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Tóth G, Golubova A, Falk A, Lind SB, Nicholas M, Lanekoff I. Interleukin-13 Treatment of Living Lung Tissue Model Alters the Metabolome and Proteome-A Nano-DESI MS Metabolomics and Shotgun Proteomics Study. Int J Mol Sci 2024; 25:5034. [PMID: 38732251 PMCID: PMC11084154 DOI: 10.3390/ijms25095034] [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: 03/06/2024] [Revised: 04/04/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Asthma is a chronic respiratory disease with one of the largest numbers of cases in the world; thus, constant investigation and technical development are needed to unravel the underlying biochemical mechanisms. In this study, we aimed to develop a nano-DESI MS method for the in vivo characterization of the cellular metabolome. Using air-liquid interface (ALI) cell layers, we studied the role of Interleukin-13 (IL-13) on differentiated lung epithelial cells acting as a lung tissue model. We demonstrate the feasibility of nano-DESI MS for the in vivo monitoring of basal-apical molecular transport, and the subsequent endogenous metabolic response, for the first time. Conserving the integrity of the ALI lung-cell layer enabled us to perform temporally resolved metabolomic characterization followed by "bottom-up" proteomics on the same population of cells. Metabolic remodeling was observed upon histamine and corticosteroid treatment of the IL-13-exposed lung cell monolayers, in correlation with alterations in the proteomic profile. This proof of principle study demonstrates the utility of in vivo nano-DESI MS for characterizing ALI tissue layers, and the new markers identified in our study provide a good starting point for future, larger-scale studies.
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Affiliation(s)
- Gábor Tóth
- Department of Chemistry—BMC, Uppsala University, 75237 Uppsala, Sweden
| | | | - Alexander Falk
- Department of Chemistry—BMC, Uppsala University, 75237 Uppsala, Sweden
| | | | | | - Ingela Lanekoff
- Department of Chemistry—BMC, Uppsala University, 75237 Uppsala, Sweden
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2
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Zeng X, Qing J, Li CM, Lu J, Yamawaki T, Hsu YH, Vander Lugt B, Hsu H, Busby J, McDowell PJ, Jackson DJ, Djukanovic R, Matthews JG, Arron JR, Bradding P, Brightling CE, Chaudhuri R, Choy DF, Cowan D, Fowler SJ, Hardman TC, Harrison T, Howarth P, Lordan J, Mansur AH, Menzies-Gow A, Pavord ID, Walker S, Woodcock A, Heaney LG. Blood transcriptomic signature in type-2 biomarker-low severe asthma and asthma control. J Allergy Clin Immunol 2023; 152:876-886. [PMID: 37315813 DOI: 10.1016/j.jaci.2023.05.023] [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: 10/31/2022] [Revised: 05/02/2023] [Accepted: 05/09/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Patients with type-2 (T2) cytokine-low severe asthma often have persistent symptoms despite suppression of T2 inflammation with corticosteroids. OBJECTIVES We sought to analyze whole blood transcriptome from 738 samples in T2-biomarker-high/-low patients with severe asthma to relate transcriptomic signatures to T2 biomarkers and asthma symptom scores. METHODS Bulk RNA-seq data were generated for blood samples (baseline, week 24, week 48) from 301 participants recruited to a randomized clinical trial of corticosteroid optimization in severe asthma. Unsupervised clustering, differential gene expression analysis, and pathway analysis were performed. Patients were grouped by T2-biomarker status and symptoms. Associations between clinical characteristics and differentially expressed genes (DEGs) associated with biomarker and symptom levels were investigated. RESULTS Unsupervised clustering identified 2 clusters; cluster 2 patients were blood eosinophil-low/symptom-high and more likely to be receiving oral corticosteroids (OCSs). Differential gene expression analysis of these clusters, with and without stratification for OCSs, identified 2960 and 4162 DEGs, respectively. Six hundred twenty-seven of 2960 genes remained after adjusting for OCSs by subtracting OCS signature genes. Pathway analysis identified dolichyl-diphosphooligosaccharide biosynthesis and assembly of RNA polymerase I complex as significantly enriched pathways. No stable DEGs were associated with high symptoms in T2-biomarker-low patients, but numerous associated with elevated T2 biomarkers, including 15 that were upregulated at all time points irrespective of symptom level. CONCLUSIONS OCSs have a considerable effect on whole blood transcriptome. Differential gene expression analysis demonstrates a clear T2-biomarker transcriptomic signature, but no signature was found in association with T2-biomarker-low patients, including those with a high symptom burden.
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Affiliation(s)
- Xue Zeng
- Amgen Research, Amgen, Inc, South San Francisco, Calif
| | - Jing Qing
- Amgen Research, Amgen, Inc, South San Francisco, Calif
| | - Chi-Ming Li
- Amgen Research, Amgen, Inc, South San Francisco, Calif
| | - Jiamiao Lu
- Amgen Research, Amgen, Inc, South San Francisco, Calif
| | | | | | | | - Hailing Hsu
- Amgen Research, Amgen, Inc, Thousand Oaks, Calif
| | - John Busby
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom
| | - P J McDowell
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom
| | - David J Jackson
- Guy's & St Thomas' NHS Trust and Department of Asthma, Allergy & Lung Biology, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, University of Southampton, NIHR Southampton Biomedical Research Centre, Southampton, United Kingdom
| | | | | | - Peter Bradding
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Christopher E Brightling
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Rekha Chaudhuri
- Gartnavel General Hospital, Glasgow, and University of Glasgow, Glasgow, United Kingdom
| | | | - D Cowan
- NHS Greater Glasgow and Clyde, Stobhill Hospital, Glasgow, United Kingdom
| | - S J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | | | - Tim Harrison
- Nottingham Respiratory NIHR Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom
| | - Peter Howarth
- School of Clinical and Experimental Sciences, University of Southampton, NIHR Southampton Biomedical Research Centre, Southampton, United Kingdom
| | - James Lordan
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - A H Mansur
- University of Birmingham and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Ian D Pavord
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
| | - Samantha Walker
- Asthma UK & British Lung Foundation Partnership, London, United Kingdom
| | - Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Liam G Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom.
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3
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Qiu Q, Zhang W, Liu K, Huang F, Su J, Deng L, He J, Lin Q, Luo L. Schisandrin A ameliorates airway inflammation in model of asthma by attenuating Th2 response. Eur J Pharmacol 2023:175850. [PMID: 37329976 DOI: 10.1016/j.ejphar.2023.175850] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/09/2023] [Accepted: 06/09/2023] [Indexed: 06/19/2023]
Abstract
Asthma is a persistent respiratory ailment that displays periodicity and is linked to the equilibrium of T cells. Several compounds obtained from Chinese herbal medicines display beneficial impacts on T cell regulation and the attenuation of inflammatory mediator synthesis. Schisandrin A, an active lignan derived from the Schisandra fruit, exhibits anti-inflammatory characteristics. In the present study, the network analysis conducted revealed that the nuclear factor-kappaB (NF-κB) signaling pathway is likely a prominent contributor to the anti-asthmatic effects of schisandrin A. In addition, it has been established that the inhibition of cyclooxygenase 2 (COX-2/PTGS2) is likely a significant factor in this process. The results of in vitro experiments have substantiated that schisandrin A can effectively lower the expression of COX-2 and inducible nitric oxide synthase (iNOS) in 16 HBE cells and RAW264.7 cells in a manner that is dependent on the dosage administered. It was able to effectively reduce the activation of the NF-κB signaling pathway while simultaneously improving the injury to the epithelial barrier function. Furthermore, an investigation utilizing immune infiltration as a metric revealed an inequity in Th1/Th2 cells and a surge in Th2 cytokines in asthma patients. In the OVA-induced asthma mice model, it was observed that schisandrin A treatment effectively suppressed inflammatory cell infiltration, reduced the Th2 cell ratio, inhibited mucus secretion, and prevented airway remodeling. To summarize, the administration of schisandrin A has been found to effectively alleviate the symptoms of asthma by impeding the production of inflammation, which includes reducing the Th2 cell ratio and improving the integrity of the epithelial barrier function. These findings offer valuable insights into the potential therapeutic applications of schisandrin A for the treatment of asthma.
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Affiliation(s)
- Qin Qiu
- Graduate School, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China
| | - Weizhen Zhang
- Department of Respiratory and Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdon, 51000, China
| | - Kangdi Liu
- The First Clinical College, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China
| | - Fangfang Huang
- Graduate School, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China
| | - Jiating Su
- The First Clinical College, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China
| | - Liyan Deng
- Graduate School, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China
| | - Jiake He
- The First Clinical College, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China
| | - Qianwen Lin
- Department of Pediatrics, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, 524023, China
| | - Lianxiang Luo
- The Marine Biomedical Research Institute, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China; The Marine Biomedical Research Institute of Guangdong Zhanjiang, Zhanjiang, Guangdong, 524023, China.
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Siddiqui S, Haf Davies E, Afshar M, Denlinger LC. Clinical Trial Design Innovations for Precision Medicine in Asthma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1426:395-412. [PMID: 37464130 DOI: 10.1007/978-3-031-32259-4_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Severe asthma is a spectrum disorder with numerous subsets, many of which are defined by clinical history and a general predisposition for T2 inflammation. Most of the approved therapies for severe asthma have required clinical trial designs with population enrichment for exacerbation frequency and/or elevation of blood eosinophils. Moving beyond this framework will require trial designs that increase efficiency for studying nondominant subsets and continue to improve upon biomarker signatures. In addition to reviewing the current literature on biomarker-informed trials for severe asthma, this chapter will also review the advantages of master protocols and adaptive design methods for establishing the efficacy of new interventions in prospectively defined subsets of patients. The incorporation of methods that allow for data collection outside of traditional study visits at academic centers, called remote decentralized trial design, is a growing trend that may increase diversity in study participation and allow for enhanced resiliency during the COVID-19 pandemic. Finally, reaching the goals of precision medicine in asthma will require increased emphasis on effectiveness studies. Recent advances in real-world data utilization from electronic health records are also discussed with a view toward pragmatic trial designs that could also incorporate the evaluation of biomarker signatures.
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Affiliation(s)
- Salman Siddiqui
- National Heart and Lung Institute, Imperial College, London, England, UK
| | | | - Majid Afshar
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Loren C Denlinger
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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McDowell PJ, Busby J, Hanratty CE, Djukanovic R, Woodcock A, Walker S, Hardman TC, Arron JR, Choy DF, Bradding P, Brightling CE, Chaudhuri R, Cowan D, Mansur AH, Fowler SJ, Diver SE, Howarth P, Lordan J, Menzies-Gow A, Harrison T, Robinson DS, Holweg CTJ, Matthews JG, Pavord ID, Heaney LG. Exacerbation Profile and Risk Factors in a Type-2-Low Enriched Severe Asthma Cohort: A Clinical Trial to Assess Asthma Exacerbation Phenotypes. Am J Respir Crit Care Med 2022; 206:545-553. [PMID: 35549845 PMCID: PMC9716911 DOI: 10.1164/rccm.202201-0129oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The past 25 years have seen huge progress in understanding of the pathobiology of type-2 (T2) asthma, identification of measurable biomarkers, and the emergence of novel monoclonal antibody treatments. Although present in a minority of patients with severe asthma, very little is known about the mechanisms underlying T2-low asthma, making it a significant unmet need in asthma research. Objectives: The objective of this study was to explore the differences between study exacerbators and nonexacerbators, to describe physiological changes at exacerbation in those who are T2HIGH and T2LOW at the time of exacerbation, and to evaluate the stability of inflammatory phenotypes when stable and at exacerbation. Methods: Exacerbation assessment was a prespecified secondary analysis of data from a 48-week, multicenter, randomized controlled clinical study comparing the use of biomarkers and symptoms to adjust steroid treatment in a T2-low severe asthma-enriched cohort. Participants were phenotyped as T2LOW (fractional exhaled nitric oxide ⩽ 20 ppb and blood eosinophil count ⩽ 150 cells/µl) or T2HIGH (fractional exhaled nitric oxide > 20 or blood eosinophil count > 150) at study enrollment and at each exacerbation. Here, we report the findings of the exacerbation analyses, including comparison of exacerbators and nonexacerbators, the physiological changes at exacerbation in those who had evidence of T2 biology at exacerbation versus those that did not, and the stability of inflammatory phenotypes when stable and at exacerbation. Measurements and Main Results: Of the 301 participants, 60.8% (183) had one or more self-reported exacerbations (total of 390). Exacerbators were more likely to be female, have a higher body mass index, and have more exacerbations requiring oral corticosteroid and unscheduled primary care attendances for exacerbations. At enrollment, 23.6% (71) were T2LOW and 76.4% (230) T2HIGH. The T2LOW group had more asthma primary care attendances, were more likely to have a previous admission to HDU (high dependency unit)/ICU and to be receiving maintenance oral corticosteroids. At exacerbation, the T2LOW events were indistinguishable from T2HIGH exacerbations in terms of lung function (mean fall in T2LOW FEV1, 200 [400] ml vs. T2HIGH 200 [300] ml; P = 0.93) and symptom increase (ACQ5: T2LOW, 1.4 [0.8] vs. T2HIGH, 1.3 [0.8]; P = 0.72), with no increase in T2 biomarkers from stable to exacerbation state in the T2LOW exacerbations. The inflammatory phenotype within individual patients was dynamic; inflammatory phenotype at study entry did not have a significant association with exacerbation phenotype. Conclusions: Asthma exacerbations demonstrating a T2LOW phenotype were physiologically and symptomatically similar to T2HIGH exacerbations. T2LOW asthma was an unstable phenotype, suggesting that exacerbation phenotyping should occur at the time of exacerbation. The clinically significant exacerbations in participants without evidence of T2 biology at the time of exacerbation highlight the unmet and pressing need to further understand the mechanisms at play in non-T2 asthma. Clinical trial registered with www.clinicaltrials.gov (NCT02717689).
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Affiliation(s)
- P. Jane McDowell
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - John Busby
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - Catherine E. Hanratty
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, University of Southampton, National Institute for Health and Care Research (NIHR) Southampton Biomedical Research Center, Southampton, United Kingdom
| | - Ashley Woodcock
- Manchester Academic Health Science Center and NIHR Manchester Biomedical Research Center, Manchester University Hospitals National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Samantha Walker
- Asthma UK and British Lung Foundation Partnership, London, United Kingdom
| | | | | | | | - Peter Bradding
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Chris E. Brightling
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Rekha Chaudhuri
- Gartnavel General Hospital, Glasgow and University of Glasgow, Glasgow, United Kingdom
| | - Douglas Cowan
- NHS Greater Glasgow and Clyde, Stobhill Hospital, Glasgow, United Kingdom
| | - Adel H. Mansur
- University of Birmingham and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Stephen J. Fowler
- Manchester Academic Health Science Center and NIHR Manchester Biomedical Research Center, Manchester University Hospitals National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Sarah E. Diver
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Peter Howarth
- School of Clinical and Experimental Sciences, University of Southampton, National Institute for Health and Care Research (NIHR) Southampton Biomedical Research Center, Southampton, United Kingdom
| | - James Lordan
- the Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew Menzies-Gow
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, the University of Manchester, Royal Brompton and Harefield Hospitals, London, United Kingdom
| | - Timothy Harrison
- Nottingham Respiratory NIHR Biomedical Research Center, University of Nottingham, Nottingham, United Kingdom
| | | | | | | | - Ian D. Pavord
- Oxford Respiratory NIHR Biomedical Research Center, Nuffield Department of Medicine, the University of Oxford, Oxford, United Kingdom
| | - Liam G. Heaney
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
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Keim-Malpass J, Malpass HC. Cost Utility of Bronchial Thermoplasty for Severe Asthma: Implications for Future Cost-Effectiveness Analyses Based on Phenotypic Heterogeneity. CLINICOECONOMICS AND OUTCOMES RESEARCH 2022; 14:427-437. [PMID: 35747136 PMCID: PMC9211745 DOI: 10.2147/ceor.s362530] [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] [Received: 02/24/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022] Open
Abstract
Background Asthma is a disease with tremendous phenotypic heterogeneity, and the patients who are most severely impacted by the disease are high utilizers of the United States healthcare system. In the past decade, there has been many advances in asthma therapy for those with severe disease, including the use of a procedure called bronchial thermoplasty (BT) and the use of biologic therapy for certain phenotypes, but questions remain regarding the long-term durability and cost effectiveness of these therapies. The purpose of this analysis was (1) to assess the cost utility of BT relative to usual care (base case) and (2) to assess the cost utility of BT relative to usual care plus biologic therapy (omalizumab) (scenario analysis) based on updated 10-year clinical trial outcomes. Methods A Markov cohort model was developed and used to estimate the cost utility of BT to estimate the costs and quality-of-life impact of BT versus the comparisons over a 10-year time frame using a limited societal perspective, which included both direct health utilization costs and indirect costs associated with missed days of work, among those with severe persistent asthma. Results In the base case and the scenario analysis, BT was the dominant treatment strategy compared to usual care alone and usual care plus biologic therapy. The net monetary benefit for BT was $483,555.49 over a 10-year time horizon. Conclusion Cost-utility models are central to policy decisions dictating coverage, and can be extended to inform the patient and provider, during clinical decision-making, of the relative trade-offs of therapy, assessing long-term clinical and cost outcomes. Phenotypic classification of severe asthma is central to patient management and should also be integrated into economic analysis frameworks, particularly as new biologic agents are developed that are specific to a phenotype. Despite a larger upfront cost of BT therapy, there is a durable clinical and economic benefit over time for those with severe asthma.
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Affiliation(s)
- Jessica Keim-Malpass
- University of Virginia School of Nursing, Charlottesville, VA, USA.,Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.,University of Virginia Center for Advanced Medical Analytics, Charlottesville, VA, USA
| | - H Charles Malpass
- Department of Pulmonary and Critical Care Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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Casale TB, Burnette A, Bourdin A, Howarth P, Hahn B, Stach-Klysh A, Khurana S. Oral corticosteroid-sparing effects of mepolizumab in severe eosinophilic asthma: evidence from randomized controlled trials and real-world studies. Ther Adv Respir Dis 2022; 16:17534666221107313. [PMID: 35972211 PMCID: PMC9386863 DOI: 10.1177/17534666221107313] [Citation(s) in RCA: 2] [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: 12/21/2021] [Accepted: 05/30/2022] [Indexed: 11/16/2022] Open
Abstract
Oral corticosteroids (OCS) have long been a mainstay of treatment for asthma exacerbations and chronic severe asthma. However, it is increasingly recognized that both long-term and short-term OCS use are directly associated with a wide range of serious adverse effects, and as such OCS-sparing treatment alternatives are now widely recommended for patients with severe asthma. While several international guidelines recommend these treatments, guidance on OCS tapering, and which patients are most likely to tolerate OCS reduction and/or discontinuation, is still lacking. Several biologics have demonstrated efficacy in patients with OCS-dependent asthma. One OCS-sparing treatment is the anti-interleukin-5 monoclonal antibody mepolizumab, which is approved for the treatment of severe eosinophilic asthma. In addition to improved exacerbation rates, asthma control, quality of life, and lung function among patients with severe eosinophilic asthma, mepolizumab also has an OCS-sparing effect, which has been demonstrated in randomized controlled trials and real-world studies. Both physicians and patients express concerns about the adverse effects of OCS, and additional data from the randomized, controlled SIRIUS trial (NCT01691508) highlight the high level of concern among patients regarding OCS-related burden. In this article, we discuss current guidance on OCS-sparing strategies for patients with severe asthma, provide a summary of the available evidence of the OCS-sparing effect of mepolizumab, and highlight patient and physician perspectives on the use of OCS and OCS-sparing treatments in severe asthma.
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Affiliation(s)
- Thomas B. Casale
- Division of Allergy and Immunology, University of South Florida, Tampa, FL, USA
| | - Autumn Burnette
- Division of Allergy and Immunology, Howard University Hospital, Washington, DC, USA
| | - Arnaud Bourdin
- Department of Respiratory Diseases, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | | | - Beth Hahn
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Alexandra Stach-Klysh
- US Medical Affairs, GlaxoSmithKline, 5 Moore Drive, Research Triangle Park, NC 27709-3398, USA
| | - Sandhya Khurana
- Mary Parkes Center for Asthma, Division of Pulmonary and Critical Care Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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8
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Zorampari C, Prakash A, Rehan HS, Gupta LK. Serum dipeptidyl peptidase-4 and eosinophil cationic protein levels in patients of bronchial asthma. Pulm Pharmacol Ther 2021; 72:102109. [PMID: 34979240 DOI: 10.1016/j.pupt.2021.102109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 11/08/2021] [Accepted: 12/27/2021] [Indexed: 12/19/2022]
Affiliation(s)
- C Zorampari
- Lady Hardinge Medical College & Smt. S.K. Hospital, New Delhi, 110 001, India
| | - Anupam Prakash
- Department of Pharmacology, Department of Medicine, India
| | - Harmeet S Rehan
- Lady Hardinge Medical College & Smt. S.K. Hospital, New Delhi, 110 001, India
| | - Lalit K Gupta
- Lady Hardinge Medical College & Smt. S.K. Hospital, New Delhi, 110 001, India.
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9
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Menzella F, Ghidoni G, Fontana M, Capobelli S, Livrieri F, Castagnetti C, Facciolongo N. The role of systemic corticosteroids in severe asthma and new evidence in their management and tapering. Expert Rev Clin Immunol 2021; 17:1283-1299. [PMID: 34761712 DOI: 10.1080/1744666x.2021.2004123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Based on the latest literature evidence, between 30% and 60% of adults with severe refractory asthma (SRA) are systemic corticosteroid (SCS) dependent. There are numerous therapeutic options in asthma, which are often not effective in severe forms. In these cases, SCS should be considered, but it is increasingly recognized that their regular use is often associated with significant and potentially serious adverse events. AREAS COVERED The aim of this article is to provide an update about the recent and significant literature on SCS and to establish their role in the management of SRA. We summarized the most important and recent evidence and we provided useful indications for clinicians. EXPERT OPINION There is now strong evidence supporting the increased risk of comorbidities and complications with long-term SCS therapies, regardless of the dose. New evidence on SCS tapering and withdrawal will allow to define protocols to address SCS management with greater safety and effectiveness, after starting efficient steroid-sparing strategies. In the next 5years, it will be necessary to implement corrective actions to address these unmet needs, to reduce the inappropriate use of SCS by maximizing the application of more innovative and effective therapies.
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Affiliation(s)
- Francesco Menzella
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Giulia Ghidoni
- University Hospital of Modena, 208968,Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Matteo Fontana
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Silvia Capobelli
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Francesco Livrieri
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Claudia Castagnetti
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Nicola Facciolongo
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
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10
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Busby J, Matthews JG, Chaudhuri R, Pavord ID, Hardman TC, Arron JR, Bradding P, Brightling CE, Choy DF, Cowan DC, Djukanovic R, Hanratty CE, Harrison TW, Holweg CT, Howarth PH, Fowler SJ, Lordan JL, Mansur AH, Menzies-Gow A, Niven RM, Robinson DS, Walker SM, Woodcock A, Heaney LG. Factors affecting adherence with treatment advice in a clinical trial of patients with severe asthma. Eur Respir J 2021; 59:13993003.00768-2021. [PMID: 34561291 PMCID: PMC9202483 DOI: 10.1183/13993003.00768-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/24/2021] [Indexed: 11/25/2022]
Abstract
Background Understanding why patients with severe asthma do not follow healthcare provider (HCP) advice to adjust treatment is critical to achieving personalised disease management. Methods We reviewed patient choice to follow HCP advice to adjust asthma treatment in a UK-based randomised, controlled, single-blind (study participant), multicentre, parallel group 48-week clinical study comparing biomarker-directed treatment adjustment with standard care in severe asthma. Results Of 1572 treatment advisories (291 participants), instructions were followed in 1377 cases (87.6%). Patients were more likely to follow advice to remain on treatment (96.7%) than to either reduce (70.3%) or increase (67.1%) their treatment, with 64% of patients following all treatment advice. Multivariate analysis associated belonging to an ethnic minority group (OR 3.10, 95% CI 1.68–5.73) and prior study medication changes (two or more changes: OR 2.77, 95% CI 1.51–5.10) with failure to follow treatment advice. In contrast, emergency room attendance in the prior year (OR 0.54, 95% CI 0.32–0.92) was associated with following treatment advice. The largest effect was seen with transition onto or off oral corticosteroids (OR 29.28, 95% CI 16.07–53.36) when compared with those requested to maintain treatment. Centre was also an important determinant regarding the likelihood of patients to follow treatment advice. Conclusions Belonging to an ethnic minority group and multiple prior treatment adjustments were associated with not following HCP treatment advice. Patients also responded differently to HCP advice across UK specialist centres. These findings have implications for the generalisability of models of care in severe asthma and require further focused studies. Belonging to a minority ethnic group, multiple prior medication changes, being treated at a specific clinical centre, introduction of systemic corticosteroids and increased asthma symptoms were associated with resistance to asthma treatment modificationhttps://bit.ly/3gYb66S
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Affiliation(s)
- John Busby
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | | | - Rekha Chaudhuri
- NHS Greater Glasgow and Clyde Health Board, Gartnavel General Hospital, and University of Glasgow, Glasgow, UK
| | - Ian D Pavord
- Nuffield Department of Medicine, Oxford Respiratory NIHR BRC, The University of Oxford, Oxford, UK
| | | | | | - Peter Bradding
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christopher E Brightling
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - David F Choy
- Genentech Inc., South San Francisco, California, USA
| | - Douglas C Cowan
- NHS Greater Glasgow and Clyde, Stobhill Hospital, Glasgow, UK
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, University of Southampton, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Catherine E Hanratty
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Tim W Harrison
- Nottingham Respiratory NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | | | - Peter H Howarth
- School of Clinical and Experimental Sciences, University of Southampton, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - James L Lordan
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Adel H Mansur
- University of Birmingham and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Robert M Niven
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | | | | | - Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Liam G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
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11
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Lee Y, Quoc QL, Park HS. Biomarkers for Severe Asthma: Lessons From Longitudinal Cohort Studies. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2021; 13:375-389. [PMID: 33733634 PMCID: PMC7984946 DOI: 10.4168/aair.2021.13.3.375] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 01/24/2021] [Indexed: 12/16/2022]
Abstract
Severe asthma (SA) is a heterogeneous disease characterized by uncontrolled symptoms, frequent exacerbations, and lung function decline. The discovery of phenotypes and endotypes of SA significantly improves our understanding of its pathophysiology and allows the advent of biologics blocking multiple molecular targets. The advances have mainly been made in type 2-high asthma associated with elevated type 2 inflammatory biomarkers such as immunoglobulin E (IgE), interleukins (IL)-4, IL-5, and IL-13. Previous clinical trials have demonstrated that type 2 biomarkers, including blood/sputum eosinophils and the fraction of exhaled nitric oxide (FeNO), were correlated to severe airway inflammation, persistent symptoms, frequent exacerbations, and the clinical efficacy of these biomarkers in predicting treatment outcomes of type 2-targeting biologics. However, it is well known that type 2 inflammation is partially attributable to the pathogenesis of SA. Although some recent studies have suggested that type 2-low and mixed phenotypes of asthma are important contributors to the heterogeneity of SA, many questions about these non-type 2 asthma phenotypes remain to be solved. Consequently, many efforts to investigate and find novel biomarkers for SA have also made in their methods. Many cross-sectional experimental studies in large-scale cohorts and randomized clinical trials have proved their value in understanding SA. More recently, real-world cohort studies have been in the limelight for SA research, which is unbiased and expected to give us an answer to the unmet needs of the heterogeneity of SA.
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Affiliation(s)
- Youngsoo Lee
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Quang Luu Quoc
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
- Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
- Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea.
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12
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Boulet LP, Godbout K. Oral Corticosteroids Tapering in Severe Asthma. Am J Respir Crit Care Med 2021; 203:795-796. [PMID: 33211979 PMCID: PMC8017580 DOI: 10.1164/rccm.202010-4001ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - Krystelle Godbout
- Québec Heart and Lung Institute Laval University Quebec City, Quebec, Canada
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13
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Kolmert J, Gómez C, Balgoma D, Sjödin M, Bood J, Konradsen JR, Ericsson M, Thörngren JO, James A, Mikus M, Sousa AR, Riley JH, Bates S, Bakke PS, Pandis I, Caruso M, Chanez P, Fowler SJ, Geiser T, Howarth P, Horváth I, Krug N, Montuschi P, Sanak M, Behndig A, Shaw DE, Knowles RG, Holweg CTJ, Wheelock ÅM, Dahlén B, Nordlund B, Alving K, Hedlin G, Chung KF, Adcock IM, Sterk PJ, Djukanovic R, Dahlén SE, Wheelock CE. Urinary Leukotriene E 4 and Prostaglandin D 2 Metabolites Increase in Adult and Childhood Severe Asthma Characterized by Type 2 Inflammation. A Clinical Observational Study. Am J Respir Crit Care Med 2021; 203:37-53. [PMID: 32667261 PMCID: PMC7781128 DOI: 10.1164/rccm.201909-1869oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Rationale: New approaches are needed to guide personalized treatment of asthma.Objectives: To test if urinary eicosanoid metabolites can direct asthma phenotyping.Methods: Urinary metabolites of prostaglandins (PGs), cysteinyl leukotrienes (CysLTs), and isoprostanes were quantified in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Diseases Outcomes) study including 86 adults with mild-to-moderate asthma (MMA), 411 with severe asthma (SA), and 100 healthy control participants. Validation was performed internally in 302 participants with SA followed up after 12-18 months and externally in 95 adolescents with asthma.Measurement and Main Results: Metabolite concentrations in healthy control participants were unrelated to age, body mass index, and sex, except for the PGE2 pathway. Eicosanoid concentrations were generally greater in participants with MMA relative to healthy control participants, with further elevations in participants with SA. However, PGE2 metabolite concentrations were either the same or lower in male nonsmokers with asthma than in healthy control participants. Metabolite concentrations were unchanged in those with asthma who adhered to oral corticosteroid treatment as documented by urinary prednisolone detection, whereas those with SA treated with omalizumab had lower concentrations of LTE4 and the PGD2 metabolite 2,3-dinor-11β-PGF2α. High concentrations of LTE4 and PGD2 metabolites were associated with lower lung function and increased amounts of exhaled nitric oxide and eosinophil markers in blood, sputum, and urine in U-BIOPRED participants and in adolescents with asthma. These type 2 (T2) asthma associations were reproduced in the follow-up visit of the U-BIOPRED study and were found to be as sensitive to detect T2 inflammation as the established biomarkers.Conclusions: Monitoring of urinary eicosanoids can identify T2 asthma and introduces a new noninvasive approach for molecular phenotyping of adult and adolescent asthma.Clinical trial registered with www.clinicaltrials.gov (NCT01976767).
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Affiliation(s)
- Johan Kolmert
- The Institute of Environmental Medicine.,Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics.,The Center for Allergy Research
| | - Cristina Gómez
- The Institute of Environmental Medicine.,Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics.,The Center for Allergy Research
| | - David Balgoma
- The Institute of Environmental Medicine.,Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics.,The Center for Allergy Research
| | - Marcus Sjödin
- The Institute of Environmental Medicine.,Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics.,The Center for Allergy Research
| | - Johan Bood
- The Institute of Environmental Medicine.,The Center for Allergy Research.,Department of Women's and Children's Health, and
| | - Jon R Konradsen
- The Center for Allergy Research.,Respiratory Medicine Unit, Department of Medicine, Solna Campus, and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine and
| | - Magnus Ericsson
- Department of Clinical Pharmacology, Huddinge Campus, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - John-Olof Thörngren
- Department of Clinical Pharmacology, Huddinge Campus, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Anna James
- The Institute of Environmental Medicine.,The Center for Allergy Research
| | - Maria Mikus
- The Institute of Environmental Medicine.,The Center for Allergy Research
| | - Ana R Sousa
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - John H Riley
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Stewart Bates
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | | | - Ioannis Pandis
- Institute of Medicine, University of Bergen, Bergen, Norway
| | - Massimo Caruso
- National Heart and Lung Institute and Department of Computing & Data Science Institute, Imperial College London, London, United Kingdom.,Department of Clinical and Experimental Medicine and
| | - Pascal Chanez
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Stephen J Fowler
- Clinique des Bronches, Allergies et Sommeil, Aix Marseille Université, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Thomas Geiser
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, and Manchester Academic Health Science Centre and National Institute for Health Research Biomedical Research Centre, Manchester University Hospitals National Health Service Foundation Trust, Manchester, United Kingdom
| | - Peter Howarth
- Department of Pulmonary Medicine, University Hospital Bern, Bern, Switzerland
| | - Ildikó Horváth
- Faculty of Medicine, Southampton University, and National Institute for Health Research Southampton Respiratory Biomedical Research Center, University Hospital Southampton, Southampton, United Kingdom
| | - Norbert Krug
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Paolo Montuschi
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Marek Sanak
- Department of Pharmacology, Catholic University of the Sacred Heart, and Agostino Gemelli University Hospital Foundation, IRCCS, Rome, Italy
| | - Annelie Behndig
- Department of Internal Medicine, Medical College, Jagiellonian University, Cracow, Poland
| | - Dominick E Shaw
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Richard G Knowles
- Nottingham National Institute for Health Research Biomedical Research Centre, University of Nottingham, United Kingdom
| | - Cécile T J Holweg
- Knowles Consulting, Stevenage Bioscience Catalyst, Stevenage, United Kingdom
| | | | - Barbro Dahlén
- The Center for Allergy Research.,Department of Women's and Children's Health, and
| | - Björn Nordlund
- Respiratory Medicine Unit, Department of Medicine, Solna Campus, and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine and
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; and
| | - Gunilla Hedlin
- The Center for Allergy Research.,Respiratory Medicine Unit, Department of Medicine, Solna Campus, and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine and
| | - Kian Fan Chung
- Institute of Medicine, University of Bergen, Bergen, Norway
| | - Ian M Adcock
- Institute of Medicine, University of Bergen, Bergen, Norway
| | - Peter J Sterk
- Department of Respiratory Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Ratko Djukanovic
- Department of Pulmonary Medicine, University Hospital Bern, Bern, Switzerland
| | - Sven-Erik Dahlén
- The Institute of Environmental Medicine.,The Center for Allergy Research
| | - Craig E Wheelock
- Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics.,The Center for Allergy Research
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14
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Hinks TSC, Levine SJ, Brusselle GG. Treatment options in type-2 low asthma. Eur Respir J 2021; 57:13993003.00528-2020. [PMID: 32586877 DOI: 10.1183/13993003.00528-2020] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022]
Abstract
Monoclonal antibodies targeting IgE or the type-2 cytokines interleukin (IL)-4, IL-5 and IL-13 are proving highly effective in reducing exacerbations and symptoms in people with severe allergic and eosinophilic asthma, respectively. However, these therapies are not appropriate for 30-50% of patients in severe asthma clinics who present with non-allergic, non-eosinophilic, "type-2 low" asthma. These patients constitute an important and common clinical asthma phenotype, driven by distinct, yet poorly understood pathobiological mechanisms. In this review we describe the heterogeneity and clinical characteristics of type-2 low asthma and summarise current knowledge on the underlying pathobiological mechanisms, which includes neutrophilic airway inflammation often associated with smoking, obesity and occupational exposures and may be driven by persistent bacterial infections and by activation of a recently described IL-6 pathway. We review the evidence base underlying existing treatment options for specific treatable traits that can be identified and addressed. We focus particularly on severe asthma as opposed to difficult-to-treat asthma, on emerging data on the identification of airway bacterial infection, on the increasing evidence base for the use of long-term low-dose macrolides, a critical appraisal of bronchial thermoplasty, and evidence for the use of biologics in type-2 low disease. Finally, we review ongoing research into other pathways including tumour necrosis factor, IL-17, resolvins, apolipoproteins, type I interferons, IL-6 and mast cells. We suggest that type-2 low disease frequently presents opportunities for identification and treatment of tractable clinical problems; it is currently a rapidly evolving field with potential for the development of novel targeted therapeutics.
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Affiliation(s)
- Timothy S C Hinks
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Nuffield Dept of Medicine, Experimental Medicine, University of Oxford, Oxford, UK
| | - Stewart J Levine
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Guy G Brusselle
- Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.,Depts of Epidemiology and Respiratory Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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15
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Heaney LG, Busby J, Hanratty CE, Djukanovic R, Woodcock A, Walker SM, Hardman TC, Arron JR, Choy DF, Bradding P, Brightling CE, Chaudhuri R, Cowan DC, Mansur AH, Fowler SJ, Niven RM, Howarth PH, Lordan JL, Menzies-Gow A, Harrison TW, Robinson DS, Holweg CTJ, Matthews JG, Pavord ID. Composite type-2 biomarker strategy versus a symptom-risk-based algorithm to adjust corticosteroid dose in patients with severe asthma: a multicentre, single-blind, parallel group, randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2020; 9:57-68. [PMID: 32916135 PMCID: PMC7783382 DOI: 10.1016/s2213-2600(20)30397-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Asthma treatment guidelines recommend increasing corticosteroid dose to control symptoms and reduce exacerbations. This approach is potentially flawed because symptomatic asthma can occur without corticosteroid responsive type-2 (T2)-driven eosinophilic inflammation, and inappropriately high-dose corticosteroid treatment might have little therapeutic benefit with increased risk of side-effects. We compared a biomarker strategy to adjust corticosteroid dose using a composite score of T2 biomarkers (fractional exhaled nitric oxide [FENO], blood eosinophils, and serum periostin) with a standardised symptom-risk-based algorithm (control). METHODS We did a single-blind, parallel group, randomised controlled trial in adults (18-80 years of age) with severe asthma (at treatment steps 4 and 5 of the Global Initiative for Asthma) and FENO of less than 45 parts per billion at 12 specialist severe asthma centres across England, Scotland, and Northern Ireland. Patients were randomly assigned (4:1) to either the biomarker strategy group or the control group by an online electronic case-report form, in blocks of ten, stratified by asthma control and use of rescue systemic steroids in the previous year. Patients were masked to study group allocation throughout the entirety of the study. Patients attended clinic every 8 weeks, with treatment adjustment following automated treatment-group-specific algorithms: those in the biomarker strategy group received a default advisory to maintain treatment and those in the control group had their treatment adjusted according to the steps indicated by the trial algorithm. The primary outcome was the proportion of patients with corticosteroid dose reduction at week 48, in the intention-to-treat (ITT) population. Secondary outcomes were inhaled corticosteroid (ICS) dose at the end of the study; cumulative dose of ICS during the study; proportion of patients on maintenance oral corticosteroids (OCS) at study end; rate of protocol-defined severe exacerbations per patient year; time to first severe exacerbation; number of hospital admissions for asthma; changes in lung function, Asthma Control Questionnaire-7 score, Asthma Quality of Life Questionnaire score, and T2 biomarkers from baseline to week 48; and whether patients declined to progress to OCS. A secondary aim of our study was to establish the proportion of patients with severe asthma in whom T2 biomarkers remained low when corticosteroid therapy was decreased to a minimum ICS dose. This study is registered with ClinicalTrials.gov, NCT02717689 and has been completed. FINDINGS Patients were recruited from Jan 8, 2016, to July 12, 2018. Of 549 patients assessed, 301 patients were included in the ITT population and were randomly assigned to the biomarker strategy group (n=240) or to the control group (n=61). 28·4% of patients in the biomarker strategy group were on a lower corticosteroid dose at week 48 compared with 18·5% of patients in the control group (adjusted odds ratio [aOR] 1·71 [95% CI 0·80-3·63]; p=0·17). In the per-protocol (PP) population (n=121), a significantly greater proportion of patients were on a lower corticosteroid dose at week 48 in the biomarker strategy group (30·7% of patients) compared with the control group (5·0% of patients; aOR 11·48 [95% CI 1·35-97·83]; p=0·026). Patient choice to not follow treatment advice was the principle reason for loss to PP analysis. There was no difference in secondary outcomes between study groups and no loss of asthma control among patients in the biomarker strategy group who reduced their corticosteroid dose. INTERPRETATION Biomarker-based corticosteroid adjustment did not result in a greater proportion of patients reducing corticosteroid dose versus control. Understanding the reasons for patients not following treatment advice in both treatment strategies is an important area for future research. The prevalence of T2 biomarker-low severe asthma was low. FUNDING This study was funded, in part, by the Medical Research Council UK.
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Affiliation(s)
- Liam G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK.
| | - John Busby
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Catherine E Hanratty
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, University of Southampton, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | | | | | | | | | - Peter Bradding
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christopher E Brightling
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Rekha Chaudhuri
- NHS Greater Glasgow and Clyde Health Board, Gartnavel Hospital, and University of Glasgow, Glasgow, UK
| | - Douglas C Cowan
- NHS Greater Glasgow and Clyde, Stobhill Hospital, Glasgow, UK
| | - Adel H Mansur
- University of Birmingham and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Robert M Niven
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Peter H Howarth
- School of Clinical and Experimental Sciences, University of Southampton, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - James L Lordan
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Tim W Harrison
- Nottingham Respiratory NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | | | | | | | - Ian D Pavord
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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16
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Ora J, Calzetta L, Matera MG, Cazzola M, Rogliani P. Advances with glucocorticoids in the treatment of asthma: state of the art. Expert Opin Pharmacother 2020; 21:2305-2316. [PMID: 32808828 DOI: 10.1080/14656566.2020.1807514] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Asthma is one of the most frequent chronic diseases all over the world. Glucocorticoids (GCs), both inhaled (ICSs) and oral (OCSs), are the most effective treatment in asthma because they control symptoms and prevent exacerbations. AREAS COVERED The present article reviews the new therapeutic indications of GCs for the treatment of asthma and focuses on new molecules and safety issues. EXPERT OPINION Most patients with asthma benefit from corticosteroid-based treatments. Side effects are mainly due to prolonged use of oral GCs, while they are minor with inhaled GCs. Interesting insights come from the new ICSs, which are characterized by lower oral bioavailability and higher lipophilicity and are more effective with less side effects. Recent trials have shown the efficacy of early use of ICSs in mild asthma. Furthermore, the possibility to prescribe targeted therapies using specific biomarkers in steroid-sensitive asthma can reduce doses and duration of treatment, while biological agents should be reserved for non-responding patients. All this evidence confirm the need to continue on the path toward precision medicine, in which the treatments are based on clinical and molecular traits.
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Affiliation(s)
- Josuel Ora
- Division of Respiratory Medicine, University Hospital "Policlinico Tor Vergata" , Rome, Italy
| | - Luigino Calzetta
- Department of Experimental Medicine, University of Rome Tor Vergata , Rome, Italy
| | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli , Naples, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome Tor Vergata , Rome, Italy
| | - Paola Rogliani
- Division of Respiratory Medicine, University Hospital "Policlinico Tor Vergata" , Rome, Italy.,Department of Experimental Medicine, University of Rome Tor Vergata , Rome, Italy
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17
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Menzies-Gow A, Mansur AH, Brightling CE. Clinical utility of fractional exhaled nitric oxide in severe asthma management. Eur Respir J 2020; 55:13993003.01633-2019. [PMID: 31949116 DOI: 10.1183/13993003.01633-2019] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/25/2019] [Indexed: 02/06/2023]
Abstract
Asthma is a chronic inflammatory disease of the airways, affecting over 350 million people worldwide and placing a significant burden on healthcare providers and wider society. Approximately 5-10% of asthma patients are diagnosed with severe asthma and typically are associated with increased risk of hospitalisation from exacerbations, increased morbidity, mortality and higher asthma-associated healthcare costs. Nitric oxide (NO) is an important regulator of immune responses and is a product of inflammation in the airways that is over-produced in asthma. Fractional exhaled NO (F eNO) is predominantly used as a predictor of response to inhaled corticosteroids (ICSs), to monitor adherence and as a diagnostic tool in ICS-naïve patients. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines recommend the use of F eNO for the initial diagnosis of patients with suspected asthma. In the USA, American Thoracic Society (ATS) guidelines recommend F eNO as part of the initial diagnosis of asthma and for monitoring of airway inflammation. F eNO has also been shown to be a predictive factor for asthma exacerbations, with higher levels being associated with a greater number of exacerbations. In addition, higher levels of F eNO have been shown to be associated with a decline in lung function. F eNO testing is a cost-effective procedure and has been shown to improve patient management when combined with standard assessment methods. Recent evidence suggests that F eNO may also be useful as a surrogate biomarker for the assessment and management of severe asthma and to predict responsiveness to some biological therapies.
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Affiliation(s)
| | - Adel H Mansur
- Dept of Respiratory Medicine, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Christopher E Brightling
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Dept of Respiratory Sciences, University of Leicester, Leicester, UK
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18
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Vähätalo I, Ilmarinen P, Tuomisto LE, Tommola M, Niemelä O, Lehtimäki L, Nieminen P, Kankaanranta H. 12-year adherence to inhaled corticosteroids in adult-onset asthma. ERJ Open Res 2020; 6:00324-2019. [PMID: 32211439 PMCID: PMC7086072 DOI: 10.1183/23120541.00324-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/06/2020] [Indexed: 11/14/2022] Open
Abstract
Adherence to inhaled corticosteroids (ICS) has been suggested to be poor but long-term follow-ups are lacking. The objective of the present study was to assess adherence to ICS treatment in patients with adult-onset asthma during 12-year follow-up. A total of 181 patients with clinically confirmed, new-onset adult asthma were followed for 12 years as part of the Seinäjoki Adult Asthma Study. Adherence to ICS was assessed individually as the percentage of true dispensed ICS in micrograms per true prescribed daily ICS in micrograms over 12 years. Mean 12-year adherence to ICS was 69% (mean±sd dispensed 2.5±1.8 g and prescribed 3.6±1.5 g budesonide equivalent per patient for 12 years), annual adherence varying between 81% (year 1) and 67% (year 12). Patients with good 12-year adherence (≥80%) used oral corticosteroids more often, and had add-on drugs in use and asthma-related visits to healthcare more often. In addition, they showed less reversibility in forced expiratory volume in 1 s and had higher peripheral blood neutrophil counts. However, lung function decline was steeper in patients with poorer adherence (<80%) and this association remained in multiple linear regression analysis. No difference was found in symptom scores, blood eosinophil counts, exhaled nitric oxide or immunoglobulin E between the patients with different levels of adherence. In patients with adult-onset asthma, adherence to ICS was moderate. Poorer adherence (<80%) to ICS was associated with more rapid decline in lung function but was not associated to symptoms or markers of inflammatory endotypes. Mean long-term adherence to ICS treatment is 69% in patients with confirmed adult-onset asthma. While good ICS adherence (≥80%) is associated with features of more severe asthma, poorer adherence (<80%) predicts more rapid lung function decline.http://bit.ly/37mvh74
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Affiliation(s)
- Iida Vähätalo
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Pinja Ilmarinen
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Leena E Tuomisto
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Minna Tommola
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Onni Niemelä
- Dept of Laboratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Pentti Nieminen
- Medical Informatics and Statistics Research Group, University of Oulu, Oulu, Finland
| | - Hannu Kankaanranta
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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19
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McDowell PJ, Heaney LG. Different endotypes and phenotypes drive the heterogeneity in severe asthma. Allergy 2020; 75:302-310. [PMID: 31267562 DOI: 10.1111/all.13966] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/05/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
The identification of sputum eosinophilia indicating corticosteroid responsiveness in subjects with severe asthma heralded the beginning of phenotyping asthmatic subjects based on airways inflammation. Since then, the heterogeneity of severe asthma has been explored and the importance of immunobiology has come sharply into focus with the identification of the key type-2 cytokine pathways driving eosinophilic inflammation. The development of molecules targeting these type-2 pathways has transformed severe asthma treatment, but necessitates robust clinical evaluation, biomarker profiling and assessment of comorbid factors to identify subjects most likely to benefit from these therapies. It has also become clear that targeting these pathways does not eradicate asthma symptoms and exacerbation risk; further work is needed to clarify underlying non-type-2 mechanisms in severe asthma pathways and possible therapeutic targets. This review addresses progress to date in clinical assessment and management of severe asthma and some of the challenges and unmet needs in severe asthma to achieve the goal of delivering individualized patient care.
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Affiliation(s)
- P. Jane McDowell
- Centre for Experimental Medicine Queen's University Belfast Belfast UK
| | - Liam G. Heaney
- Centre for Experimental Medicine Queen's University Belfast Belfast UK
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20
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Chung LP, Upham JW, Bardin PG, Hew M. Rational oral corticosteroid use in adult severe asthma: A narrative review. Respirology 2019; 25:161-172. [PMID: 31713955 PMCID: PMC7027745 DOI: 10.1111/resp.13730] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022]
Abstract
OCS play an important role in the management of asthma. However, steroid‐related AE are common and represent a leading cause of morbidity. Limited published studies suggest OCS usage varies across countries and recent registry data indicate that at least 25–60% of patients with severe asthma in developed countries may at some stage be prescribed OCS. Recent evidence indicate that many patients do not receive optimal therapy for asthma and are often prescribed maintenance OCS or repeated steroid bursts to treat exacerbations. Given the recent progress in adult severe asthma and new treatment options, judicious appraisal of steroid use is merited. A number of strategies and add‐on therapies are now available to treat severe asthma. These include increasing specialist referral for multidisciplinary assessments and implementing OCS‐sparing interventions, such as improving guideline adherence and add‐on tiotropium and macrolides. Biologics have recently become available for severe asthma; these agents reduce asthma exacerbations and lower OCS exposure. Further research, collaboration and consensus are necessary to develop a structured stewardship approach including realistic OCS‐weaning programmes for patients with severe asthma on regular OCS; education and public health campaigns to improve timely access to specialized severe asthma services for treatment optimization; and implementing targeted strategies to identify patients who warrant OCS use using objective biomarker‐based strategies.
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Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - John W Upham
- Department of Respiratory Medicine, Princess Alexandra Hospital and University of Queensland, Brisbane, QLD, Australia
| | - Philip G Bardin
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Hospital, Melbourne, VIC, Australia
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21
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Diamant Z, Vijverberg S, Alving K, Bakirtas A, Bjermer L, Custovic A, Dahlen S, Gaga M, Gerth van Wijk R, Del Giacco S, Hamelmann E, Heaney LG, Heffler E, Kalayci Ö, Kostikas K, Lutter R, Olin A, Sergejeva S, Simpson A, Sterk PJ, Tufvesson E, Agache I, Seys SF. Toward clinically applicable biomarkers for asthma: An EAACI position paper. Allergy 2019; 74:1835-1851. [PMID: 30953574 DOI: 10.1111/all.13806] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/17/2019] [Indexed: 12/13/2022]
Abstract
Inflammation, structural, and functional abnormalities within the airways are key features of asthma. Although these processes are well documented, their expression varies across the heterogeneous spectrum of asthma. Type 2 inflammatory responses are characterized by increased levels of eosinophils, FeNO, and type 2 cytokines in blood and/or airways. Presently, type 2 asthma is the best-defined endotype, typically found in patients with allergic asthma, but surprisingly also in nonallergic patients with (severe) asthma. The etiology of asthma with non-type 2 inflammation is less clear. During the past decade, targeted therapies, including biologicals and small molecules, have been increasingly integrated into treatment strategies of severe asthma. These treatments block specific inflammatory pathways or single mediators. Single or composite biomarkers help to identify patients who will benefit from these treatments. So far, only a few inflammatory biomarkers have been validated for clinical application. The European Academy of Allergy & Clinical Immunology Task Force on Biomarkers in Asthma was initiated to review different biomarker sampling methods and to investigate clinical applicability of new and existing inflammatory biomarkers (point-of-care) to support diagnosis, targeted treatment, and monitoring of severe asthma. Subsequently, we discuss existing and novel targeted therapies for asthma as well as applicable biomarkers.
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Affiliation(s)
- Zuzana Diamant
- Department of Respiratory Medicine and Allergology Institute for Clinical Science Skane University Hospital Lund Sweden
- Department of Clinical Pharmacy and Pharmacology UMCG and QPS‐NL Groningen The Netherlands
- Department of Respiratory Medicine First Faculty of Medicine Charles University and Thomayer Hospital Prague Czech Republic
| | - Susanne Vijverberg
- Department of Respiratory Medicine Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Kjell Alving
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Arzu Bakirtas
- Department of Pediatrics Division of Pediatric Allergy and Asthma Gazi University School of Medicine Ankara Turkey
| | - Leif Bjermer
- Department of Clinical Pharmacy and Pharmacology UMCG and QPS‐NL Groningen The Netherlands
| | - Adnan Custovic
- Section of Paediatrics Department of Medicine Imperial College London London UK
| | - Sven‐Erik Dahlen
- Experimental Asthma and Allergy Research Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Mina Gaga
- 7th Respiratory Medicine Department and Asthma Centre Athens Chest Hospital Athens Greece
| | - Roy Gerth van Wijk
- Section of Allergology Department of Internal Medicine Erasmus Medical Center Rotterdam the Netherlands
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - Eckard Hamelmann
- Children's Center Protestant Hospital Bethel Bielefeld Germany
- Allergy Center Ruhr University Bochum Bochum Germany
| | - Liam G. Heaney
- Centre for Experimental Medicine, School of MedicineDentistry and Biomedical Sciences, Queen's University Belfast Belfast UK
| | - Enrico Heffler
- Department of Biomedical Sciences Humanitas University Milan Italy
- Personalized Medicine, Asthma and Allergy Humanitas Research Hospital Milan Italy
| | - Ömer Kalayci
- Division of Pediatric Allergy Faculty of Medicine Hacettepe University Ankara Turkey
| | - Konstantinos Kostikas
- Respiratory Medicine Department University of Ioannina Medical School Ioannina Greece
| | - Rene Lutter
- Department of Respiratory Medicine Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Anna‐Carin Olin
- Section of Occupational and Environmental Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | | | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine Faculty of Biology, Medicine and Health Manchester Academic Health Sciences Centre University of Manchester and University Hospital of South Manchester NHS Foundation Trust Manchester UK
| | - Peter J. Sterk
- Department of Respiratory Medicine Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Ellen Tufvesson
- Department of Clinical Pharmacy and Pharmacology UMCG and QPS‐NL Groningen The Netherlands
| | - Ioana Agache
- Department of Allergy and Clinical Immunology Faculty of Medicine Transylvania University Brasov Brasov Romania
| | - Sven F. Seys
- Allergy and Clinical Immunology Research Group Department of Microbiology, Immunology and Transplantation KU Leuven Leuven Belgium
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22
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O'Byrne P, Fabbri LM, Pavord ID, Papi A, Petruzzelli S, Lange P. Asthma progression and mortality: the role of inhaled corticosteroids. Eur Respir J 2019; 54:1900491. [PMID: 31048346 PMCID: PMC6637285 DOI: 10.1183/13993003.00491-2019] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/24/2019] [Indexed: 01/22/2023]
Abstract
Overall, asthma mortality rates have declined dramatically in the last 30 years, due to improved diagnosis and to better treatment, particularly in the 1990s following the more widespread use of inhaled corticosteroids (ICSs). The impact of ICS on other long-term outcomes, such as lung function decline, is less certain, in part because the factors associated with these outcomes are incompletely understood. The purpose of this review is to evaluate the effect of pharmacological interventions, particularly ICS, on asthma progression and mortality. Furthermore, we review the potential mechanisms of action of pharmacotherapy on asthma progression and mortality, the effects of ICS on long-term changes in lung function, and the role of ICS in various asthma phenotypes.Overall, there is compelling evidence of the value of ICS in improving asthma control, as measured by improved symptoms, pulmonary function and reduced exacerbations. There is, however, less convincing evidence that ICS prevents the decline in pulmonary function that occurs in some, although not all, patients with asthma. Severe exacerbations are associated with a more rapid decline in pulmonary function, and by reducing the risk of severe exacerbations, it is likely that ICS will, at least partially, prevent this decline. Studies using administrative databases also support an important role for ICS in reducing asthma mortality, but the fact that asthma mortality is, fortunately, an uncommon event makes it highly improbable that this will be demonstrated in prospective trials.
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Affiliation(s)
- Paul O'Byrne
- Faculty of Health Sciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Leonardo M Fabbri
- Section of Cardiorespiratory and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
- COPD Center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Peter Lange
- Section of Epidemiology, Dept of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical Dept, Respiratory Section, Herlev and Gentofte Hospital, Herlev, Denmark
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23
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Ramsahai JM, Wark PA. Appropriate use of oral corticosteroids for severe asthma. Med J Aust 2019; 209:S18-S21. [PMID: 30453868 DOI: 10.5694/mja18.00134] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/25/2018] [Indexed: 12/21/2022]
Abstract
Severe asthma represents a significant burden of disease, particularly in high income nations; oral corticosteroids (OCS) remain an important part of the management toolkit for these patients. Corticosteroids are effective at targeting numerous elements of the type 2/eosinophilic inflammatory pathway and lead to both rapid reduction in eosinophilic inflammation and longer term reduction in airway hyper-responsiveness. Resistance or insensitivity to corticosteroids is a feature of severe asthma, with persistent type 2 inflammation often occurring despite regular use of OCS. OCS remain the only accepted, effective treatment for acute asthma, and also continue to play an important role in the long term management of severe asthma, in spite of their significant side effect profile. Even with the availability of the new biological therapies against IgE and interleukin-5, it is likely that a large proportion of patients will continue to require OCS to control their asthma. Future work should focus on optimising the balance between OCS efficacy and safety, and continued development of agents that allow reduction, or ideally discontinuation of their use, is needed.
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Affiliation(s)
- J Michael Ramsahai
- Centre for Healthy Lungs, Hunter Medical Research Institute University of Newcastle, Newcastle, NSW
| | - Peter Ab Wark
- Centre for Healthy Lungs, Hunter Medical Research Institute University of Newcastle, Newcastle, NSW
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24
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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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25
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Gallagher NE, Hanratty CE, Humbert M, Bel E, Djukanovic R, Hudson V, Amos N, Heaney LG. Biomarker-based corticosteroid adjustment in severe asthma: a modified Delphi consensus. ERJ Open Res 2018; 4:00081-2018. [PMID: 30538996 PMCID: PMC6284095 DOI: 10.1183/23120541.00081-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/22/2018] [Indexed: 11/05/2022] Open
Abstract
Asthma is managed using “step-wise” adjustment of corticosteroid therapy to achieve asthma control. When corticosteroid treatment is adjusted using sputum eosinophil count or exhaled nitric oxide fraction, exacerbations are reduced [1, 2]; however, implementation in clinical care has been slow. In parallel, airway transcriptomic analysis has demonstrated that type 2 eosinophilic inflammation is absent in many patients with minimal response to corticosteroid treatment [3–5]. The UK Refractory Asthma Stratification Programme (RASP-UK) (http://rasp.org.uk/) is exploring non-sputum biomarker-based strategies to target corticosteroid treatment in severe asthma [6, 7], and sought to determine clinician and patient views on clinically relevant reductions in corticosteroid treatment. UK asthma physicians are supportive of biomarker-based steroid adjustment, but European physicians need more evidencehttp://ow.ly/sTrf30my3jw
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Affiliation(s)
- Nicola E Gallagher
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Catherine E Hanratty
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Marc Humbert
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Elisabeth Bel
- Academic Medical Centre of the University of Amsterdam, Amsterdam, The Netherlands
| | - Ratko Djukanovic
- NIHR Southampton Biomedical Research Centre, Southampton, UK.,RASP-UK, London, UK
| | | | - Nile Amos
- Asthma UK RASP-UK Patient Input Platform, London, UK
| | - Liam G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK.,RASP-UK, London, UK
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