. Finnish unit costs were applied to pooled resource use data, and multinomial cost-effectiveness plane and acceptability curves were formed based on bootstrapping. RESULTS Use of budesonide/formoterol maintenance and reliever therapy significantly reduced the rate of severe asthma exacerbations as compared with a fixed dose of budesonide/formoterol or salmeterol/fluticasone and terbutaline as needed. Total costs over 6 months were 496 euros per patient for those who used the budesonide/formoterol maintenance and reliever therapy treatment model, which was 78-101 euros lower than the cost of fixed combinations of salmeterol/fluticasone or budesonide/formoterol with terbutaline as needed. The results indicate that the budesonide/formoterol maintenance and reliever therapy achieves a high probability (> 93%) of cost effectiveness irrespective of willingness to pay level. CONCLUSIONS Budesonide/formoterol maintenance and reliever therapy may be considered in the treatment of moderate-to-severe asthma instead of conventional treatment with combination products in view of its good clinical efficacy and a high probability of cost-effectiveness in the Finnish setting. However, a cost-effectiveness analysis with a longer time horizon, more Finnish-specific data, and ICS + short/long-acting inhaled beta(2)-agonist as an additional comparator is still warranted.
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Perttunen H, Moilanen E, Zhang X, Barnes PJ, Kankaanranta H. Beta2-agonists potentiate corticosteroid-induced neutrophil survival. COPD 2008; 5:163-9. [PMID: 18568840 DOI: 10.1080/15412550802092969] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Neutrophils are considered to play a role in the pathogenesis of chronic obstructive pulmonary disease (COPD) and severe asthma. Recent guidelines recommend the use of a combination of inhaled corticosteroids (ICS) and long-acting beta2-agonists (LABA) in the treatment of COPD with exacerbations and asthma not adequately controlled by ICS alone. LABA have been proposed to have a synergistic effect with corticosteroids by activating glucocorticoid receptors. The aim of this study was to investigate the effect of beta2-agonists on the inhibitory effects of corticosteroids on human neutrophil apoptosis. In addition, the effects of beta2-agonists on spontaneous neutrophil apoptosis and on GM-CSF- and LTB4-afforded survival were also evaluated. Neutrophils were isolated from human blood under sterile conditions and cultured for 16 hours. Apoptosis was assessed by relative DNA fragmentation assay. Morphological analysis was used as a control method to confirm the occurrence of apoptosis. Salbutamol, formoterol and salmeterol prolonged the lifespan of budesonide- and fluticasone propionate-treated neutrophils by inhibiting apoptosis. Formoterol and salbutamol partly reversed the inhibitory effect of GM-CSF on neutrophil apoptosis. In contrast, the effects of beta(2)-agonists on spontaneous neutrophil apoptosis and on LTB(4)-afforded survival were negligible. beta2-agonists potentiate corticosteroid-induced neutrophil survival at clinically relevant drug concentrations. Whether these effects translate into clinically relevant changes in lung neutrophil numbers remains to be demonstrated.
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Affiliation(s)
- Heli Perttunen
- The Immunopharmacology Research Group, Medical School, University of Tampere and Research Unit, Tampere University Hospital, Tampere, Finland.
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Crameri R, Rhyner C. Impact of native, recombinant, and cross-reactive allergens on humoral and T-cell-mediated immune responses. Immunol Allergy Clin North Am 2007; 27:65-78. [PMID: 17276879 DOI: 10.1016/j.iac.2006.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Many native allergens have been purified to homogeneity from natural sources, and whole arrays of recombinant and cross-reactive allergens have been produced in large amounts as biologically active molecules. These allergens offer potent research tools to investigate humoral and T cell-mediated immune responses to allergens in healthy and allergic individuals, providing methods for verifying the responses in a reproducible and dose-dependent manner. Dissecting the immune responses to allergens at cellular and molecular levels provides models for studying the different aspects of T-cell activation and the development of immunologic memory and effector functions. A deep understanding of these mechanisms will fundamentally change the current practice of allergy diagnosis, treatment, and prevention.
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Affiliation(s)
- Reto Crameri
- Division of Molecular Allergology, Swiss Institute of Allergy and Asthma Research (SIAF), Obere Strasse 22, CH-7270 Davos, Switzerland.
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Lee HS, Lee HK, Kwon HJ, Kim JH, Rha YH, Kim JT, Kim YH, Lee HR, Pyun BY. Therapeutic comparison between low-dose sustained-release theophylline dry syrup and capsule in children with mild persistent asthma. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.3.284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hyun Seung Lee
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Seoul, Korea
| | - Hae Kyung Lee
- Department of Clinical Pathology, College of Medicine The Catholic University of Korea, Seoul, Korea
| | - Hi Jeong Kwon
- Department of Clinical Pathology, College of Medicine The Catholic University of Korea, Seoul, Korea
| | - Jeong Hee Kim
- Department of Pediatrics, College of Medicine, Inha University, Incheon, Korea
| | - Yeong Ho Rha
- Department of Pediatrics, College of Medicine, Kyunghee University, Seoul, Korea
| | - Jin Tack Kim
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Seoul, Korea
| | - Young Ho Kim
- Department of Pediatrics, College of Medicine, Hallym University, Seoul, Korea
| | - Hae Rhan Lee
- Department of Pediatrics, College of Medicine, Hallym University, Seoul, Korea
| | - Bok Yang Pyun
- Department of Pediatrics, College of Medicine, Soonchunhyang University, Seoul, Korea
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Raux Demay MC, Magny JP, Idrès N, Grimfeld A, Le Bouc Y. Use of the low-dose corticotropin stimulation test for the monitoring of children with asthma treated with inhaled corticosteroids. HORMONE RESEARCH 2006; 66:51-60. [PMID: 16714852 DOI: 10.1159/000093468] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Accepted: 03/24/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Subnormal hypothalamic-pituitary-adrenal (HPA) function and rare cases of adrenal crisis have been reported in asthmatic children treated with inhaled corticosteroids. We investigated subnormal HPA activity and followed up affected patients until recovery of normal HPA functions. STUDY DESIGN 100 children with persistent asthma underwent low-dose corticotropin testing, with the administration of 1 microg of 1-24 ACTH intravenously. Treatments were beclomethasone dipropionate as a metered-dose inhaler, n = 14, budesonide as a dry-powder inhaler, n = 16, fluticasone propionate as a metered-dose inhaler n = 31 or a dry-powder inhaler n = 39. The mean commercially labelled dose was 520 +/- 29 microg/day (mean +/- SEM, range: 160-1,000) and the equipotent dose (which compares the efficiency of these drugs for treating asthma and their responsibility for systemic effects) was 890 +/- 55 microg/day (range: 200-2,000). RESULTS The mean stimulated cortisol level +/- SEM (and range) of the patient was 482 +/- 12 (148-801), and that of 40 age-matched controls was 580 +/- 12.5 (439-726), (SD = 79). The result was subnormal (more than 2 SD below the mean of the controls) in28 of the 100 patients. One-four stepwise decreases of 10-100% in the daily equipotent doses received by the patients with abnormal low-dose corticotropin testing results led to normal results in subsequent low-dose corticotropin testing in 27 retested patients. The mean time interval between two tests was 5 months (range: 2-6 months) and the mean period required for normalization of the test was 13 months (range: 2-21). Only one case of asthma exacerbation and no adrenal crisis were observed over these periods. CONCLUSIONS Decreasing daily equipotent doses led to recovery of normal HPA function without asthma exacerbation. Thus, a revision of the doses of inhaled corticosteroids used in asthmatic children with a progressive decrease to the consensus-recommended doses should decrease the systemic effects of inhaled corticosteroids, while minimizing the risk of asthma exacerbation.
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Affiliation(s)
- M C Raux Demay
- Laboratoire d'Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau (APHP), Paris, France.
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Guerra A, Campillo NE, Páez JA. Glycopyrrolate combinations for the treatment of respiratory diseases. Expert Opin Ther Pat 2006. [DOI: 10.1517/13543776.16.5.723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Corticosteroids are the most effective anti-inflammatory therapy for asthma and other chronic inflammatory and immune diseases. Recently new insights have been gained into the molecular mechanisms whereby corticosteroids suppress inflammation. Inflammation is characterised by the increased expression of multiple inflammatory genes that are regulated by proinflammatory transcription factors, such as nuclear factor-kappaB and activator protein-1. These transcription factors bind to and activate coactivator molecules, which acetylate core histones and switch on gene transcription. Corticosteroids suppress the multiple inflammatory genes that are activated in asthmatic airways mainly by reversing histone acetylation of activated inflammatory genes through binding of glucocorticoid receptors to coactivators and recruitment of histone deacetylase-2 (HDAC2) to the activated inflammatory gene transcription complex. Activated glucocorticoid receptors also bind to recognition sites in the promoters of certain genes to activate their transcription, resulting in secretion of anti-inflammatory proteins, such as mitogen-activated protein kinase phosphatase, which inhibits MAP kinase signalling pathways. Glucocorticoid receptors may also interact with other recognition sites to inhibit transcription, for example of several genes linked to their side effects. In some patients with steroid-resistant asthma there are abnormalities in GR signalling pathways. In chronic obstructive pulmonary disease (COPD) patients and asthmatic patients who smoke HDAC2 is markedly impaired as a result of oxidative and nitrative stress so that inflammation is resistant to the anti-inflammatory effects of corticosteroids. Corticosteroids are likely to remain the mainstay of asthma therapy and new therapeutic strategies may reverse the corticosteroid insensitivity in COPD and severe asthma.
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Affiliation(s)
- Peter J Barnes
- Department of Thoracic Medicine, National Heart and Lung Institute, Imperial College, Dovehouse St, London SW3 6LY, UK.
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