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Li H, Lin J, Zhang Q, Wang J, Li C. Domiciliary monitoring of exhaled nitric oxide in the management of asthma: a pilot study. BMC Pulm Med 2024; 24:244. [PMID: 38760654 PMCID: PMC11102187 DOI: 10.1186/s12890-024-03031-8] [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: 01/02/2024] [Accepted: 04/22/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Whether asthma patients could benefit from home monitoring for fractional exhaled nitric oxide (flow of 50 mL/s, FeNO50) is unknown. We explore the application value of home monitoring FeNO50 in daily asthma management. METHODS Twenty-two untreated, uncontrolled asthma patients were selected. Medical history, blood and sputum samples, pulmonary function, Asthma Control Test (ACT), and other clinical data of the subjects were collected. All subjects underwent daily monitoring for four weeks using a FeNO50 monitor and mobile spirometry (mSpirometry). The diurnal differences and dynamic changes were described. Compare the effect-acting time and the relative plateau of treatment between FeNO50 and mSpirometry monitoring. RESULTS In the first two weeks, the morning median (IQR) level of FeNO50 was 44 (35, 56) ppb, which was significantly higher than the evening median level [41 (32, 53) ppb, P = 0.028]. The median (IQR) effect-acting time assessed by FeNO50 was 4 (3, 5) days, which was significantly earlier than each measure of mSpirometry (P < 0.05). FeNO50 reached the relative plateau significantly earlier than FEV1 (15 ± 2 days vs. 21 ± 3 days, P < 0.001). After treatment, the daily and weekly variation rates of FeNO50 showed a gradually decreasing trend (P < 0.05). The ACT score, sputum eosinophils, and blood eosinophils also significantly improved (P ≤ 0.01). CONCLUSIONS The daily home monitoring of FeNO50 in asthmatic patients showed significant circadian rhythm, and the sensitivity of FeNO50 in evaluating the response to treatment was higher than mSpirometry. The daily and weekly variation rates of FeNO50 change dynamically with time, which may be used to assess the condition of asthma.
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Affiliation(s)
- Hongwen Li
- Department of Geriatric Respiratory Disease, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, China
| | - Jiangtao Lin
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
| | - Qing Zhang
- Department of Pulmonary and Critical Care Medicine, The first affiliated hospital of Nanchang University, Nanchang, China
| | - Jingru Wang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Chunxiao Li
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
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2
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Jang JH, Yang EM, Lee Y, Shin YS, Ye YM, Park HS. Diagnostic biomarkers for chronic rhinosinusitis in adult asthmatics in real-world practice. World Allergy Organ J 2024; 17:100879. [PMID: 38380106 PMCID: PMC10877182 DOI: 10.1016/j.waojou.2024.100879] [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: 07/31/2023] [Revised: 01/06/2024] [Accepted: 01/27/2024] [Indexed: 02/22/2024] Open
Abstract
Background Chronic rhinosinusitis (CRS) is a common comorbid condition of asthma that affects the long-term outcome of asthmatic patients. CRS is a heterogeneous disease requiring multiple biomarkers to explain its pathogenesis. This study aimed to develop potential biomarkers for predicting CRS in adult asthmatic patients in a real-world clinical setting. Methods This study enrolled 108 adult asthmatic patients who had maintained anti-asthmatic medications, including medium-to-high doses of inhaled corticosteroid plus long-acting β2-agonists, and compared clinical characteristics between patients with CRS (CRS group) and those without CRS (non-CRS group). CRS was diagnosed based on the results of paranasal sinus X-ray and/or osteomeatal-unit CT as well as clinical symptoms. Type-2 parameters, including blood eosinophil count, serum levels of periostin/dipeptidyl peptidase 10 (DPP10) and clinical parameters, such as FEV1% and fractional exhaled nitric oxide (FeNO), were analyzed. All biomarkers were evaluated by logistic regression and classification/regression tree (CRT) analyses. Results The CRS group had higher blood eosinophil counts/FeNO levels and prevalence of aspirin-exacerbated respiratory disease (AERD) than the non-CRS group (n = 57, 52.8% vs. n = 75, 47.2%; P < 0.05), but no differences in sex/smoking status or asthma control status were noted. The CRS group had higher serum periostin/DPP10 levels than the non-CRS group. Moreover, logistic regression demonstrated that serum periostin/DPP10 and the AERD phenotype were significant factors for predicting CRS in asthmatic patients (adjusted odds ratio, 2.14/1.94/12.39). A diagnostic algorithm and the optimal cutoff values determined by CRT analysis were able to predict CRS with 86.27% sensitivity (a 0.17 negative likelihood ratio). Conclusion Serum periostin, DPP10 and the phenotype of AERD are valuable biomarkers for predicting CRS in adult asthmatic patients in clinical practice.
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Affiliation(s)
- Jae-Hyuk Jang
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Eun-Mi Yang
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Youngsoo Lee
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Yoo Seob Shin
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Young-Min Ye
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hae-Sim Park
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Republic of Korea
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Lipworth B, Chan R. Domiciliary assessment of the type 2 inflammatory FeNO type. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1981. [PMID: 37295862 DOI: 10.1016/j.jaip.2023.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland, United Kingdom.
| | - Rory Chan
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland, United Kingdom
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4
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Tay TR, Yii A, Chan YH, Choo XN. Interval change in fractional exhaled nitric oxide (FENO) reflects short-term change in adherence following electronic inhaler reminders. J Asthma 2023:1-9. [PMID: 36647191 DOI: 10.1080/02770903.2023.2169931] [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: 01/18/2023]
Abstract
BACKGROUND In asthma, suppression of fractional exhaled nitric oxide (FENO) is a marker of adherence in the short-term. The usefulness of FENO to indicate change in adherence in the longer term is unknown. The aims of this study were to determine the relationship between changes in adherence and corresponding changes in FENO over short (1 week) and long-term (3 month) periods. METHODS After establishing initial ICS adherence using electronic inhaler monitor (EIM) devices, reminders were switched on for 1 week ('short-term') to optimize adherence. Reminders were then switched off and patients followed up after 3 months ('long-term'). FENO was measured at the start and end of each period. Using linear regression, we analyzed change in FENO in relation to change in adherence. RESULTS Forty-two patients contributed complete data for analysis. In the short-term, change in adherence was independently associated with change in FENO (β = -0.36, p = 0.036) even after adjusting for initial adherence and ICS dose. The higher the initial FENO, the greater the decline in FENO with improved adherence. This relationship between change in adherence and change in FENO was not observed in the long-term. CONCLUSION Change in adherence over 1 week following the use of EIM reminders independently predicted change in FENO. This relationship was not maintained at 3 months.
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Affiliation(s)
- Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Anthony Yii
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Xue Ning Choo
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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5
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Chan R, Duraikannu C, Lipworth B. Clinical Associations of Mucus Plugging in Moderate to Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:195-199.e2. [PMID: 36152990 DOI: 10.1016/j.jaip.2022.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Mucus plugging is recognized as a contributory factor to airway obstruction and symptoms in persistent asthma. OBJECTIVE We aimed to determine phenotypic associations of mucus plugging in patients with moderate to severe asthma in a real-life clinic setting. METHODS Mucus plugs (MPs) were identified by a thoracic radiologist upon high-resolution computed tomography imaging. A MP score was subsequently calculated and analyzed along with type 2 biomarkers, spirometry, severe exacerbations, and asthma control for 126 patients with moderate to severe asthma before biologic therapy. RESULTS Asthma patients with MP had significantly worse FEV1%, forced expiratory flow at 25% to 75% of FVC percent, and FEV1/FVC as well as higher levels of peripheral blood eosinophils, FeNO, total IgE, and Aspergillus fumigatus IgE titers, and had previously experienced more frequent severe exacerbations. FEV1/FVC, more than two exacerbations per year, blood eosinophils, total IgE, and A fumigatus IgE titers were associated with MPs after adjusting for confounders. CONCLUSIONS Poorly controlled asthma patients with MPs exhibited significantly worse airflow obstruction and greater type 2 inflammation associated with more frequent severe exacerbations. Impaired spirometry, more frequent exacerbations, raised blood eosinophils, total IgE, and A fumigatus IgE increased the likelihood of MPs.
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Affiliation(s)
- Rory Chan
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland, United Kingdom
| | - Chary Duraikannu
- Department of Radiology, Ninewells Hospital, Dundee Scotland, United Kingdom
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland, United Kingdom.
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6
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Newman B, Babiskin A, Bielski E, Boc S, Dhapare S, Fang L, Feibus K, Kaviratna A, Li BV, Luke MC, Ma T, Spagnola M, Walenga RL, Wang Z, Zhao L, El-Gendy N, Bertha CM, Abd El-Shafy M, Gaglani DK. Scientific and regulatory activities initiated by the U.S. Food and drug administration to foster approvals of generic dry powder inhalers: Bioequivalence perspective. Adv Drug Deliv Rev 2022; 190:114526. [PMID: 36067967 DOI: 10.1016/j.addr.2022.114526] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 01/24/2023]
Abstract
Regulatory science for generic dry powder inhalers (DPIs) in the United States (U.S.) has evolved over the last decade. In 2013, the U.S. Food and Drug Administration (FDA) published the draft product-specific guidance (PSG) for fluticasone propionate and salmeterol xinafoate inhalation powder. This was the first PSG for a DPI available in the U.S., which provided details on a weight-of-evidence approach for establishing bioequivalence (BE). A variety of research activities including in vivo and in vitro studies were used to support these recommendations, which have led to the first approval of a generic DPI in the U.S. for fluticasone propionate and salmeterol xinafoate inhalation powder in January of 2019. This review describes the scientific and regulatory activities that have been initiated by FDA to support the current BE recommendations for DPIs that led to the first generic DPI approvals, as well as research with novel in vitro and in silico methods that may potentially facilitate generic DPI development and approval.
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Affiliation(s)
- Bryan Newman
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Andrew Babiskin
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elizabeth Bielski
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Susan Boc
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sneha Dhapare
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lanyan Fang
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Katharine Feibus
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Anubhav Kaviratna
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bing V Li
- Office of Bioequivalence, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Markham C Luke
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Tian Ma
- Division of Bioequivalence I, Office of Bioequivalence, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Michael Spagnola
- Division of Clinical Safety and Surveillance, Office of Safety and Clinical Evaluation, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ross L Walenga
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA.
| | - Zhong Wang
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Liang Zhao
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nashwa El-Gendy
- Division of Immediate and Modified Release Drug Products III, Office of Lifecycle Drug Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Craig M Bertha
- Division of New Drug Products II, Office of New Drug Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mohammed Abd El-Shafy
- Division of Immediate and Modified Release Drug Products III, Office of Lifecycle Drug Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Dhaval K Gaglani
- Division of Immediate and Modified Release Drug Products III, Office of Lifecycle Drug Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Lake CD, Wong KKH, Perry CP, Koskela HO, Brannan JD. Daily Inhaled Corticosteroids Treatment Abolishes Airway Hyperresponsiveness to Mannitol in Defence and Police Recruits. FRONTIERS IN ALLERGY 2022; 3:864890. [PMID: 35769582 PMCID: PMC9234904 DOI: 10.3389/falgy.2022.864890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Airway hyperresponsiveness (AHR) is a key pathophysiological feature of asthma and causes exercise-induced bronchoconstriction (EIB). Indirect bronchial provocation tests (BPTs) (e.g., exercise, mannitol) aid to diagnose asthma and identify EIB. Daily inhaled corticosteroids (ICS) can abolish AHR caused by indirect stimuli. Where strenuous physical exertion is integral to an occupation, identification of those at risk of EIB is important and documentation of inhibition of AHR with ICS is required before recruitment. Methods/Objectives A retrospective analysis was performed on 155 potential recruits with AHR to mannitol who underwent follow-up assessment after daily ICS treatment to determine the proportion that can abolish AHR using ICS and to determine any predictors of the persistence of AHR. Results Airway hyperresponsiveness was abolished in the majority (84%, n = 130) over the treatment period (mean ± SD 143 ± 72days), and it was defined as the provoking dose of mannitol to cause a 15% fall in FEV1 (cumulative inhaled dose of mannitol to cause 15% fall in FEV1, PD15) improved from (GeoMean) 183 to 521 mg. Compared with recruits in whom AHR was abolished with daily ICS (i.e., no 15% fall in FEV1 to the maximum cumulative dose of mannitol of 635 mg), in those where AHR remained (16%, n = 25), baseline AHR was more severe (PD15: 85 mg vs. 213 mg, P < 0.001), baseline FEV1% was lower (89 vs. 96%; 95%CI:2–12, P=0.004), and they had a longer follow-up duration (180 vs. 136 days; 13–74, P = 0.006). Baseline FEV1% (adjusted odds ratio 0.85; 95%CI:0.77–0.93), FEV1/FVC (0.78; 0.67–0.90), FEF25−75% (1.15; 1.06–1.25), and airway reactivity to mannitol (%Fall/cumulative dose of mannitol multiplied by 100) (1.07; 1.03–1.11) predicted AHR remaining after daily ICS. Conclusion Airway hyperresponsiveness to mannitol can be abolished after 20 weeks of daily treatment with ICS. Inhibition of AHR is likely due to attenuation of airway inflammation in response to ICS treatment. Increased airway reactivity and lower spirometry variables predicted the persistence of AHR. Thus, those with a slower response to daily ICS on AHR can potentially be identified at the commencement of monitoring ICS using inhaled mannitol.
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Affiliation(s)
- Clair D. Lake
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Keith K. H. Wong
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - Clare P. Perry
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, NSW, Australia
| | - Heikki O. Koskela
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Sciences, University of Eastern Finland, Kuopio, Finland
| | - John D. Brannan
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- *Correspondence: John D. Brannan
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Loewenthal L, Menzies-Gow A. FeNO in Asthma. Semin Respir Crit Care Med 2022; 43:635-645. [DOI: 10.1055/s-0042-1743290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractAsthma is a common disease affecting 350 million people worldwide, which is characterized by airways inflammation and hyperreactivity. Historically diagnosis and treatment have been mainly based on symptoms, which have the potential to result in misdiagnosis and inappropriate treatment. Nitric oxide (NO) is exhaled in human breath and is a marker of airways inflammation. Levels of NO are increased in the exhaled breath of patients with type 2 asthma and fractional exhaled nitric oxide (FeNO) provides an objective biomarker of airway inflammation. FeNO testing is an accessible, noninvasive, and easy-to-use test. Cut-off values have been established by the American Thoracic Society (ATS), the Global Initiative for Asthma (GINA), and the National Institute for Health and Care Excellence (NICE) but vary between guidance. FeNO levels have been shown to be predictive of blood and sputum eosinophil levels but should not be used in isolation and current guidance emphasizes the importance of incorporating clinical symptoms and testing when utilizing FeNO results. The inclusion of FeNO testing can increase diagnostic accuracy of asthma, while high levels in asthmatic patients can help predict response to inhaled corticosteroids (ICS) and suppression of levels with ICS to monitor adherence. FeNO levels are also a predictor of asthma risk with increased exacerbation rates and accelerated decline in lung function associated with high levels as well as having an emerging role in predicting response to some biologic therapies in severe asthma. FeNO testing is cost-effective and has been shown, when combined with clinical assessment, to improve asthma management.
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Affiliation(s)
- Lola Loewenthal
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, United Kingdom
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Sverrild A, Leadbetter J, Porsbjerg C. The use of the mannitol test as an outcome measure in asthma intervention studies: a review and practical recommendations. Respir Res 2021; 22:287. [PMID: 34743708 PMCID: PMC8574016 DOI: 10.1186/s12931-021-01876-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The mannitol test is an indirect bronchial challenge test widely used in diagnosing asthma. Response to the mannitol test correlates with the level of eosinophilic and mast cell airway inflammation, and a positive mannitol test is highly predictive of a response to anti-inflammatory treatment with inhaled corticosteroids. The response to mannitol is a physiological biomarker that may, therefore, be used to assess the response to other anti-inflammatory treatments and may be of particular interest in early phase studies that require surrogate markers to predict a clinical response. The main objectives of this review were to assess the practical aspects of using mannitol as an endpoint in clinical trials and provide the clinical researcher and respiratory physician with recommendations when designing early clinical trials. METHODS The aim of this review was to summarise previous uses of the mannitol test as an outcome measure in clinical intervention studies. The PubMed database was searched using a combination of MeSH and keywords. Eligible studies included intervention or repeatability studies using the standard mannitol test, at multiple timepoints, reporting the use of PD15 as a measure, and published in English. RESULTS Of the 193 papers identified, 12 studies met the inclusion criteria and data from these are discussed in detail. Data on the mode of action, correlation with airway inflammation, its diagnostic properties, and repeatability have been summarised, and suggestions for the reporting of test results provided. Worked examples of power calculations for dimensioning study populations are presented for different types of study designs. Finally, interpretation and reporting of the change in the response to the mannitol test are discussed. CONCLUSIONS The mechanistic and practical features of the mannitol test make it a useful marker of disease, not only in clinical diagnoses, but also as an outcome measure in intervention trials. Measuring airway hyperresponsiveness to mannitol provides a novel and reproducible test for assessing efficacy in intervention trials, and importantly, utilises a test that links directly to underlying drivers of disease.
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Affiliation(s)
- Asger Sverrild
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen University, Ebba Lunds vej 48, 2400, Copenhagen, Denmark
| | | | - Celeste Porsbjerg
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen University, Ebba Lunds vej 48, 2400, Copenhagen, Denmark.
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10
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Uematsu M, Saito J, Sato S, Fukuhara A, Suzuki Y, Rikimaru M, Onuma T, Tomita H, Watanabe N, Saito M, Morimoto J, Kawamata T, Umeda T, Togawa R, Sato Y, Koizumi T, Hirai K, Minemura H, Nikaido T, Kanazawa K, Tanino Y, Munakata M, Shibata Y. Usefulness of diurnal variation of fractional exhaled nitric oxide for predicting early therapeutic response to asthma treatment. J Asthma 2021; 59:2039-2050. [PMID: 34550855 DOI: 10.1080/02770903.2021.1984524] [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: 10/20/2022]
Abstract
OBJECTIVE Fractional exhaled nitric oxide (FeNO) is considered to be an adjunct for asthma management, although its usefulness remains controversial. Therefore, it may be necessary for new approaches to use FeNO for asthma management. We evaluated whether diurnal variations of FeNO can predict response to asthma treatment. METHODS This pilot study consisted of 22 uncontrolled asthmatics and 16 healthy subjects. FeNO and peak expiratory flow (PEF) were measured by themselves twice daily at home for three weeks (asthmatics) or two weeks (healthy subjects), and daily mean and diurnal variations of FeNO and PEF levels were calculated. In uncontrolled asthmatics, treatment was intensified a week after study entry, and then control status was reevaluated after three to four weeks. Asthmatics were then divided into two groups; good or poor responders. RESULTS Diurnal variations of FeNO levels, as well as daily mean FeNO and PEF levels, in uncontrolled asthmatics before intensive treatment were significantly higher than those in healthy subjects, regardless of treatment response (p < 0.01). Furthermore, in the good responders, diurnal variations of FeNO levels were significantly decreased in the 1st week (p < 0.05) of intensive treatment, whereas the daily mean FeNO levels significantly dropped in the 2nd week (p < 0.05). In the poor responders, no such changes were observed in FeNO levels. In terms of PEF, only the daily mean levels were significantly elevated after the initiation of intensive treatment, regardless of treatment response. CONCLUSIONS Diurnal variations of FeNO may contribute to predicting early therapeutic response to asthma treatment.
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Affiliation(s)
- Manabu Uematsu
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Junpei Saito
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Suguru Sato
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Atsuro Fukuhara
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Yasuhito Suzuki
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Mami Rikimaru
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Takumi Onuma
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Hikaru Tomita
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Natsumi Watanabe
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Mikako Saito
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Julia Morimoto
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Takaya Kawamata
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Takashi Umeda
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Ryuichi Togawa
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Yuki Sato
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Tatsuhiko Koizumi
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Kenichiro Hirai
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Hiroyuki Minemura
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Takefumi Nikaido
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Kenya Kanazawa
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Yoshinori Tanino
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Mitsuru Munakata
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Yoko Shibata
- Department of Pulmonary Medicine, Fukushima Medical University, School of Medicine, Fukushima, Japan
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11
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Chan R, Lipworth B. Impact of nasal polyps on endotype and phenotype in patients with moderate to severe asthma. Ann Allergy Asthma Immunol 2021; 127:548-552. [PMID: 34153444 DOI: 10.1016/j.anai.2021.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/27/2021] [Accepted: 06/11/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Nasal polyps (NPs) are a common comorbidity of asthma. Differences in disease endotype and phenotype may have treatment implications for these concomitant conditions, including biologic therapies. OBJECTIVE To determine putative differences in type 2 biomarkers, lung function, and asthma control in patients with asthma with NPs (AwNPs) and those with asthma alone (A). METHODS A total of 140 consecutive patients with moderate to severe asthma with or without endoscopic NPs taking a daily inhaled corticosteroid dose of greater than or equal to 800 µg and at least 1 second-line controller were identified from our National Health Service specialist respiratory and rhinology clinics. Data were collected before starting on biologics, including peripheral blood eosinophils (PBEs), fractional exhaled nitric oxide (FeNO), allergy status, spirometry, impulse oscillometry, Asthma Control Questionnaire, oral corticosteroid requiring asthma exacerbations, NP score, and Lund-Mackay score. RESULTS The PBE count and FeNO levels were significantly higher (P < .01), whereas specific and total immunoglobulin E levels (P < .05) were significantly lower in AwNPs vs A. In addition, FeNO had sensitivity of 81% and specificity of 67% for detecting NPs (area under the curve = 0.76; P = .001). Patients with AwNPs had less severe asthma than those with asthma without NPs (A), as reflected by fewer exacerbations (P < .001), lower inhaled corticosteroid dose (P < .001), and less impairment of impulse oscillometry (P < .05). CONCLUSION Patients with moderate to severe asthma with NPs have higher levels of PBE and FeNO despite better asthma control and lower total and specific allergy than those without NPs.
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Affiliation(s)
- Rory Chan
- Scottish Centre for Respiratory Research, School of Medicine and Ninewells Hospital, University of Dundee, Dundee, Scotland, United Kingdom.
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, School of Medicine and Ninewells Hospital, University of Dundee, Dundee, Scotland, United Kingdom
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12
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Blais CM, Davis BE, Nair P, Cockcroft DW. Direct and indirect bronchoprovocation tests in dose-response studies of inhaled corticosteroids: Past, present, and future directions. Allergy 2021; 76:1679-1692. [PMID: 33185888 DOI: 10.1111/all.14658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/06/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022]
Abstract
Inhaled corticosteroids (ICS) are a mainstay of treatment in eosinophilic asthma. Many studies have explored the dose-response effect of different formulations of ICS through direct or indirect bronchoprovocation testing. Such studies are important for investigating efficacy and identifying the relative potency between formulations. However, lack of consistency in methods and designs has hindered the comparability of study findings. This review discusses current knowledge of the dose-response, or lack thereof, of different formulations of ICS through direct and indirect bronchoprovocation testing. The strengths and weaknesses of past studies inform recommendations for future methodological considerations in this field, such as utilizing a randomized double-blind crossover design, enrolling participants likely to respond to ICS therapy, and carefully selecting treatment durations and washout periods to assess incremental improvement in airway hyperresponsiveness while reducing the likelihood of a carryover effect.
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Affiliation(s)
- Christianne M. Blais
- Division of Respirology Critical Care and Sleep Medicine Department of Medicine University of Saskatchewan Saskatoon SK Canada
| | - Beth E. Davis
- Division of Respirology Critical Care and Sleep Medicine Department of Medicine University of Saskatchewan Saskatoon SK Canada
| | - Parameswaran Nair
- Firestone Institute for Respiratory Health St. Joseph's Healthcare & Department of Medicine McMaster University Hamilton ON Canada
| | - Donald W. Cockcroft
- Division of Respirology Critical Care and Sleep Medicine Department of Medicine University of Saskatchewan Saskatoon SK Canada
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13
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2020 Updated Asthma Guidelines: Clinical utility of fractional exhaled nitric oxide (Feno) in asthma management. J Allergy Clin Immunol 2021; 146:1281-1282. [PMID: 33280711 DOI: 10.1016/j.jaci.2020.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 11/20/2022]
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14
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Liu L, Zhang J, Zhang L, Yuan SH, Wu JH, Tang MY, Chen JD, Zhang F, Qi XY, Yin Y. The Relationship of the Test for Respiratory and Asthma Control in Kids Initial Score on the Prognosis of Pre-school Children With Asthma: A Prospective Cohort Study. Front Pediatr 2021; 9:690333. [PMID: 34277524 PMCID: PMC8277926 DOI: 10.3389/fped.2021.690333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/03/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: The test for respiratory and asthma control in kids (TRACK) is currently the only standard follow-up tool for children under 5 years of age with asthma. The purpose of this study was to investigate the relationship between the TRACK initial score (Ti) and their prognosis after 6 months of follow-up in pre-schoolers with asthma. Design: A prospective cohort study. Methods: The study included pre-schoolers diagnosed with asthma at the Shanghai Children's Medical Center between January 2019 and June 2020, and follow-up for 6 months. TRACK scores, frequency of wheezing and respiratory infections, number of Emergency Department (ED) visits and treatment regimen were collected. According to the TRACK initial score, the children were divided into "Ti < 60 group" and "Ti ≥ 60 group," and the two groups were compared in terms of TRACK score related indicators, clinical manifestations and treatment. Results: There are 102 pre-schoolers included in the analysis [78 boys (76.5%) and 24 girls (23.5%); mean (SD) age, 28.05 (11.63) months]. After 6 months of follow-up, the TRACK score was improved in both groups, and the "Ti ≥ 60 group" had a higher score, lower rate of uncontrolled asthma and fewer reassessments were required. There was no difference in the number of wheezing attacks between the two groups in terms of clinical presentation, but the "Ti < 60 group" had more respiratory infections and ED visits. Regarding the use of ICSs, in the "Ti < 60 groups," the dose of ICSs was higher and reduced slowly, and the dose difference between the two groups began to appear after 5 months of follow-up. Conclusion: TRACK is essential for pre-schoolers with asthma at the time they are diagnosed. In addition, if the TRACK initial score is < 60, the probability of poor prognosis is higher.
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Affiliation(s)
- Lu Liu
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Zhang
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lei Zhang
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shu-Hua Yuan
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jin-Hong Wu
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ming-Yu Tang
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jian-De Chen
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fen Zhang
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xin-Yi Qi
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yong Yin
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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15
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Lipworth B, Chan R, Kuo CR. Systemic effects of fluticasone on blood eosinophils in bronchiectasis. Eur Respir J 2020; 56:56/3/2002005. [PMID: 32883758 DOI: 10.1183/13993003.02005-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School Dundee, Dundee, Scotland UK
| | - Rory Chan
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School Dundee, Dundee, Scotland UK
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School Dundee, Dundee, Scotland UK
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16
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Rothe T, Fronkova A, Pein T, Latshang T. [Physical and Clinical Aspects of Inhalation Therapy for Asthma and COPD]. PRAXIS 2020; 109:985-990. [PMID: 32933396 DOI: 10.1024/1661-8157/a003510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Physical and Clinical Aspects of Inhalation Therapy for Asthma and COPD Abstract. Inhalations form the basis of the medicinal treatment of respiratory diseases. In recent years, therapy has become more complex for patients, but also for medical professionals, as new systems have come onto the market. The knowledge required for this shall be conveyed in this article.
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Affiliation(s)
- Thomas Rothe
- Pneumologie, Departement Innere Medizin, Kantonsspital Graubünden, Chur
| | - Andrea Fronkova
- Pneumologie, Departement Innere Medizin, Kantonsspital Graubünden, Chur
| | - Thomas Pein
- Innere Medizin, Kantonsspital St. Gallen, St. Gallen
| | - Tsogyal Latshang
- Pneumologie, Departement Innere Medizin, Kantonsspital Graubünden, Chur
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17
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Zhang O, Minku LL, Gonem S. Detecting asthma exacerbations using daily home monitoring and machine learning. J Asthma 2020; 58:1518-1527. [PMID: 32718193 DOI: 10.1080/02770903.2020.1802746] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Acute exacerbations contribute significantly to the morbidity of asthma. Recent studies have shown that early detection and treatment of asthma exacerbations leads to improved outcomes. We aimed to develop a machine learning algorithm to detect severe asthma exacerbations using easily available daily monitoring data. METHODS We analyzed daily peak expiratory flow and symptom scores recorded by participants in the SAKURA study (NCT00839800), an international multicentre randomized controlled trial comparing budesonide/formoterol as maintenance and reliever therapy versus budesonide/formoterol maintenance plus terbutaline as reliever, in adults with persistent asthma. The dataset consisted of 728,535 records of daily monitoring data in 2010 patients, with 576 severe exacerbation events. Data post-processing techniques included normalization, standardization, calculation of differences or slopes over time and the use of smoothing filters. Principal components analysis was used to reduce the large number of derived variables to a smaller number of linearly independent components. Logistic regression, decision tree, naïve Bayes, and perceptron algorithms were evaluated. Model accuracy was assessed using stratified cross-validation. The primary outcome was the detection of exacerbations on the same day or up to three days in the future. RESULTS The best model used logistic regression with input variables derived from post-processed data using principal components analysis. This had an area under the receiver operating characteristic curve of 0.85, with a sensitivity of 90% and specificity of 83% for severe asthma exacerbations. CONCLUSION Asthma exacerbations may be detected using machine learning algorithms applied to daily self-monitoring of peak expiratory flow and asthma symptoms.
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Affiliation(s)
- Olivier Zhang
- Department of Computer Engineering (INFO), INSA Rennes, Rennes, France
| | | | - Sherif Gonem
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham, UK.,Department of Respiratory Science, University of Leicester, Leicester, UK
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18
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Albertson TE, Pugashetti JV, Chau-Etchepare F, Chenoweth JA, Murin S. Pharmacotherapeutic management of asthma in the elderly patient. Expert Opin Pharmacother 2020; 21:1991-2010. [PMID: 32686969 DOI: 10.1080/14656566.2020.1795131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines. AREAS COVERED A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed. EXPERT OPINION Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Florence Chau-Etchepare
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
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19
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Chan R, RuiWen Kuo C, Lipworth B. Pragmatic Clinical Perspective on Biologics for Severe Refractory Type 2 Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3363-3370. [PMID: 32673880 DOI: 10.1016/j.jaip.2020.06.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/07/2020] [Accepted: 06/28/2020] [Indexed: 12/18/2022]
Abstract
Patients with severe refractory asthma present a challenging clinical conundrum for practicing clinicians. Biologics that target key mediators in the type 2 inflammation cascade, including IL-4, IL-5, IL-13, and IgE, can be effective strategies for these patients. However, with various biologics available, choosing the optimal one for a particular patient becomes a nuanced decision. We propose a pragmatic algorithm that identifies the optimal biologic class for patients who have specific type 2 disease endotypes. Patients with eosinophilic endotypes fare well with anti-IL-5(rα) medications, comprising mepolizumab, benralizumab, and reslizumab because they have been shown to reduce exacerbations in severe eosinophilic asthma by approximately 50%. In patients with fractional exhaled nitric oxide-high endotypes, anti-IL-4rα such as dupilumab is deemed to be most effective and has demonstrated a 47% reduction in asthma exacerbations. For patients with severe uncontrolled allergic asthma, anti-IgE (omalizumab) is effective and has been shown to confer a 25% reduction in asthma exacerbations. Type 2 comorbidities including chronic rhinosinusitis with nasal polyps, atopic dermatitis, chronic idiopathic urticaria, and eosinophilic esophagitis are important to bear in mind before the prescription of biologics. Further head-to-head studies are indicated to compare biologics in patients with mixed endotypes according to peripheral blood eosinophils, fractional exhaled nitric oxide, and allergic status. The evidence strongly supports endotype-driven prescribing of biologics to achieve clinically relevant outcomes in severe refractory asthma and related comorbidities.
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Affiliation(s)
- Rory Chan
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom.
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20
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Harrison T, Pavord ID, Chalmers JD, Whelan G, Fagerås M, Rutgersson A, Belton L, Siddiqui S, Gustafson P. Variability in airway inflammation, symptoms, lung function and reliever use in asthma: anti-inflammatory reliever hypothesis and STIFLE study design. ERJ Open Res 2020; 6:00333-2019. [PMID: 32550224 PMCID: PMC7276524 DOI: 10.1183/23120541.00333-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/24/2020] [Indexed: 11/05/2022] Open
Abstract
Asthma is a chronic inflammatory airway disease. Increase in airway inflammation is hypothesised to contribute to worsening of asthma symptoms and deterioration in lung function, resulting in the use of reliever medication. Short-acting β2-agonists only treat the symptoms, whereas an anti-inflammatory reliever is believed to treat both symptoms and the underlying inflammation, thereby arresting the progression to an exacerbation. As-needed budesonide/formoterol as an anti-inflammatory reliever reduces the risk of severe exacerbations. However, supporting mechanistic evidence has not yet been described, specifically the temporal dynamics of parameters including airway inflammation, over time and during asthma worsening. The STIFLE study aims to characterise daily variability in airway inflammation, symptoms, lung function and reliever use in people with asthma. This phase IV, open-label, parallel-group, multicentre, exploratory study will enrol 60-80 adult patients with asthma receiving low- or medium-dose inhaled corticosteroids/long-acting β2-agonists (EudraCT identifier number 2018-003467-64). Participants will be randomised 1:1 to either as-needed budesonide/formoterol dry-powder inhaler or salbutamol reliever for 24 weeks, in addition to their maintenance therapy. Daily data will be captured for fractional exhaled nitric oxide, spirometry, asthma symptoms and medication use using devices connected to a smartphone via the STIFLE application. STIFLE will thereby enable not only characterisation of the variability of airway inflammation and clinical outcomes in relation to asthma worsening, but also elucidate the effect of as-needed budesonide/formoterol on airway inflammation against a background of daily maintenance therapy.
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Affiliation(s)
- Tim Harrison
- Nottingham NIHR Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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21
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Xiong Y, Li B, Zhang Y, Shi F, Qiu C, Wang L, Wang J, Le Y, Du Y, Yao C, Li S, Liu W, Chen D, Feng M. Expression of herpesvirus entry mediator gene as a potential biomarker for disease severity in patients with persistent asthma. J Asthma 2020; 58:717-724. [PMID: 32045312 DOI: 10.1080/02770903.2020.1729382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: Herpes virus entry mediator (HVEM) is a costimulatory molecule, and has been proved to play an important role in airway inflammatory and remodeling processes of asthma. We aimed to investigate the expression of HVEM gene in patients with asthma as a means of assessing disease severity.Methods: This study was carried out on 59 subjects, 16 patients with mild persistent asthma, 11 patients with moderate persistent asthma, 13 patients with severe persistent asthma, and 19 age and gender matched healthy controls. The HVEM mRNA expressions of all subjects were determined by real time PCR. Correlations between HVEM mRNA expression and fractional exhaled nitric oxide (FeNO), pulmonary function test values, total blood white cell count and differential, total immunoglobulin E (IgE) level, and Asthma Control Test (ACT) score were analyzed, respectively. The discrimination abilities of HVEM mRNA between different groups were tested using receiver operating characteristics (ROC) curve analyses.Results: This study showed the expressions of HVEM mRNA were significantly higher in the patients with severe and moderate persistent asthma than in patients with mild persistent asthma and healthy subjects (2.97 ± 1.23 vs. 1.17 ± 0.42 vs. 0.62 ± 0.38 vs. 0.46 ± 0.18/NAPDH, p < 0.001), but there was no significant difference between patients with mild persistent asthma and health controls (0.62 ± 0.38 vs. 0.46 ± 0.18/NAPDH, p = 0.557). HVEM mRNA expression at cut off point [1.01/NAPDH, area under the ROC curve (AUC) = 0.99] is sufficient to discriminate severe patients from mild-to-moderate patients, and at cut off point (0.93/NAPDH, AUC = 0.91) for discrimination of moderate-to-severe patients from mild ones, while at cut off point (0.76/NAPDH, AUC = 0.75) for discrimination of asthmatic patients from controls. Furthermore, HVEM mRNA expression was positively correlated with FeNO level (r = 0.524, p = 0.015), and total lymphocyte count (r = 0.426, p = 0.017) in patients with persistent asthma.Conclusions: HVEM gene expressions can be used as a potential biomarker for evaluating the severity of patients with persistent asthma.
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Affiliation(s)
- Yi Xiong
- Shenzhen Key Laboratory for Neuronal Structural Biology, Biomedical Research Institute, Shenzhen Peking University - The Hong Kong University of Science and Technology Medical Center, Shenzhen, China
| | - Binbin Li
- Emergency Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Yidan Zhang
- Shenzhen Key Laboratory for Neuronal Structural Biology, Biomedical Research Institute, Shenzhen Peking University - The Hong Kong University of Science and Technology Medical Center, Shenzhen, China
| | - Fei Shi
- Emergency Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Chen Qiu
- Respiratory Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Lingwei Wang
- Respiratory Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Jin Wang
- Emergency Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Ying Le
- Respiratory Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Yujie Du
- Respiratory Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Can Yao
- Respiratory Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Sinian Li
- Respiratory Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Wenwen Liu
- Emergency Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Dandan Chen
- Respiratory Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
| | - Mengjie Feng
- Respiratory Department, Shenzhen Institute of Respiratory Diseases, Jinan University, The Second Clinical College, Shenzhen, China
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22
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Ramadan AA, Gaffin JM, Israel E, Phipatanakul W. Asthma and Corticosteroid Responses in Childhood and Adult Asthma. Clin Chest Med 2020; 40:163-177. [PMID: 30691710 DOI: 10.1016/j.ccm.2018.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Corticosteroids are the most effective treatment for asthma; inhaled corticosteroids (ICSs) are the first-line treatment for children and adults with persistent symptoms. ICSs are associated with significant improvements in lung function. The anti-inflammatory effects of corticosteroids are mediated by both genomic and nongenomic factors. Variation in the response to corticosteroids has been observed. Patient characteristics, biomarkers, and genetic features may be used to predict response to ICSs. The existence of multiple mechanisms underlying glucocorticoid insensitivity raises the possibility that this might indeed reflect different diseases with a common phenotype.
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Affiliation(s)
- Amira Ali Ramadan
- Division of Allergy and Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Beth Israel Deaconess Center, Cardiovascular institute, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Jonathan M Gaffin
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Elliot Israel
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Brigham and Women's Hospital, 15 Francis Street, Boston, MA 02115, USA
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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23
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Affiliation(s)
- Susamita Kesh
- University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Bridgette L Jones
- University of Missouri-Kansas City School of Medicine, Kansas City, MO
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24
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Kuo CR, Jabbal S, Anderson W, Lipworth BJ. Pragmatic evaluation of inhaled corticosteroid particle size formulations on asthma control. Clin Exp Allergy 2019; 49:1321-1327. [PMID: 31264282 DOI: 10.1111/cea.13453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/07/2019] [Accepted: 06/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Extra-fine particle formulations of inhaled corticosteroid (ICS) are associated with improved lung delivery. OBJECTIVES A pragmatic study to assess patient-reported outcomes after switching from fine to extra-fine particle ICS in persistent asthma. METHODS Twenty-four patients (mean age 48 year, FEV1 84%, ACQ 1.67) received 4 weeks run-in with a constant dose of fine particle ICS (mean dose 710 µg), followed by switching to an equivalent dose of extra-fine particle hydrofluoroalkane beclomethasone dipropionate (mean dose 355µg). Asthma control questionnaire (ACQ), the primary outcome and mini asthma quality of life questionnaire (mAQLQ) were measured pre- and post-run-in (baseline) and after 4 weeks and 8 weeks of switching. RESULTS Comparing pre- vs post-run-in, there were no differences for ACQ: 1.67 vs 1.65 or AQLQ: 5.08 vs 5.34. There were mean (95%CI) improvements (P < 0.001) from baseline after 8 weeks for ACQ: -0.53 (-0.83, -0.23) and AQLQ: 0.69 (0.35, 1.04), which exceeded the minimal clinically important difference (MCID) of 0.5 for both. There were also differences (P < 0.05) in domiciliary symptoms and reliever use. There were no significant changes at 8 weeks in lung function, FeNO or blood eosinophils. CONCLUSIONS Pragmatic switching from fine to extra-fine particle ICS at half the dose was associated with clinically relevant improvements in asthma control and quality of life, but not lung function or type 2 biomarkers.
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Affiliation(s)
- Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Sunny Jabbal
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - William Anderson
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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Kuo CR, Spears M, Haughney J, Smith A, Miller J, Bradshaw T, Murray L, Williamson P, Lipworth B. Scottish consensus statement on the role of FeNO in adult asthma. Respir Med 2019; 155:54-57. [PMID: 31299469 DOI: 10.1016/j.rmed.2019.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/14/2019] [Accepted: 07/05/2019] [Indexed: 01/15/2023]
Abstract
Fractional exhaled nitric oxide (FeNO) is the only available point of care test to assess type-2 inflammation in asthma. In making a diagnosis of asthma, FeNO should be used together with blood eosinophils and spirometry, alongside a history. Raised FeNO in conjunction with blood eosinophilia are treatable traits of type 2 inflammation in asthma, which in turn may guide personalised management. A FeNO suppression test can be used to assess adherence and device use with ICS therapy. Furthermore FeNO may be used to provide feedback to patients in response to ICS, especially when spirometry is normal. FeNO may facilitate appropriate referral to secondary care for more definitive specialist investigations. In summary, FeNO is cost effective in the diagnosis and management of asthma and should be incorporated into primary and secondary care as part of routine clinical practice.
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Affiliation(s)
- Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, DD1 9SY, UK
| | - Mark Spears
- Respiratory Medicine, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK
| | - John Haughney
- Clinical R&D, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Andrew Smith
- Department of Respiratory Medicine, University Hospital Wishaw, ML2 0DP, UK
| | - Joy Miller
- Respiratory Medicine Unit, Aberdeen Royal Infirmary, University of Aberdeen, AB25 2ZN, UK
| | - Tracey Bradshaw
- Respiratory Medicine Unit, Royal Infirmary of Edinburgh, EH16 4SA, UK
| | - Lorna Murray
- Department of Respiratory Medicine, Raigmore Hospital, Inverness, IV2 4AG, UK
| | | | - Brian Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, DD1 9SY, UK.
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Allan R, Haughie S, Kerwin E, Ward J. A Dose-Response Study to Examine the Methodology for Demonstrating the Local Therapeutic Equivalence of the Fluticasone Propionate Component of an Orally Inhaled Combination Therapy of Fluticasone Propionate/Salmeterol Dry Powder. J Aerosol Med Pulm Drug Deliv 2019; 32:364-373. [PMID: 31259655 DOI: 10.1089/jamp.2018.1520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Asthma is widely treated using inhaled corticosteroid/long-acting beta-agonist combinations, such as fluticasone propionate/salmeterol (FPS) dry powder inhaler. Some regulators require generic medications to demonstrate local therapeutic equivalence (LTE) for each component of the FPS reference product. Fractional exhaled nitric oxide (FeNO) was developed as a possible LTE endpoint for the fluticasone propionate (FP) component of FPS in a randomized, double-blind, crossover study in steroid-naive asthma patients with elevated FeNO (≥45 parts per billion). Methods: Thirty-four patients received three of five treatments: FPS 100/50 μg once daily (QD), FPS 100/50 μg twice daily (BID), FPS 250/50 μg BID, FPS 500/50 μg BID, or placebo, each for 2 weeks separated by 14-day washout. FeNO was measured on days 1, 2, 3, 5, 7, and 14 of each period, according to American Thoracic Society standards. Results: FPS treatments decreased FeNO compared with placebo, with the largest differentiation between doses noted on day 14; the mean decreases from days 1 to 14 ranged from -46.6% to -64.5% with FPS versus -9.1% with placebo. The dose-response plateaued at 200 μg/day (FPS 100/50 μg BID). Linear regression analysis revealed significant slopes between FPS doses, with the steepest between 100/50 μg QD and 100/50 μg BID (-0.0039, p = 0.020). An estimated sample size (SS) of 160 or 48 patients would be required to demonstrate LTE of generic and FPS reference products (0.80-1.25 and 0.67-1.50 bioequivalence limits, respectively). However, as the slope between BID FPS doses was shallow, a larger SS may be needed if only an approved dose regimen was used. Conclusion: FeNO could be a valid endpoint to determine LTE between the FP component of generic and reference FPS products, but only if QD dosing and wide equivalence limits are included. As QD dosing is not an approved regimen, this approach is unlikely to be acceptable.
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Affiliation(s)
| | | | - Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, Oregon
| | - Jon Ward
- Mylan Pharma UK Limited, Sandwich, United Kingdom
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Lipworth B, Kuo CR, Jabbal S. Current appraisal of single inhaler triple therapy in COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:3003-3009. [PMID: 30319248 PMCID: PMC6167973 DOI: 10.2147/copd.s177333] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
A single inhaler containing inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA) is a more convenient way of delivering triple therapy in patients with COPD. Single triple therapy has been shown to be superior at reducing exacerbations and improving quality of life compared to LABA/LAMA, especially in patients with a prior history of frequent exacerbations and blood eosinophilia, who have ICS responsive disease. The corollary is that patients with infrequent exacerbations who are noneosinophilic may be safely de-escalated from triple therapy to LABA/LAMA without loss of control. Pointedly, there is a substantially increased risk of pneumonia associated with the triple therapy containing fluticasone furoate but not beclometasone dipropionate or budesonide. Since triple therapy is also better than ICS/LABA at reducing exacerbations and improving lung function, symptoms, and quality of life, this brings into question the rationale for using ICS/LABA. Hence, we propose a simplified pragmatic decision process based on symptoms, prior to exacerbation history, and blood eosinophils to select which patients should be given a single triple inhaler or LABA/LAMA. Differences in patient preference of inhaler device, formulations and drugs will also determine which triple inhaler prescribers elect to use.
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Affiliation(s)
- Brian Lipworth
- Division of Molecular & Clinical Medicine, Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK,
| | - Chris RuiWen Kuo
- Division of Molecular & Clinical Medicine, Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK,
| | - Sunny Jabbal
- Division of Molecular & Clinical Medicine, Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK,
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Kuo CR, Jabbal S, Lipworth B. Is small airways dysfunction related to asthma control and type 2 inflammation? Ann Allergy Asthma Immunol 2018; 121:631-632. [PMID: 30134181 DOI: 10.1016/j.anai.2018.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/19/2018] [Accepted: 08/13/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland, UK
| | - Sunny Jabbal
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland, UK
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland, UK.
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Jabbal S, Lipworth BJ. Blood eosinophils: The forgotten man of inhaled steroid dose titration. Clin Exp Allergy 2017; 48:93-95. [PMID: 29117628 DOI: 10.1111/cea.13057] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- S Jabbal
- Scottish Centre for Respiratory Research, Ninewells Hospital & Medical School, Dundee, Scotland
| | - B J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital & Medical School, Dundee, Scotland
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Weiler JM, Sorkness CA, Hendeles L, Nichols S, Zhu Y. Randomized, Double-Blind, Crossover, Clinical-End-Point Pilot Study to Examine the Use of Exhaled Nitric Oxide as a Bioassay for Dose Separation of Inhaled Fluticasone Propionate. J Clin Pharmacol 2017; 58:448-456. [PMID: 29193247 DOI: 10.1002/jcph.1043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/20/2017] [Indexed: 11/06/2022]
Abstract
This was a randomized, double-blind, crossover, clinical-end-point pilot study examining the hypothesis that inhaled fluticasone propionate decreases exhaled nitric oxide (eNO) concentrations within a week of beginning treatment and shows evidence of dose separation across the marketed dose range. Subjects had a ≥6-month history of asthma and screening eNO ≥60 parts per billion. At the start of each treatment period, eNO was ≥55 parts per billion, and forced expiratory volume in 1 second was ≥50% predicted. Subjects attended a clinic visit daily on consecutive mornings during each of 3 1-week treatment periods to measure eNO and receive once-daily doses of 100/50, 250/50, or 500/50 fluticasone propionate/salmeterol combination product (Advair® Diskus). Daily eNO value recorded was the highest of 3 measurements; 1 inhalation of treatment was then administered. Procedures were repeated for 3 treatment cycles, separated by 14-day minimum washouts. A total of 105 subjects were screened; 22 were randomized; and 17 completed all treatments. Mean percentage eNO decrease (standard deviation) from day 1 baseline for each treatment period was 36.6 (±18.7), 45.3 (±16.5), and 54.6 (±12.5) with Advair® 100/50, 250/50, and 500/50, respectively. Mean percentage decrease in eNO across each treatment (dose) was modeled using a mixed-model ANOVA. Although the overall treatment was significant (P = .0015), because of the relatively small sample size and within-subject variability, only the 100/50 vs 500/50 (P = .0003) and 250/50 vs 500/50 (P = .047) treatments were significantly different.
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Affiliation(s)
| | - Christine A Sorkness
- Clinical Research Program, Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin, Madison, WI, USA
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Lipworth BJ, Jabbal S. Un-diagnosing persistent adult asthma. Eur Respir J 2017; 50:50/5/1701433. [PMID: 29097435 DOI: 10.1183/13993003.01433-2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 08/16/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Dundee, UK
| | - Sunny Jabbal
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Dundee, UK
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Singh D. Evaluation of New Drugs for Asthma and COPD: Endpoints, Biomarkers and Clinical Trial Design. Handb Exp Pharmacol 2017; 237:243-264. [PMID: 27838852 DOI: 10.1007/164_2016_70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There remains a considerable need to develop novel therapies for patients with asthma and chronic obstructive pulmonary disease (COPD). The greatest challenge at the moment is measuring the effects of novel anti-inflammatory drugs, as these drugs often cause only small effects on lung function. Measurements that demonstrate the pharmacological and clinical effects of these drugs are needed. Furthermore, we now recognise that only subgroups of patients are likely to respond to these novel drugs, so using biomarkers to determine the clinical phenotype most suitable for such therapies is important. An endotype is a subtype of a (clinical) condition defined by a distinct pathophysiological mechanism. An endotype-driven approach may be more helpful in drug development, enabling drugs to be targeted specifically towards specific biological mechanisms rather than clinical characteristics. This requires the development of biomarkers to define endotypes and/or to measure drug effects. This newer approach should continue alongside efforts to optimise the measurement of clinical endpoints, including patient-reported outcome measurements, required by drug regulatory authorities.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, University Hospital of South Manchester Foundations Trust, Langley Building, Southmoor Road, Wythenshawe, Manchester, M23 9Q2, UK.
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Anderson WJ, Short PM, Jabbal S, Lipworth BJ. Inhaled corticosteroid dose response in asthma: Should we measure inflammation? Ann Allergy Asthma Immunol 2017; 118:179-185. [PMID: 28065396 DOI: 10.1016/j.anai.2016.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/11/2016] [Accepted: 11/22/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Inhaled corticosteroid (ICS) titration in asthma is primarily based on symptoms and pulmonary function. ICSs may not be increased on this basis despite residual airway inflammation. OBJECTIVE To compare the dose-response relationships of ICSs on measures of pulmonary function, symptoms, and inflammation in patients with persistent asthma. METHODS We performed a pooled post hoc analysis of 121 patients with mild to moderate asthma from 4 randomized clinical trials that incorporated an ICS dose ramp. Dose ramps were 0 to 200, 0 to 800, and 200 to 800 μg/d (beclomethasone equivalents). Outcome measures included spirometry, fractional exhaled nitric oxide, airway hyperresponsiveness (AHR), symptoms, serum eosinophilic cationic protein, and blood eosinophils. RESULTS We found a plateau beyond a small improvement at 0 to 200 μg for forced expiratory volume in 1 second: 3.3% (95% confidence interval [CI], 2.0%-4.7%) at 0 to 200 μg vs 0.3% (95% CI, -0.8% to 1.4%) 200 to 800 μg (P = .001). A similar plateau was seen for symptom improvement beyond 0 to 200 μg. Inflammatory and AHR outcomes revealed further room for improvement beyond low-dose ICSs. There was dose-related suppression (P < .001) for fractional exhaled nitric oxide: 40.4 ppb (95% CI, 34.7-46.9 ppb) for ICS free, 26.8 ppb (95% CI, 23.4-30.2 ppb) for 200 μg, and 20.8 ppb (95% CI, 18.8-23.1 ppb) for 800 μg. Eosinophilic cationic protein concentration was significantly reduced with both higher dose ramps. Eosinophil counts also improved across all 3 dose ramps, with dose separation of 370/μL (95% CI, 280-450/μL) for ICS free vs 250/μL (95% CI, 200-300/μL) 800 μg (P = .03). AHR improved with all 3 dose ramps, with greater improvement at lower doses for indirect vs direct challenges. CONCLUSION ICS dose response may extend beyond low dose for inflammation and AHR but not symptoms or spirometry. Further study is required to identify whether this correlates with suboptimal longitudinal asthma control. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT00667992, NCT00995657, NCT01216579, NCT01544634.
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Affiliation(s)
- William J Anderson
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland
| | - Philip M Short
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland
| | - Sunny Jabbal
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland.
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Neelamegan R, Saka V, Tamilarasu K, Rajaram M, Selvarajan S, Chandrasekaran A. Clinical Utility of Fractional exhaled Nitric Oxide (FeNO) as a Biomarker to Predict Severity of Disease and Response to Inhaled Corticosteroid (ICS) in Asthma Patients. J Clin Diagn Res 2016; 10:FC01-FC06. [PMID: 28208871 DOI: 10.7860/jcdr/2016/20656.8950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 08/17/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Bronchial asthma is a common chronic inflammatory airway disease diagnosed and is based on symptomatic history and Pulmonary Function Tests (PFT). Fractional exhaled Nitric Oxide (FeNO) is exclusively a non-invasive biomarker of on-going eosinophilic airway inflammation which remains unpredictable only with PFTs. FeNO measurement is recommended in predicting asthma severity and Inhaled Corticosteroid (ICS) response but further research is required to understand its clinical utility and agreement with current recommendations in a specific population. AIM To estimate FeNO levels in Tamilian patients with mild-to-moderate persistent asthma and to correlate with disease severity and ICS response. MATERIALS AND METHODS The study was a prospective cohort with a single group of 102 persistent asthma patients under standard ICS regimen for 8 weeks (follow-up period). PFT and FeNO were measured using portable spirometry and chemiluminescence based exhaled breath analyser, at baseline and during follow-up visits. Based on PFT and FeNO parameters, the study population was sub-grouped with respect to asthma severity (as mild, moderate and moderately severe), FeNO cut-off (> or < 50ppb) and ICS response classification (good vs poor ICS responders). RESULTS Significant decrease in mean FeNO levels were found in mild, moderate and moderately severe asthmatic groups following ICS treatment (90.15±27.36, 75.74±31.98 and 77.18±32.79 ppb) compared to similar baseline FeNO levels (103.03±34.08, 91.38±37.60 and 97.90±43.84 ppb) in all the above groups. Similarly, significant decrease in mean FeNO levels was found - FeNO>50ppb, good and poor ICS responders groups, in post- ICS treatment (89.63±24.04, 77.90±31.12 and 86.49±32.57 ppb) compared to baseline levels (110.183±1.23, 97.12±42.04 and 99.68±34.71 ppb). CONCLUSION The observed baseline FeNO values in all groups as stated above did not show significant difference to differentiate asthma severity or ICS responders groups. The present study results do not support the predictive association of baseline FeNO levels with asthma severity and future ICS response, but the decrements in FeNO levels on ICS treatment, supports its clinical utility in monitoring of ongoing airway inflammation and understanding treatment response rate.
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Affiliation(s)
| | - Vinodkumar Saka
- Professor and Head, Department of Pulmonary Medicine, JIPMER , Puducherry, India
| | | | - Manju Rajaram
- Associate Professor, Department of Pulmonary Medicine, JIPMER , Puducherry, India
| | - Sandhiya Selvarajan
- Assistant Professor, Department of Clinical Pharmacology, JIPMER , Puducherry, India
| | - Adithan Chandrasekaran
- Director, CIDRF, MGMCRI, Puducherry and Retd. Senior Professor and Head, Department of Clinical Pharmacology, JIPMER , Puducherry, India
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Abstract
BACKGROUND Asthma guidelines aim to guide health practitioners to optimise treatment for patients to minimise symptoms, improve or maintain good lung function, and prevent acute exacerbations. The principle of asthma guidelines is based on a step-up or step-down regimen of asthma medications to maximise health using minimum doses. Fractional exhaled nitric oxide (FeNO) is a marker of eosinophilic inflammation and tailoring asthma medications in accordance to airway eosinophilic levels may improve asthma outcomes such as indices of control or reduce exacerbations, or both. OBJECTIVES To evaluate the efficacy of tailoring asthma interventions based on fractional exhaled nitric oxide (FeNO), in comparison to not using FeNO, that is, management based on clinical symptoms (with or without spirometry/peak flow) or asthma guidelines (or both), for asthma-related outcomes in children. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and reference lists of articles. The last searches were in June 2016. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing adjustment of asthma medications based on FeNO levels compared to those not using FeNO, that is, management based on clinical symptoms or asthma guidelines (or both) involving children. DATA COLLECTION AND ANALYSIS We reviewed results of searches against predetermined criteria for inclusion. Two review authors independently selected relevant studies, assessed trial quality and extracted data. We contacted study authors for further information with responses provided from three. MAIN RESULTS The review included nine studies; these studies differed in a variety of ways including definition of asthma exacerbations, FeNO cut-off levels used (12 parts per billion (ppb) to 30 ppb), the way in which FeNO was used to adjust therapy and duration of study (6 to 12 months). Of 1426 children randomised, 1329 completed the studies. The inclusion criteria for the participants in each study varied but all had a diagnosis of asthma. There was a significant difference in the number of children having one or more asthma exacerbations over the study period, they were significantly lower in the FeNO group in comparison to the control group (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.45 to 0.75; 1279 participants; 8 studies). The number needed to treat for an additional beneficial outcome (NNTB) over 52 weeks was 9 (95% CI 6 to 15). There was no difference between the groups when comparing exacerbation rates (mean difference (MD) -0.37, 95% CI -0.8 to 0.06; 736 participants; 4 studies; I2 = 67%). The number of children in the FeNO group requiring oral corticosteroid courses was lower in comparison to the children in the control group (OR 0.63, 95% CI 0.48 to 0.83; 1169 participants; 7 studies; I2 = 0%). There was no statistically significant difference between the groups for exacerbations requiring hospitalisation (OR 0.75, 95% CI 0.41 to 1.36; 1110 participants; 6 studies; I2 = 0%). There were no significant differences between the groups for any of the secondary outcomes (forced expiratory volume in one second (FEV1), FeNO levels, symptom scores or inhaled corticosteroid doses at final visit). The included studies recorded no adverse events.Three studies had inadequate blinding and were thus considered to have a high risk of bias. However, when these studies were removed in subgroup analysis, the difference between the groups for the primary outcome (exacerbations) remained statistically significant. The GRADE quality of the evidence ranged from moderate (for the outcome 'Number of participants who had one or more exacerbations over the study period') to very low (for the outcome 'Exacerbation rates'), based on lack of blinding, statistical heterogeneity and imprecision. AUTHORS' CONCLUSIONS In this updated review with five new included studies, tailoring asthma medications based on FeNO levels (in comparison with primarily guideline management) significantly decreased the number of children who had one or more exacerbations over the study period but did not impact on the day-to-day clinical symptoms or inhaled corticosteroid doses. Therefore, the use of FeNO to guide asthma therapy in children may be beneficial in a subset of children, it cannot be universally recommended for all children with asthma.Further RCTs need to be conducted and these should encompass different asthma severities, different settings including primary care and less affluent settings, and consider different FeNO cut-offs.
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Affiliation(s)
- Helen L Petsky
- Griffith UniversitySchool of Nursing and Midwifery, Griffith University and Menzies Health Institute QueenslandBrisbaneQueenslandAustralia
| | - Kayleigh M Kew
- BMJBritish Medical Journal Technology Assessment Group (BMJ‐TAG)BMA HouseTavistock SquareLondonUKWC1H 9JR
| | - Anne B Chang
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionPO Box 41096DarwinNorthern TerritoriesAustralia0811
- Queensland University of TechnologyInstitute of Health and Biomedical InnovationBrisbaneAustralia
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Coop CA, Adams KE, Webb CN. SCUBA Diving and Asthma: Clinical Recommendations and Safety. Clin Rev Allergy Immunol 2016; 50:18-22. [PMID: 25666876 DOI: 10.1007/s12016-015-8474-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this article is to review the available studies regarding asthma and SCUBA (self-contained underwater breathing apparatus) diving. A literature search was conducted in MEDLINE to identify peer-reviewed articles related to asthma and SCUBA diving using the following keywords: asthma, allergy, and SCUBA diving. SCUBA diving is a popular sport with more than 9 million divers in the USA. SCUBA diving can be a dangerous sport. Bronchospasm can develop in asthmatic patients and cause airway obstruction. Airway obstruction may be localized to the distal airway which prevents gas elimination. Uncontrolled expansion of the distal airway may result in pulmonary barotrauma. There is also the risk of a gas embolism. Asthmatic divers can also aspirate seawater which may induce bronchospasm. Pollen contamination of their oxygen tank may exacerbate atopic asthma in patients. Diving may be hazardous to the lung function of patients with asthma. Despite the risks of SCUBA diving, many asthmatic individuals can dive without serious diving events. Diving evaluations for asthmatic patients have focused on a thorough patient history, spirometry, allergy testing, and bronchial challenges. For patients that wish to dive, their asthma should be well controlled without current chest symptoms. Patients should have a normal spirometry. Some diving societies recommend that an asthmatic patient should successfully pass a bronchial provocation challenge. Recommendations also state that exercise-, emotion-, and cold-induced asthmatics should not dive. Asthmatic patients requiring rescue medication within 48 h should not dive.
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Affiliation(s)
- Christopher A Coop
- Department of Allergy and Immunology, Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, TX, USA.
| | - Karla E Adams
- Department of Allergy and Immunology, Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, TX, USA
| | - Charles N Webb
- Department of Allergy and Immunology, Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, TX, USA
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Petsky HL, Kew KM, Turner C, Chang AB. Exhaled nitric oxide levels to guide treatment for adults with asthma. Cochrane Database Syst Rev 2016; 9:CD011440. [PMID: 27580628 PMCID: PMC6457753 DOI: 10.1002/14651858.cd011440.pub2] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Asthma guidelines aim to guide health practitioners to optimise treatment for patients so as to minimise symptoms, improve or maintain good lung function, and prevent acute exacerbations or flare-ups. The principle of asthma guidelines is based on a step-up or step-down regimen of asthma medications to maximise good health outcomes using minimum medications. Asthma maintenance therapies reduce airway inflammation that is usually eosinophilic. Tailoring asthma medications in accordance with airway eosinophilic levels may improve asthma outcomes such as indices of control or reduce exacerbations or both. Fractional exhaled nitric oxide (FeNO) is a marker of eosinophilic inflammation, and as it is easy to measure, has an advantage over other measurements of eosinophilic inflammation (for example sputum eosinophils). OBJECTIVES To evaluate the efficacy of tailoring asthma interventions based on exhaled nitric oxide (FeNO), in comparison to not using FeNO, that is management based on clinical symptoms (with or without spirometry/peak flow) or asthma guidelines or both, for asthma-related outcomes in adults. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and reference lists of articles. The last searches were undertaken in June 2016. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing adjustment of asthma medications based on exhaled nitric oxide levels compared to not using FeNO, that is management based on clinical symptoms (with or without spirometry/peak flow) or asthma guidelines or both. DATA COLLECTION AND ANALYSIS We reviewed results of searches against predetermined criteria for inclusion. We independently selected relevant studies in duplicate. Two review authors independently assessed trial quality and extracted data. We contacted study authors for further information, receiving responses from four. MAIN RESULTS We included seven adult studies; these studies differed in a variety of ways including definition of asthma exacerbations, FeNO cutoff levels used (15 to 35 ppb), the way in which FeNO was used to adjust therapy, and duration of study (4 to 12 months). Of 1700 randomised participants, 1546 completed the trials. The mean ages of the participants ranged from 28 to 54 years old. The inclusion criteria for the participants in each study varied, but all had a diagnosis of asthma and required asthma medications. In the meta-analysis, there was a significant difference in the primary outcome of asthma exacerbations between the groups, favouring the FeNO group. The number of people having one or more asthma exacerbations was significantly lower in the FeNO group compared to the control group (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.43 to 0.84). The number needed to treat to benefit (NNTB) over 52 weeks was 12 (95% CI 8 to 32). Those in the FeNO group were also significantly more likely to have a lower exacerbation rate than the controls (rate ratio 0.59, 95% CI 0.45 to 0.77). However, we did not find a difference between the groups for exacerbations requiring hospitalisation (OR 0.14, 95% CI 0.01 to 2.67) or rescue oral corticosteroids (OR 0.86, 95% CI 0.50 to 1.48). There was also no significant difference between groups for any of the secondary outcomes (FEV1, FeNO levels, symptoms scores, or inhaled corticosteroid doses at final visit).We considered three included studies that had inadequate blinding to have a high risk of bias. However, when these studies were excluded from the meta-analysis, the difference between the groups for the primary outcomes (exacerbations) remained statistically significant. The GRADE quality of the evidence ranged from moderate (for the outcome 'exacerbations') to very low (for the outcome 'inhaled corticosteroid dose at final visit') based on the lack of blinding and statistical heterogeneity. Six of the seven studies were industry supported, but the company had no role in the study design or data analyses. AUTHORS' CONCLUSIONS With new studies included since the last version of this review, which included adults and children, this updated meta-analysis in adults with asthma showed that tailoring asthma medications based on FeNO levels (compared with primarily on clinical symptoms) decreased the frequency of asthma exacerbations but did not impact on day-to-day clinical symptoms, end-of-study FeNO levels, or inhaled corticosteroid dose. Thus, the universal use of FeNO to help guide therapy in adults with asthma cannot be advocated. As the main benefit shown in the studies in this review was a reduction in asthma exacerbations, the intervention may be most useful in adults who have frequent exacerbations. Further RCTs encompassing different asthma severity, ethnic groups in less affluent settings, and taking into account different FeNO cutoffs are required.
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Affiliation(s)
- Helen L Petsky
- Queensland University of TechnologyInstitute of Health and Biomedical InnovationBrisbaneQueenslandAustralia
| | - Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
| | - Cathy Turner
- The University of QueenslandSchool of Nursing, Midwifery & Social WorkBrisbaneQueenslandAustralia
| | - Anne B Chang
- Queensland University of TechnologyInstitute of Health and Biomedical InnovationBrisbaneQueenslandAustralia
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionPO Box 41096DarwinNorthern TerritoriesAustralia0811
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Mori K, Fujisawa T, Inui N, Hashimoto D, Enomoto N, Nakamura Y, Kuroishi S, Yokomura K, Toyoshima M, Imokawa S, Yamada T, Shirai T, Masuda M, Hayakawa H, Chida K, Suda T. Step-down treatment from medium-dosage of budesonide/formoterol in controlled asthma. Respir Med 2016; 119:1-6. [PMID: 27692128 DOI: 10.1016/j.rmed.2016.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/12/2016] [Accepted: 08/13/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND The stepping down of asthma treatment can be considered when asthma symptoms have been well controlled with inhaled corticosteroids (ICSs)/long-acting β2 adrenergic agonists (LABAs). However, few data are available comparing the efficacy between two step-down strategies, to reduce ICS/LABA dose or to withdraw LABA continuing ICS, in well-controlled asthmatics. METHODS This was a prospective multicentre randomized, two-arm, controlled study. Ninety-one asthmatic patients controlled by budesonide/formoterol combination (BFC) 320/9 μg twice daily were assigned to 2 stepping-down treatments as follows: the BFC group; BUD/FM 160/4.5 μg twice daily, and the ICS group; ICS (budesonide 400 μg twice daily or equivalent dose of ICS) without LABA, and followed for 12 weeks. The primary outcome was the incidence of asthma exacerbations. Asthma control, pulmonary function tests, and fraction of exhaled nitric oxide (FeNO) were evaluated at the beginning and end of the period. RESULTS The incidence of exacerbations was 16.3% in the BFC groups and 12.5% in the ICS group, which were not different between the groups (p = 0.766). No significant differences were found in QOL score and FeNO between 0 week and 12 week in the both group. FEV1 and FEV1 percentage of the predicted value were lower at week 12 than at week 0 in the ICS group, but not in the BFC group. CONCLUSIONS The two step-down strategies for 12 weeks have equal acceptability in well-controlled asthmatics treated with medium-dose of BFC, however, withdrawal of LABA may have potential risk to deteriorate FEV1. CLINICAL TRIAL REGISTRATION This study was registered to UMIN-CTR (http://www.umin.ac.jp/ctr/), UMIN000010333.
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Affiliation(s)
- Kazutaka Mori
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
| | - Naoki Inui
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Dai Hashimoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Shigeki Kuroishi
- Department of Respiratory Medicine, Ensyu Hospital, 1-1-1 Chuou, Naka-ku, Hamamatsu, 430-0929, Japan
| | - Koshi Yokomura
- Department of Respiratory Medicine, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, 433-8558, Japan
| | - Mikio Toyoshima
- Department of Respiratory Medicine, Hamamatsu Rosai Hospital, 25 Shougen-cho, Higashi-ku, Hamamatsu, 430-8525, Japan
| | - Shiro Imokawa
- Department of Respiratory Medicine, Iwata City Hospital, 513-2 Ohkubo, Iwata, 438-8550, Japan
| | - Takashi Yamada
- Department of Respiratory Medicine, Shizuoka City Shizuoka Hospital, 10-93 Ote-cho, Aoi-ku, Shizuoka, 420-8630, Japan
| | - Toshihiro Shirai
- Department of Respiratory Medicine, Shizuoka General Hospital, 4-27-1 Kita-ando, Aoi-ku, Shizuoka, 420-0881, Japan
| | - Masafumi Masuda
- Department of Respiratory Medicine, Shizuoka City Shimizu Hospital, 1231 Miyakami, Shimizu-ku, Shizuoka, 424-8636, Japan
| | - Hiroshi Hayakawa
- Department of Respiratory Medicine, Tenryu Hospital, National Hospital Organization, 4201-2 Oro, Hamakita-ku, Hamamatsu, 434-8511, Japan
| | - Kingo Chida
- Department of Internal Medicine, Hamamatsu Toyooka Hospital, 110 Toyooksa-cho, Kita-ku, Hamamatsu, 433-8103, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Presence of rhinovirus in the respiratory tract of adolescents and young adults with asthma without symptoms of infection. Respir Med 2016; 115:1-6. [PMID: 27215496 PMCID: PMC7125923 DOI: 10.1016/j.rmed.2016.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 04/10/2016] [Accepted: 04/13/2016] [Indexed: 12/15/2022]
Abstract
Background Viral respiratory infections have been associated with up to 80% of wheezing episodes and asthma exacerbations. However, studies on the role of these viruses in asthmatic patients in the interval between exacerbations are sparse. This study aimed to determine the presence of respiratory viruses, without symptoms of infection, in the airways of young asthmatics as compared to healthy controls. Material and Methods Patients 10–35 years of age with stable asthma and a group of healthy controls were analyzed regarding the presence of RNA from common respiratory viruses in nasopharyngeal aspirates by PCR. Self-reported asthma control and quality of life, fraction of exhaled nitric oxide (FeNO), spirometry, and bronchial responsiveness to methacholine were recorded. Blood samples were collected to assess IgE sensitisation and eosinophil cationic protein (ECP) levels. Results In 354 patients with asthma and 108 healthy controls, human rhinovirus (HRV) was the only virus detected (4.5% of asthmatics vs. 0.9% of controls; p = 0.08). HRV+ asthma patients had a higher degree of aeroallergen IgE sensitisation (median 37.7 vs. 10.4 kUA/L, p = 0.04), and a tendency for higher levels of serum ECP (median 17.2 vs. 12.6 μg/L, p = 0.07), as compared to their HRV− counterparts. Conclusions Absence of symptoms of respiratory tract infection notwithstanding, HRV seems to be more prevalent in the airways of adolescents and young adults with asthma and a high degree of aeroallergen IgE sensitisation than in controls. The presence of HRV seems also to be related to systemic eosinophilic inflammation despite ongoing treatment with inhaled corticosteroids. Cross-sectional study on adolescents and young adults with asthma and healthy controls. Common respiratory viruses examined in nasopharyngeal aspirates by PCR. Only rhinovirus detected in subjects without symptoms of respiratory tract infection. Prevalence of rhinovirus tended to be higher in asthmatics compared to controls. Presence of rhinovirus associated with high degree of aeroallergen IgE sensitisation.
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Zhou X, Hong J, Cheng H, Xie J, Yang J, Chen Q, He S, Li Y, Zhou X, Li C. Budesonide suspension nebulization treatment in Chinese pediatric patients with cough variant asthma: a multi-center observational study. J Asthma 2016; 53:532-7. [PMID: 26517446 DOI: 10.3109/02770903.2015.1111903] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe the impact of nebulized budesonide inhalation suspension (BIS) on guardian-reported symptoms in Chinese pediatric patients with cough variant asthma (CVA). METHODS This was a secondary analysis of a prospective, non-interventional study conducted at 39 Chinese sites. Patients with CVA aged ≤5 years were classified according to the severity of baseline symptoms: mild (symptom score ≤3) or severe (symptom score >3). Daytime and night-time symptom scores, disease control, use of bronchodilators, and improvements in symptoms control were compared after 1, 3, 5 and 7 weeks of treatment between groups. RESULTS Among 914 patients, 821 (89.8%) completed the 7-week treatment. Among all patients, 368 (40.3%) were classified as mild CVA and 529 (57.9%), as severe CVA. Symptom scores in the severe group were higher than those in the mild group at weeks 1, 3, and 5 (p < 0.05), but not at week 7 (p > 0.05). Further, more patients in the mild group achieved disease control at any time point (98.6% at 3 weeks and 99.7% at 7 weeks), compared with the patients in the severe group (p < 0.001). The proportion of patients requiring bronchodilators differed between the groups until week 5 (p < 0.001). No severe or drug-related adverse events were reported. CONCLUSIONS Individualized BIS treatment should be formulated according to the severity of baseline symptoms in CVA patients. Patients with mild CVA showed improvement after a shorter treatment time, while patients with severe CVA might require a longer time to respond to the treatment.
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Affiliation(s)
- Xiaojian Zhou
- a Department of Pediatrics , Shanghai General Hospital, Shanghai Jiaotong University , Shanghai , P.R. China
| | - Jianguo Hong
- b Department of Pediatrics , First Affiliated People's Hospital, Shanghai Jiaotong University , Shanghai , P.R. China
| | - Huanji Cheng
- c First Affiliated Hospital, Jilin University , Changchun , Jilin , China
| | - Juanjuan Xie
- d Wuxi City Eighth People's Hospital , Wuxi , Jiangsu , P.R. China
| | - Jianzhi Yang
- e Children's Hospital of Quanzhou City , Quanzhou , Fujian , China
| | - Qiang Chen
- f Children's Hospital of Jiangxi Province , Jiangxi , Nanchang , China
| | - Shaoru He
- g Guangdong People's Hospital , Guangzhou , Guangdong , China
| | - Yun Li
- h People's Hospital of Hunan Province , Changsha , Hunan , P.R. China
| | - Xiaoqin Zhou
- i Hubei Maternal & Child Healthcare Hospital , Wuhan , Hubei , P.R. China , and
| | - Changchong Li
- j Second Affiliated Hospital, Wenzhou Medical College , Wenzhou , Zhejiang , P.R. China
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Lin J, Yin K, Su N, Huang M, Qiu C, Liu C, Cai S, Hao C. Chinese expert consensus on clinical use of non-invasive airway inflammation assessment in bronchial asthma. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:302. [PMID: 26697462 PMCID: PMC4669313 DOI: 10.3978/j.issn.2305-5839.2015.11.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | - on behalf of the Chinese Society of Chest Physicians
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
| | - Chinese Medical Doctor Association
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
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Lin J, Yin K, Su N, Huang M, Qiu C, Liu C, Cai S, Hao C. Chinese expert consensus on clinical use of non-invasive airway inflammation assessment in bronchial asthma. J Thorac Dis 2015; 7:2061-78. [PMID: 26716047 PMCID: PMC4669291 DOI: 10.3978/j.issn.2072-1439.2015.11.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | - on behalf of the Chinese Society of Chest Physicians
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
| | - Chinese Medical Doctor Association
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
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Albertson TE, Schivo M, Gidwani N, Kenyon NJ, Sutter ME, Chan AL, Louie S. Pharmacotherapy of critical asthma syndrome: current and emerging therapies. Clin Rev Allergy Immunol 2015; 48:7-30. [PMID: 24178860 DOI: 10.1007/s12016-013-8393-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.
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Affiliation(s)
- T E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA,
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Manoharan A, von Wilamowitz-Moellendorff A, Morrison A, Lipworth BJ. Effects of formoterol or salmeterol on impulse oscillometry in patients with persistent asthma. J Allergy Clin Immunol 2015. [PMID: 26220533 DOI: 10.1016/j.jaci.2015.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Effects of small-particle long-acting β-agonists on the small airways have been poorly documented. OBJECTIVE We used impulse oscillometry (IOS) to compare single and repeated dosing effects of small- and large-particle long-acting β-agonists. METHODS After a 1- to 2-week run-in period, patients received either 12 μg of small-particle hydrofluoroalkane 134a-formoterol solution or 50 μg of large-particle salmeterol dry powder twice daily plus inhaled corticosteroid for 1 to 2 weeks with a 1- to 2-week washout period in between. Measurements were made over 60 minutes after the first and last doses. RESULTS Sixteen patients completed the study as follows: mean age, 43 years; FEV1, 80%; forced midexpiratory flow between 25% and 75% of forced vital capacity (FEF(25-75)), 48%; total airway resistance at 5 Hz, 177%; peripheral airway resistance as the difference between 5 and 20 Hz, 0.18 kPa·L(-1)·s; Asthma Control Questionnaire score, 0.76; and inhaled corticosteroid dosage, 550 μg/d. There were significantly greater improvements with formoterol versus salmeterol in all IOS outcomes and FEF25-75, but not FEV1, at 5 minutes after the first dose, which were not sustained over 60 minutes. After the last dose, all IOS outcomes, but not FEV1 or FEF(25-75), were significantly better with formoterol over the entire 60 minutes: mean difference at 60 minutes between formoterol and salmeterol in total airway resistance at 5 Hz, 7.50% (95% CI, 1.56% to 13.43%, P = .02); central airway resistance at 20 Hz, 5.37% (95% CI, 0.13% to 10.62%, P = .045); peripheral airway resistance as the difference between 5 and 20 Hz, 12.76% (95% CI, 1.28% to 24.24%, P = .03); reactance area under the curve, 19.46% (95% CI, 7.56% to 31.36%, P = .003); reactance at 5 Hz, 11.19% (95% CI, 4.62% to 17.76%, P = .002); and resonant frequency, 9.34% (95% CI, 3.21% to 15.47%, P = .005). Peak expiratory flow significantly improved to a similar degree with both drugs. CONCLUSION Significant improvements in IOS outcomes but not spirometry results occurred after chronic dosing with formoterol compared with salmeterol. This might reflect better deposition to the entire lung, including the small airways.
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Affiliation(s)
- Arvind Manoharan
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| | | | - Ashley Morrison
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom.
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Tural Onur S, Yalcin AD, Celik B, Gumuslu S. Evaluation of d-dimer, CXCL8, homocysteine, eosinophil cationic peptide, 25(OH)-vitamin D and immunomodulatory OX-2 levels in allergic patients. J Asthma 2015; 52:123-7. [PMID: 24986253 DOI: 10.3109/02770903.2014.936450] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Studies on sCD200 (OX-2), 25-hydroxyvitamin-D (25(OH)D), homocysteine (hcy), eosinophil cationic peptide (ECP), d-dimer, CXCL8 and fractional exhale nitric oxide concentrations in allergic patients in Mediterranean regions under various climatic conditions have not been performed. In this report, blood samples were taken in May and June during times of high air pollination. This study was performed to compare serum biomolecule concentrations in allergic patients and matched controls and to evaluate the characteristics of allergic disease. METHODS The study participants (n = 129) included 25 healthy individuals (controls) and 104 allergic patients. Consecutive patients with managed allergic disease (Group II, III, IV and V) above the age of 18 years were included. RESULTS In the control group, there was a significant positive correlation between ECP level and body mass index (BMI). Positive correlations among ECP, IgE and OX-2 levels were detected in Group IV. In Group V patients, positive correlations between age and IgE and between BMI and 25(OH)D were identified. Statistical analysis revealed positive correlations among basophil, eosinophil and OX-2 levels, and a negative correlation between ECP and age in Group V. CONCLUSION Overall, these data suggest that hcy, 25(OH)D and OX-2 may be useful biomarkers for conventional clinical measurements.
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Affiliation(s)
- Seda Tural Onur
- Yedikule Chest Disease and Thorax Surgery Education and Research Hospital , Chest Disease Clinic, Istanbul , Turkey
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The inverse agonist propranolol confers no corticosteroid-sparing activity in mild-to-moderate persistent asthma. Clin Sci (Lond) 2014; 127:635-43. [PMID: 24938324 DOI: 10.1042/cs20140249] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The murine asthma model shows that switching off airway β2 receptors with an inverse agonist may confer anti-inflammatory effects as well as corticosteroid-sparing activity. We have assessed for any corticosteroid-sparing effects of propranolol, an inverse agonist, added to low-dose inhaled corticosteroid (ICS) compared with higher dose ICS. A randomized double-blind placebo-controlled cross-over trial in mild-to-moderate persistent asthmatic patients was performed. After a run-in (2 weeks) on hydrofluoroalkane-beclometasone dipropionate (HFA-BDP) at 100 μg/day (HFA-BDP100), patients received randomized treatments (4 weeks) with propranolol at 80 mg/day plus HFA-BDP at 100 μg/day compared with placebo plus HFA-BDP at 400 μg/day (HFA-BDP400). Propranolol was up-titrated to 80 mg/day over the initial 2 weeks. Tiotropium was co-administered until 5 days before each histamine challenge (the primary outcome). Sixteen patients completed the study [mean age, 38 years; forced expiratory volume in 1 s (FEV1), 86.4%; histamine provocative concentration causing a 20% fall in FEV1 (PC20), 1.39 mg/ml; ICS dose, 406 μg/day]. Histamine PC20 was unchanged by adding propranolol to HFA-BDP100 compared with baseline (HFA-BDP100) {0.17 doubling dilution (dd) difference [95% confidence interval (CI): -0.58 to 0.92]}, but there was a significant improvement with HFA-BDP400 compared with both baseline [1.05 dd (95% CI: 0.43-1.66); P=0.02], and propranolol+HFA-BDP100 [0.88 dd (95% CI: 0.45-1.30); P=0.006]. Significant improvements were also observed with HFA-BDP400 for exhaled nitric oxide, blood eosinophils, serum eosinophilic cationic protein and asthma quality-of-life questionnaire symptoms compared with propranolol+HFA-BDP100. Salbutamol recovery post-challenge was partially blunted by propranolol (median prolongation 5 min; P=0.002). Domiciliary evening FEV1 also fell with propranolol+HFA-BDP100 [mean reduction from baseline 0.22 litres (95% CI: 0.10-0.34); P=0.012], whereas Asthma Control Questionnaire remained unchanged. In conclusion, the inverse agonist propranolol produced no improvements when given with low-dose ICS, whereas further significant improvements in airway hyper-responsiveness and inflammation were demonstrated with higher dose ICS. Thus, propranolol does not confer corticosteroid-sparing activity in persistent asthma.
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Barnes PJ, Casale TB, Dahl R, Pavord ID, Wechsler ME. The Asthma Control Questionnaire as a clinical trial endpoint: past experience and recommendations for future use. Allergy 2014; 69:1119-40. [PMID: 25039248 DOI: 10.1111/all.12415] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2014] [Indexed: 12/24/2022]
Abstract
The goal of asthma treatment is to control the disease according to guidelines issued by bodies such as the Global Initiative for Asthma. Effective control is dependent upon evaluation of symptoms, initiation of appropriate treatment and minimization of the progressive adverse effects of the disease and its therapies. Although individual outcome measures have been shown to correlate with asthma control, composite endpoints are preferred to enable more accurate and robust monitoring of the health of the individual patient. A number of validated instruments are utilized to capture these component endpoints; however, there is no consensus on the optimal instrument for use in clinical trials. The Asthma Control Questionnaire (ACQ) has been shown to be a valid, reliable instrument that allows accurate and reproducible assessment of asthma control that compares favourably with other commonly used instruments. This analysis provides a summary of the use of ACQ in phase II, III and IV asthma trials. Comparisons between the ACQ and other instruments are also presented. Our analysis suggests that the ACQ is a valid and robust measure for use as a primary or secondary endpoint in future clinical trials.
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Affiliation(s)
- P. J. Barnes
- Airway Disease Section; National Heart & Lung Institute; London UK
| | | | - R. Dahl
- Allergy Centre; Odense University Hospital; Odense Denmark
| | - I. D. Pavord
- Department of Respiratory Medicine; Nuffield Department of Medicine; University of Oxford; Oxford UK
| | - M. E. Wechsler
- Department of Medicine; National Jewish Health; Denver CO USA
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Paredi P, Kharitonov SA, Meah S, Barnes PJ, Usmani OS. A novel approach to partition central and peripheral airway nitric oxide. Chest 2014; 145:113-119. [PMID: 23989961 DOI: 10.1378/chest.13-0843] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Determining the site of airways inflammation may lead to the targeting of therapy. Nitric oxide (NO) is a biomarker of airway inflammation and can be measured at multiple exhalation flow rates to allow partitioning into bronchial (large/central airway maximal nitric oxide flux [J'awno]) and peripheral (peripheral/small airway/alveolar nitric oxide concentration [Cano]) airway contributions by linear regression. This requires a minimum of three exhalations. We developed a simple and practical method to partition NO. METHODS In 29 healthy subjects (FEV1, 97% ± 3% predicted), 13 patients with asthma (FEV1, 90% ± 4% predicted), 14 patients with COPD (FEV1, 59% ± 3% predicted), and 12 patients with cystic fibrosis (CF) (FEV1, 60% ± 3% predicted), we measured the area under the curve of the NO concentration/exhalation time plot (AUC-NO) at exhalation flow rates of 50, 100, 200, and 300 mL/s. We determined the change of the total AUC-NO production (ΔAUC-NO) among the four different exhalation flow rates and compared these levels to Cano and J'awno indices measured conventionally by linear regression. RESULTS The change in AUC-NO between increasing exhalation flow rates of 50 to 200 mL/s (ΔAUC-NO50-200) was strongly correlated with J'awno in all patient groups as follows: healthy subjects (r = 0.94, P < .001), patients with asthma (r = 0.98, P < .001), patients with COPD (r = 0.93, P < .001), and patients with CF (r = 0.74, P < .05). In all subjects, AUC-NO at an exhalation flow rate of 200 mL/s (AUC-NO200) correlated with Cano (r = 0.69, P < .01). CONCLUSIONS The bronchial production of NO can be determined by measuring ΔAUC-NO50-200, whereas AUC-NO200 measures its peripheral concentration. This approach is simple, quick, and does not require sophisticated equipment or mathematical models.
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Affiliation(s)
- Paolo Paredi
- Airways Disease Section, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, England.
| | - Sergei A Kharitonov
- Airways Disease Section, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, England
| | - Sally Meah
- Airways Disease Section, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, England
| | - Peter J Barnes
- Airways Disease Section, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, England
| | - Omar S Usmani
- Airways Disease Section, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, England
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Lipworth B. β-Adrenoceptor Genotype and Bronchoprotective Subsensitivity with Long-Acting β-Agonists in Asthma. Am J Respir Crit Care Med 2013; 188:1386-7. [DOI: 10.1164/rccm.201311-1968ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Yalcin AD, Cilli A, Bisgin A, Strauss LG, Herth F. Omalizumab is effective in treating severe asthma in patients with severe cardiovascular complications and its effects on sCD200, d-dimer, CXCL8, 25-hydroxyvitamin D and IL-1β levels. Expert Opin Biol Ther 2013; 13:1335-41. [PMID: 23883435 DOI: 10.1517/14712598.2013.819338] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There have been concerns about the cardiovascular safety of omalizumab. OBJECTIVES In this study, the clinical status of the omalizumab receiving severe asthma patients and the cytokine expressions patterns were investigated. MATERIALS AND METHODS In a pilot study described below we examined the levels of serum eosinophil cationic peptid (ECP), CD200, d-dimer, 25-hydroxyvitamin D (25(OH)D), CXCL8 and IL-1β in asthma patients treated with anti-IgE therapy, to explore their relationship with disease activity, and the impact of anti-IgE therapy impact on those levels. Exercise stress testing and blood samples were taken at all follow up visits from the time of first diagnosis and after 20 months of treatment during the disease remission. RESULTS Fractional exhaled nitric oxide concentrations and serum levels of sTRAIL, sCD200, D-dimer, ECP, total IgE, IL-1β and Hs-CRP were decreased while CXCL8, 25(OH)D were increased after starting the treatment of anti-IgE. Our first case of a patient, who had both protein C and S deficiency and hence a high risk for thromboembolism, documents for the first time the safety of omalizumab for asthmatic patients with concurrent risk factors contributing to arteriothrombotic events. CONCLUSION Omalizumab might be used carefully in patients with cardiovascular diseases.
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Affiliation(s)
- Arzu Didem Yalcin
- Antalya Training and Research Hospital, Allergy and Clinical Immunology Unit, Antalya, Turkey
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