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Hayashi H, Ishii M, Hasegawa Y, Taniguchi M. Critical pathomechanisms of NSAID-exacerbated respiratory disease (N-ERD) clarified by treatment with omalizumab, an anti-IgE antibody. Allergol Int 2024:S1323-8930(24)00108-4. [PMID: 39419650 DOI: 10.1016/j.alit.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/18/2024] [Accepted: 08/23/2024] [Indexed: 10/19/2024] Open
Abstract
Characteristic symptoms of NSAID-exacerbated respiratory disease (N-ERD) include asthma, chronic eosinophilic rhinosinusitis with nasal polyposis, cysteinyl LT (CysLT) overproduction and NSAIDs hypersensitivity. Some N-ERD patients present with episodic treatment-resistant extra-respiratory symptoms (CysLT-associated coronary artery vasospasm, gastroenteritis, or skin rash). Even when using standard treatments for respiratory and extra-respiratory symptoms, including systemic corticosteroids and aspirin desensitization, it is difficult to control the clinical symptoms and severe type 2 inflammation involved with mast cells, eosinophils, ILC2s, and platelet activation. Few treatment options are applicable in a clinical setting. Therefore, identifying effective treatments is essential for managing N-ERD patients who suffer from these conditions. Our previous observational study demonstrated 12-month omalizumab treatment of N-ERD was clinically effective against respiratory symptoms. Despite the remaining eosinophilia, omalizumab significantly reduced urinary LTE4 and PGD2 metabolites to near normal levels at steady state. Based on the preliminary study, we demonstrated that omalizumab induced tolerance to aspirin in N-ERD patients 3 months after therapy initiation and suppressed activation of mast cells during 24 h of initiation in a randomized manner. Moreover, omalizumab had significant efficacy against extra-respiratory symptoms at baseline (lacking aspirin exposure) as well as throughout aspirin challenge. This review addresses the latest discoveries related to N-ERD pathogenesis and the significant effectiveness of omalizumab on N-ERD as a mast cell stabilizer. Our findings regarding omalizumab-associated mast cell inhibitory effects are indirect evidence that mast cell dysregulation and, possibly, IgE are pivotal components of N-ERD.
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Affiliation(s)
- Hiroaki Hayashi
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan; Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Makoto Ishii
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan; National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Masami Taniguchi
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
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Hillson K, Saglani S, Bush A. The new biologic drugs: Which children with asthma should get what? Pediatr Pulmonol 2024. [PMID: 39267467 DOI: 10.1002/ppul.27218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 07/21/2024] [Accepted: 08/09/2024] [Indexed: 09/17/2024]
Abstract
Novel biologics (targeted antibody therapies) have revolutionized the management of severe childhood asthma. However, it is important that the right biologic is selected for the right patient, and understanding the evidence base for each biologic is crucial. Currently, four biologics (all monoclonal antibodies) are licensed in the UK for the treatment of children with severe asthma - omalizumab (Xolair), mepolizumab (Nucala), and dupilumab (Dupixent) in children aged 6 years and over; and tezepelumab (Tezspire), only in children aged 12 years and over. Tezepelumab is the only licensed biological that may be beneficial in severe asthma without evidence of Type 2 inflammation. All have a good safety profile but varying degrees of clinical efficacy in children, with wide variation in treatment responsiveness between individual patients. When selecting biologics for severe asthma, it is essential to remember the limitations of the current pediatric evidence. At present, there are no results from randomized, head-to-head trials of biologics in severe asthma. TREAT is an ongoing trial comparing omalizumab to mepolizumab and will be one of the first to provide such evidence. We must be especially aware of the dangers of extrapolating data from adults to children, because the pathophysiology and role of biomarkers may differ significantly from adult asthma. Given the current level of knowledge, even after treatment has been initiated, children should be regularly reviewed to determine the efficacy of treatment, side-effect profile and consideration of when treatment with the biologic should be discontinued.
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Affiliation(s)
- K Hillson
- National Heart and Lung Institute, Imperial College London, London, UK
- Pediatric Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, UK
| | - S Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Pediatric Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, UK
| | - A Bush
- National Heart and Lung Institute, Imperial College London, London, UK
- Pediatric Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, UK
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Kyriakopoulos C, Gogali A, Markozannes G, Kostikas K. Biologic agents licensed for severe asthma: a systematic review and meta-analysis of randomised controlled trials. Eur Respir Rev 2024; 33:230238. [PMID: 38657997 PMCID: PMC11040390 DOI: 10.1183/16000617.0238-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/23/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Six biologic agents are now approved for patients with severe asthma. This meta-analysis aimed to assess the efficacy and safety of licensed biologic agents in patients with severe asthma, including the recently approved tezepelumab. METHODS We searched MEDLINE, Embase and CENTRAL to identify randomised controlled trials involving licensed biologics until 31 January 2023. We used random-effects meta-analysis models for efficacy, including subgroup analyses by individual agents and markers of T2-high inflammation (blood eosinophils and fractional exhaled nitric oxide), and assessed safety. RESULTS 48 studies with 16 350 patients were included in the meta-analysis. Biologics were associated with a 44% reduction in the annualised rate of asthma exacerbations (rate ratio 0.56, 95% CI 0.51-0.62) and 60% reduction of hospitalisations (rate ratio 0.40, 95% CI 0.27-0.60), a mean increase in the forced expiratory volume in 1 s of 0.11 L (95% CI 0.09-0.14), a reduction in asthma control questionnaire by 0.34 points (95% CI -0.46--0.23) and an increase in asthma quality of life questionnaire by 0.38 points (95% CI 0.26-0.49). There was heterogeneity between different classes of biologics in certain outcomes, with overall greater efficacy in patients with T2 inflammation. Overall, biologics exhibited a favourable safety profile. CONCLUSIONS This comprehensive meta-analysis demonstrated that licensed asthma biologics reduce exacerbations and hospitalisations, improve lung function, asthma control and quality of life, and limit the use of systemic corticosteroids, with a favourable safety profile. These effects are more prominent in patients with evidence of T2 inflammation.
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Affiliation(s)
- Christos Kyriakopoulos
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Athena Gogali
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Georgios Markozannes
- Department of Hygiene and Epidemiology, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
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Russell RJ, Boulet LP, Brightling CE, Pavord ID, Porsbjerg C, Dorscheid D, Sverrild A. The airway epithelium: an orchestrator of inflammation, a key structural barrier and a therapeutic target in severe asthma. Eur Respir J 2024; 63:2301397. [PMID: 38453256 PMCID: PMC10991852 DOI: 10.1183/13993003.01397-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/15/2024] [Indexed: 03/09/2024]
Abstract
Asthma is a disease of heterogeneous pathology, typically characterised by excessive inflammatory and bronchoconstrictor responses to the environment. The clinical expression of the disease is a consequence of the interaction between environmental factors and host factors over time, including genetic susceptibility, immune dysregulation and airway remodelling. As a critical interface between the host and the environment, the airway epithelium plays an important role in maintaining homeostasis in the face of environmental challenges. Disruption of epithelial integrity is a key factor contributing to multiple processes underlying asthma pathology. In this review, we first discuss the unmet need in asthma management and provide an overview of the structure and function of the airway epithelium. We then focus on key pathophysiological changes that occur in the airway epithelium, including epithelial barrier disruption, immune hyperreactivity, remodelling, mucus hypersecretion and mucus plugging, highlighting how these processes manifest clinically and how they might be targeted by current and novel therapeutics.
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Affiliation(s)
- Richard J Russell
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | | | - Christopher E Brightling
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ian D Pavord
- Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Celeste Porsbjerg
- Department of Respiratory Medicine and Infectious Diseases, Bispebjerg Hospital, Copenhagen University, Copenhagen, Denmark
| | - Del Dorscheid
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Asger Sverrild
- Department of Respiratory Medicine and Infectious Diseases, Bispebjerg Hospital, Copenhagen University, Copenhagen, Denmark
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Weng CM, Wu WC, Lee MJ, Chen MC, Chou CL, Lin CY, Chung KF, Kuo HP. Influence of Staphylococcal enterotoxin-specific IgE sensitization on therapeutic efficacy of omalizumab therapy in severe asthma. Respirology 2024; 29:252-255. [PMID: 38296607 DOI: 10.1111/resp.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Chih-Ming Weng
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Center of Thoracic Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wei-Ciao Wu
- Center of Thoracic Medicine, Taipei Medical University, Taipei, Taiwan
| | - Meng-Jung Lee
- Center of Thoracic Medicine, Taipei Medical University, Taipei, Taiwan
| | - Mei-Chuan Chen
- Center of Thoracic Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Thoracic Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Liang Chou
- Center of Thoracic Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Thoracic Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Yu Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Kian Fan Chung
- Airway Disease Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Royal Brompton and Harefield Hospitals, London, United Kingdom
- College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Han-Pin Kuo
- Center of Thoracic Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Thoracic Medicine, Taipei Medical University Hospital, Taipei, Taiwan
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Park J, Kang SJ. The ontogenesis and heterogeneity of basophils. DISCOVERY IMMUNOLOGY 2024; 3:kyae003. [PMID: 38567293 PMCID: PMC10941320 DOI: 10.1093/discim/kyae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/02/2024] [Accepted: 01/31/2024] [Indexed: 04/04/2024]
Abstract
Basophils are the rarest leukocytes, but they have essential roles in protection against helminths, allergic disorders, autoimmune diseases, and some cancers. For years, the clinical significance of basophils has been neglected because of the lack of proper experimental tools to study them. The development of basophil-specific antibodies and animal models, along with genomic advances like single-cell transcriptomics, has greatly enhanced our understanding of basophil biology. Recent discoveries regarding basophils prompted us to write this review, emphasizing the basophil developmental pathway. In it, we chronologically examine the steps of basophil development in various species, which reveals the apparent advent of basophils predating IgE and basophil's IgE-independent regulatory role in primitive vertebrates. Then, we cover studies of basophil development in adult bone marrow, and compare those of murine and human basophils, introducing newly identified basophil progenitors and mature basophil subsets, as well as the transcription factors that regulate the transitions between them. Last, we discuss the heterogeneity of tissue-resident basophils, which may develop through extramedullary hematopoiesis. We expect that this review will contribute to a deeper understanding of basophil biology from the intricate aspects of basophil development and differentiation, offering valuable insights for both researchers and clinicians.
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Affiliation(s)
- Jiyeon Park
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology (KAIST), Daejeon34141, Republic of Korea
| | - Suk-Jo Kang
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology (KAIST), Daejeon34141, Republic of Korea
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7
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Liao J, Tang J, Jiang Y, Wang Y, Ding J, He Y. Effects of omalizumab on lung function in patients with moderate-to-severe allergic asthma: a systematic review and meta-analysis. Ther Adv Respir Dis 2024; 18:17534666231221771. [PMID: 38235607 PMCID: PMC10798107 DOI: 10.1177/17534666231221771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 12/04/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND With the rise of targeted treatments for asthma, treatment with omalizumab is a new option. OBJECTIVES To assess the improvement of pulmonary function with additional omalizumab treatment in patients (⩾6 years old) with moderate-to-severe allergic asthma. DATA SOURCES AND METHODS Observational studies of randomized controlled trials of add-on omalizumab for the treatment of patients with moderate-to-severe allergic asthma, published from the establishment till August 2022, were retrieved from WAN FANG DATA, PubMed, CNKI, Embase, Cochrane, and Web of Science databases. Data extraction and quality evaluation were performed on the literature that met the inclusion criteria, using RevMan 5.3 to analyze the data. RESULTS A total of 11 randomized controlled clinical trials were included, involving a total of 3578 patients with asthma, 1856 patients in the omalizumab group, and 1722 patients in the control group. The improvement in Forced expiratory volume in 1 s as a percentage of predicted normal and Forced expiratory volume in 1 s was more pronounced in the omalizumab-treated group [MD = 3.91, 95% confidence interval (CI): 1.89-5.94, p = 0.0002; MD = 0.09, 95% CI: 0.05-0.13, p < 0.0001], while the improvement in Morning Peak expiratory flow rate was not statistically different between the two groups (MD = 3.64, 95% CI: -22.17-29.45, p = 0.78). CONCLUSION Additional omalizumab treatment showed some improvement in lung function in patients with moderate-to-severe asthma. TRIAL REGISTRATION PROSPERO ID:CRD42022378498.
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Affiliation(s)
- Junyi Liao
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jia Tang
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Yuanping Jiang
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Youwen Wang
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jiali Ding
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Yong He
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing 402160, China
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Nieto A, El-Sayed ZA, Gómez RM, Hossny E, Jiu-Yao W, Kalayci Ö, Morais-Almeida M, Phipatanakul W, Pitrez PM, Pozo Beltrán CF, Xepapadaki P, Papadopoulos NG. Unanswered questions on the use of biologics in pediatric asthma. World Allergy Organ J 2023; 16:100837. [PMID: 38020283 PMCID: PMC10656246 DOI: 10.1016/j.waojou.2023.100837] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
The emergence of biologic therapies for the management of asthma has been a revolutionary change in our capacity to manage this disease. Since the launch of omalizumab, several other biologics have been marketed or are close to being marketed, suggesting that a plethora of monoclonal antibodies can be expected in the coming years. This will facilitate the transition to the paradigm of personalized medicine, but on the other hand will decisively further complicate the choice of the most appropriate treatment, in the absence of reliable enough biological markers. For these reasons, along with the relatively short time of use with these treatments, there are recurrently arising questions for which there are not even moderately documented answers, and for which the only solution must be based, with all reservations, on the combination of indirect evidence and expertise. In this paper, we attempt to address such questions, providing relevant commentaries and considering the whole width of the evidence base.
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Affiliation(s)
- Antonio Nieto
- Pediatric Pulmonology & Allergy Unit. Health Research Institute. Children's Hospital La Fe, Valencia, Spain
| | - Zeinab A. El-Sayed
- Pediatric Allergy, Immunology and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Elham Hossny
- Pediatric Allergy, Immunology and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Wang Jiu-Yao
- Research Center of Allergy, Immunology, and Microbiome (A.I.M.). China Medical University Children's Hospital, Taichung, Taiwan
| | - Ömer Kalayci
- Pediatric Allergy and Asthma, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Mário Morais-Almeida
- Allergy Center, CUF Descobertas Hospital, CUF Academic and Research Medical Center, Lisbon, Portugal
| | - Wanda Phipatanakul
- Pediatric Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Paulo Marcio Pitrez
- School of Medicine, Pediatric Pulmonary Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | | | | | - Nikolaos G. Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
- Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
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Schleich F, Moermans C, Gerday S, Ziant S, Louis G, Bougard N, Paulus V, Guissard F, Henket M, Bachert C, Louis R. Patients With Asthma Only Sensitized to Staphylococcus aureus Enterotoxins Have More Exacerbations, Airflow Limitation, and Higher Levels of Sputum IL-5 and IgE. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3055-3061.e4. [PMID: 37301436 DOI: 10.1016/j.jaip.2023.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Staphylococcus aureus enterotoxins (SE) may act as superantigens and induce an intense T-cell activation, causing local production of polyclonal IgE and resultant eosinophil activation. OBJECTIVE To assess whether asthma with sensitization to SE but not to common aeroallergens (AAs) displays different inflammatory characteristics. METHODS We conducted a prospective study on a series of 110 consecutive patients with asthma recruited from the University Asthma Clinic of Liège. We compared clinical, functional, and inflammatory characteristics of this general population of patients with asthma categorized into 4 groups according to sensitization to AAs and/or SE. We also compared sputum supernatant cytokines in patients sensitized to SE or not. RESULTS Patients with asthma sensitized only to AAs represented 30%, while 29% were sensitized to both AAs and SE. One-fifth of the population had no specific IgE. Sensitization to SE but not to AA (21%) was associated with later onset of disease, higher rate of exacerbations, nasal polyps, and more severe airway obstruction. As for airway type 2 biomarkers, patients presenting with specific IgE against SE displayed higher fractional exhaled nitric oxide, sputum IgE, and sputum IL-5 levels but not IL-4. We confirm that the presence of specific IgE against SE is associated with elevated serum IgE to levels well above those observed in patients sensitized only to AAs. CONCLUSIONS Our study suggests that asthma specialists should measure specific IgE against SE during the phenotyping process because it may allow the identification of a subgroup of patients with more asthma exacerbations, more nasal polyposis and chronic sinusitis, lower lung function, and more intense type 2 inflammation.
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Affiliation(s)
- Florence Schleich
- CHU Liège Sart-Tilman, University of Liège, GIGA I(3), Liège, Belgium.
| | | | - Sara Gerday
- CHU Liège Sart-Tilman, University of Liège, GIGA I(3), Liège, Belgium
| | - Stéphanie Ziant
- CHU Liège Sart-Tilman, University of Liège, GIGA I(3), Liège, Belgium
| | - Gilles Louis
- CHU Liège Sart-Tilman, University of Liège, GIGA I(3), Liège, Belgium
| | - Nicolas Bougard
- CHU Liège Sart-Tilman, University of Liège, GIGA I(3), Liège, Belgium
| | - Virginie Paulus
- CHU Liège Sart-Tilman, University of Liège, GIGA I(3), Liège, Belgium
| | | | - Monique Henket
- CHU Liège Sart-Tilman, University of Liège, GIGA I(3), Liège, Belgium
| | - Claus Bachert
- ENT-Clinic, University Hospital of Münster, Münster, Germany; Division of ENT Diseases, CLINTEC, Karolinska Institute, Stockholm, Sweden; Upper Airway Research Laboratory, Ghent University, Ghent, Belgium
| | - Renaud Louis
- CHU Liège Sart-Tilman, University of Liège, GIGA I(3), Liège, Belgium
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Wang W, Li J, Zou C, Zhao L, Zhu Y, Guo Y, Wang F. Omalizumab for Chinese patients with moderate-to-severe allergic asthma in real-world clinical setting: a prospective, observational study. BMJ Open Respir Res 2023; 10:e001549. [PMID: 37734750 PMCID: PMC10514615 DOI: 10.1136/bmjresp-2022-001549] [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: 11/14/2022] [Accepted: 08/25/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND We aimed to investigate the effectiveness of omalizumab, a monoclonal anti-immunoglobulin E antibody, in Chinese patients with moderate-to-severe allergic asthma in real-world clinical practice. METHODS This single-centre, prospective, observational study included Chinese patients aged 14-75 years with moderate-to-severe allergic asthma according to the Global Initiative for Asthma criteria. Omalizumab was administered subcutaneously, and the investigator collected real-world data on exacerbations, steroid exposure, pulmonary function and laboratory assessments at weeks 16, 24, 52, 104 and 156 after treatment initiation. The primary outcome was reduced exacerbations, measured as the proportion of patients with exacerbations in the year following omalizumab initiation. Bowker's test for paired proportions was performed to compare exacerbation rates before and after treatment initiation. A generalised linear mixed model was used to compare the number of exacerbations. RESULTS The mean treatment duration was 46.6 weeks for the full analysis set (n=398). The proportion of patients with exacerbations in the year before and after omalizumab initiation was 80.4% (181/225) and 18.7% (42/225) (difference: -61.8%, 95% CI -68.5 to -54.0, p<0.0001), respectively. At week 52, 67.4% of patients discontinued oral corticosteroids, and 19.5% reduced inhaled corticosteroids. The Asthma Control Test scores increased by 4.6 at week 52 from baseline (p<0.001). Forced expiratory volume in 1 s increased by 11.2% and 9.0% at weeks 24 and 52, respectively, from baseline (p<0.01). Injection site reactions (5.2%) were the most frequently reported adverse event. CONCLUSIONS In real-world clinical practice, omalizumab treatment remarkably reduced exacerbations in Chinese patients with moderate-to-severe asthma. Omalizumab reduced the use of oral corticosteroids and improved asthma control and pulmonary function.
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Affiliation(s)
- Wen Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jieying Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Congying Zou
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Lifang Zhao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ya Zhu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yue Guo
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Feiran Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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11
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Lommatzsch M, Criée CP, de Jong CCM, Gappa M, Geßner C, Gerstlauer M, Hämäläinen N, Haidl P, Hamelmann E, Horak F, Idzko M, Ignatov A, Koczulla AR, Korn S, Köhler M, Lex C, Meister J, Milger-Kneidinger K, Nowak D, Pfaar O, Pohl W, Preisser AM, Rabe KF, Riedler J, Schmidt O, Schreiber J, Schuster A, Schuhmann M, Spindler T, Taube C, Christian Virchow J, Vogelberg C, Vogelmeier CF, Wantke F, Windisch W, Worth H, Zacharasiewicz A, Buhl R. [Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]. Pneumologie 2023; 77:461-543. [PMID: 37406667 DOI: 10.1055/a-2070-2135] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.
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Affiliation(s)
- Marek Lommatzsch
- Zentrum für Innere Medizin, Abt. für Pneumologie, Universitätsmedizin Rostock
| | | | - Carmen C M de Jong
- Abteilung für pädiatrische Pneumologie, Abteilung für Pädiatrie, Inselspital, Universitätsspital Bern
| | - Monika Gappa
- Klinik für Kinder und Jugendliche, Evangelisches Krankenhaus Düsseldorf
| | | | | | | | - Peter Haidl
- Abteilung für Pneumologie II, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg
| | - Eckard Hamelmann
- Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld
| | | | - Marco Idzko
- Abteilung für Pulmologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien
| | - Atanas Ignatov
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum Magdeburg
| | - Andreas Rembert Koczulla
- Schön-Klinik Berchtesgadener Land, Berchtesgaden
- Klinik für Innere Medizin Schwerpunkt Pneumologie, Universitätsklinikum Marburg
| | - Stephanie Korn
- Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg
| | - Michael Köhler
- Deutsche Patientenliga Atemwegserkrankungen, Gau-Bickelheim
| | - Christiane Lex
- Klinik für Kinder- und Jugendmedizin, Universitätsmedizin Göttingen
| | - Jochen Meister
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Aue
| | | | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - Oliver Pfaar
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Sektion für Rhinologie und Allergie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg
| | - Wolfgang Pohl
- Gesundheitszentrum Althietzing, Karl Landsteiner Institut für klinische und experimentelle Pneumologie, Wien
| | - Alexandra M Preisser
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Klaus F Rabe
- Pneumologie, LungenClinic Großhansdorf, UKSH Kiel
| | - Josef Riedler
- Abteilung für Kinder- und Jugendmedizin, Kardinal Schwarzenberg Klinikum Schwarzach
| | | | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg
| | - Antje Schuster
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf
| | | | | | - Christian Taube
- Klinik für Pneumologie, Universitätsmedizin Essen-Ruhrlandklinik
| | | | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Wolfram Windisch
- Lungenklinik Köln-Merheim, Lehrstuhl für Pneumologie, Universität Witten/Herdecke
| | - Heinrich Worth
- Pneumologische & Kardiologische Gemeinschaftspraxis, Fürth
| | | | - Roland Buhl
- Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz
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12
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Günaydın F, Ediger D, Erbay M, Pekbak G. Can omalizumab be an alternative treatment for non-atopic severe asthma? A real-life experience with omalizumab. Tuberk Toraks 2023; 71:24-33. [PMID: 36912406 PMCID: PMC10795235 DOI: 10.5578/tt.20239904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/28/2023] [Indexed: 03/14/2023] Open
Abstract
Introduction Omalizumab, a humanized monoclonal anti-IgE antibody, has largely demonstrated its efficacy in severe allergic asthma. There are limited data about the effectiveness of omalizumab in patients with non-atopic severe persistent asthma. In this study, we aimed to determine the effect of omalizumab in patients with non-atopic severe asthma and compare the data obtained with those in patients with allergic severe asthma. Materials and Methods This study was an observational, retrospective, tertiary single-center study that assessed and compared the clinical outcome of adult patients with severe asthma (165 atopic and 41 non-atopic) who have been on omalizumab for one year or longer between January 2008 and January 2020. Effectiveness was assessed by considering symptom scores (GINA symptom control score), daily systemic corticosteroids (SCS) dosage, blood eosinophil counts, pulmonary function, and number of severe exacerbations and hospitalizations within the last one year. Result Omalizumab exhibited significant improvement in the clinical status of non-atopic asthma patients as measured by GINA symptom score [decreased from 3.77 ± 0.63 to 1.36 ± 1.27 (p<0.001)], the number of emergency room visits for asthma [decreased from 11.25 ± 14.69 to 0.25 ± 0.55 (p<0.001)], and the number of hospitalizations [decreased from 1.17 ± 2.87 to 0.14 ± 0.36 (p= 0.036)]. These results were not significantly different from those obtained in allergic asthma patients. FEV1 improved significantly from 2.08 ± 0.86 to 2.14 ± 0.84 (p= 0.041) and oral corticosteroid doses decreased significantly from 1.67 ± 7.49 to 0.46 ± 2.74 (p= 0.015) in the only atopic group. Conclusions Omalizumab, which is a proven and effective treatment option for allergic asthma, may also be an efficacious alternative option in non-atopic severe asthma.
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Affiliation(s)
- F.E. Günaydın
- Department of Allergy and Immunology, Bursa Uludağ University Faculty of Medicine, Bursa, Türkiye
| | - D. Ediger
- Department of Allergy and Immunology, Bursa Uludağ University Faculty of Medicine, Bursa, Türkiye
| | - M. Erbay
- Department of Allergy and Immunology, Bursa Uludağ University Faculty of Medicine, Bursa, Türkiye
| | - G. Pekbak
- Department of Allergy and Immunology, Bursa Uludağ University Faculty of Medicine, Bursa, Türkiye
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13
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Omalizumab effectiveness is independent of Staphylococcal Enterotoxin sensitization. Respir Med Res 2022; 83:100986. [PMID: 36630776 DOI: 10.1016/j.resmer.2022.100986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/15/2022]
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14
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Sim S, Choi Y, Park HS. Immunologic Basis of Type 2 Biologics for Severe Asthma. Immune Netw 2022; 22:e45. [PMID: 36627938 PMCID: PMC9807964 DOI: 10.4110/in.2022.22.e45] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 12/30/2022] Open
Abstract
Asthma is a chronic airway inflammatory disease characterized by reversible airway obstruction and airway hyperreactivity to various environmental stimuli, leading to recurrent cough, dyspnea, and wheezing episodes. Regarding inflammatory mechanisms, type 2/eosinophilic inflammation along with activated mast cells is the major one; however, diverse mechanisms, including structural cells-derived and non-type 2/neutrophilic inflammations are involved, presenting heterogenous phenotypes. Although most asthmatic patients could be properly controlled by the guided treatment, patients with severe asthma (SA; classified as a treatment-refractory group) suffer from uncontrolled symptoms with frequent asthma exacerbations even on regular anti-inflammatory medications, raising needs for additional controllers, including biologics that target specific molecules found in asthmatic airway, and achieving the precision medicine for asthma. This review summarizes the immunologic basis of airway inflammatory mechanisms and current biologics for SA in order to address unmet needs for future targets.
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Affiliation(s)
- Soyoon Sim
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon 16499, Korea.,Department of Biomedical Sciences, Graduate School of Ajou University, Suwon 16499, Korea
| | - Youngwoo Choi
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon 16499, Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon 16499, Korea.,Department of Biomedical Sciences, Graduate School of Ajou University, Suwon 16499, Korea
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15
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Melscoet L, Khayath N, Migueres N, Goltzene MA, Meyer N, de Blay F. Severe non-atopic asthma: omalizumab can reduce severe asthma exacerbations. J Asthma 2022; 60:881-889. [PMID: 35862624 DOI: 10.1080/02770903.2022.2103427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Introduction: Humanized monoclonal anti-IgE antibody (omalizumab) has demonstrated efficacy in severe atopic asthma. However, few studies have assessed its efficacy in non-atopic and even less in T2-low severe asthma. The objective was to determinate the omalizumab response according to atopic status.Methods: This retrospective, real-world study was performed in the Chest Diseases Department of Strasbourg University Hospital from January 1, 2006, to June 30, 2017. The response to omalizumab was assessed in 139 patients 4, 6, and 12 months after treatment and compared to data collected prior to omalizumab initiation.Results: Forty-four patients (31.7%) had severe non-atopic asthma and 95 (68.3%) had a severe atopic asthma. In the non-atopic group, omalizumab significantly reduced the severe exacerbation rate by 44% (95% CI 18-64%, p < 0.05), 43% (CI 95% 20-60%, p < 0.05), and 54% (CI 95% 36-67%, p < 0.05), at 4, 6 and 12 months, respectively. A trend toward improvement in FEV1, asthma control and oral corticosteroid use was also observed. These results were not significantly different from those obtained in atopic asthmatics except a more effective oral corticosteroid sparing in atopic group (p < 0.05). Similar reduction of severe exacerbation rates were observed in T2-low asthma subgroup (non-atopic, non-eosinophilic).Conclusion: Omalizumab was effective in severe asthma, regardless of atopic status.
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Affiliation(s)
- Lise Melscoet
- Chest diseases Department, Strasbourg University Hospital, Strasbourg, France
| | - Naji Khayath
- Chest diseases Department, Strasbourg University Hospital, Strasbourg, France.,EA 3070 Federation of Translational Medicine, FHU Homicare, University of Strasbourg, Strasbourg, France
| | - Nicolas Migueres
- Chest diseases Department, Strasbourg University Hospital, Strasbourg, France
| | - Marc-André Goltzene
- Public Health Department, Strasbourg University Hospital, Strasbourg, France
| | - Nicolas Meyer
- Public Health Department, Strasbourg University Hospital, Strasbourg, France
| | - Frédéric de Blay
- Chest diseases Department, Strasbourg University Hospital, Strasbourg, France.,EA 3070 Federation of Translational Medicine, FHU Homicare, University of Strasbourg, Strasbourg, France
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16
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Abstract
BACKGROUND This is the second update of previously published reviews in the Cochrane Library (2015, first update 2017). Interleukin-5 (IL-5) is the main cytokine involved in the proliferation, maturation, activation and survival of eosinophils, which cause airway inflammation and are a classic feature of asthma. Studies of monoclonal antibodies targeting IL-5 or its receptor (IL-5R) suggest they reduce asthma exacerbations, improve health-related quality of life (HRQoL) and lung function in appropriately selected patients, justifying their inclusion in the latest guidelines. OBJECTIVES To compare the effects of therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Rα) with placebo on exacerbations, health-related quality-of-life (HRQoL) measures and lung function in adults and children with chronic asthma, and specifically in those with eosinophilic asthma refractory to existing treatments. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trials registers, manufacturers' websites, and reference lists of included studies. The most recent search was 7 February 2022. SELECTION CRITERIA We included randomised controlled trials comparing mepolizumab, reslizumab and benralizumab versus placebo in adults and children with asthma. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by Cochrane. MAIN RESULTS Seventeen studies on about 7600 participants met the inclusion criteria. Six used mepolizumab, five used reslizumab, and six used benralizumab. One study using benralizumab was terminated early due to sponsor decision and contributed no data. The studies were predominantly on people with severe eosinophilic asthma, which was similarly but variably defined. One was in children aged 6 to 17 years; nine others included children over 12 years but did not report results by age group separately. We deemed the overall risk of bias to be low, with all studies contributing data of robust methodology. We considered the certainty of the evidence for all comparisons to be high overall using the GRADE scheme, except for intravenous (IV) mepolizumab and subcutaneous (SC) reslizumab because these are not currently licensed delivery routes. The anti-IL-5 treatments assessed reduced rates of 'clinically significant' asthma exacerbation (defined by treatment with systemic corticosteroids for three days or more) by approximately half in participants with severe eosinophilic asthma on standard care (at least medium-dose inhaled corticosteroids (ICS)) with poorly controlled disease (either two or more exacerbations in the preceding year or Asthma Control Questionnaire (ACQ) score of 1.5 or more), except for reslizumab SC. The rate ratios for these effects were 0.45 (95% confidence interval (CI) 0.36 to 0.55; high-certainty evidence) for mepolizumab SC, 0.53 (95% CI 0.44 to 0.64; moderate-certainty evidence) for mepolizumab IV, 0.43 (95% CI 0.33 to 0.55; high-certainty evidence) for reslizumab IV, and 0.59 (95% CI 0.52 to 0.66; high-certainty evidence) for benralizumab SC. Non-eosinophilic participants treated with benralizumab also showed a significant reduction in exacerbation rates, an effect not seen with reslizumab IV, albeit in only one study. No data were available for non-eosinophilic participants treated with mepolizumab. There were improvements in validated HRQoL scores with all anti-IL-5 agents in severe eosinophilic asthma. This met the minimum clinically important difference (MCID) for the broader St. George's Respiratory Questionnaire (SGRQ; 4-point change) for benralizumab only, but the improvement in the ACQ and Asthma Quality of Life Questionnaire (AQLQ), which focus on asthma symptoms, fell short of the MCID (0.5 point change for both ACQ and AQLQ) for all of the interventions. The evidence for an improvement in HRQoL scores in non-eosinophilic participants treated with benralizumab and reslizumab was weak, but the tests for subgroup difference were negative. All anti-IL-5 treatments produced small improvements in mean pre-bronchodilator forced expiratory flow in one second (FEV1) of between 0.08 L and 0.15 L in eosinophilic participants, which may not be sufficient to be detected by patients. There were no excess serious adverse events with any anti-IL-5 treatment; in fact, there was a reduction in such events with benralizumab, likely arising from fewer asthma-related hospital admissions. There was no difference compared to placebo in adverse events leading to discontinuation with mepolizumab or reslizumab, but significantly more discontinued benralizumab than placebo, although the absolute numbers were small (42/2026 (2.1%) benralizumab versus 11/1227 (0.9%) placebo). The implications for efficacy or adverse events are unclear. AUTHORS' CONCLUSIONS Overall this analysis supports the use of anti-IL-5 treatments as an adjunct to standard care in people with severe eosinophilic asthma and poor symptom control. These treatments roughly halve the rate of asthma exacerbations in this population. There is limited evidence for improved HRQoL scores and lung function, which may not meet clinically detectable levels. The studies did not report safety concerns for mepolizumab or reslizumab, or any excess serious adverse events with benralizumab, although there remains a question over adverse events significant enough to prompt discontinuation. Further research is needed on biomarkers for assessing treatment response, optimal duration and long-term effects of treatment, risk of relapse on withdrawal, non-eosinophilic patients, children (particularly under 12 years), comparing anti-IL-5 treatments to each other and, in patients meeting relevant eligibility criteria, to other biological (monoclonal antibody) therapies. For benralizumab, future studies should closely monitor rates of adverse events prompting discontinuation.
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Affiliation(s)
| | - Amanda Wilson
- School of Nursing and Midwifery, University of Technology Sydney, Sydney, Australia
| | - Stephen Milan
- Health Innovation Campus and Centre for Health Futures, Lancaster University, Lancaster, UK
| | | | - Freda Yang
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Colin Ve Powell
- Department of Emergency Medicine, Sidra Medciine, Doha, Qatar
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17
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Kavanagh JE, Hearn AP, Jackson DJ. A pragmatic guide to choosing biologic therapies in severe asthma. Breathe (Sheff) 2022; 17:210144. [PMID: 35296105 PMCID: PMC8919802 DOI: 10.1183/20734735.0144-2021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/30/2021] [Indexed: 11/05/2022] Open
Abstract
There are now several monoclonal antibody (mAb) therapies (“biologics”) available to treat severe asthma. Omalizumab is an anti-IgE mAb and is licensed in severe allergic asthma. Current evidence suggests it may decrease exacerbations by augmenting deficient antiviral immune responses in asthma. Like all other biologics, clinical efficacy is greatest in those with elevated T2 biomarkers. Three biologics target the interleukin (IL)-5–eosinophil pathway, including mepolizumab and reslizumab that target IL-5 itself, and benralizumab that targets the IL-5 receptor (IL-5R-α). These drugs all reduce the exacerbation rate in those with raised blood eosinophil counts. Mepolizumab and benralizumab have also demonstrated steroid-sparing efficacy. Reslizumab is the only biologic that is given intravenously rather than by the subcutaneous route. Dupilumab targets the IL-4 receptor and like mepolizumab and benralizumab is effective at reducing exacerbation rate as well as oral corticosteroid requirements. It is also effective for the treatment of nasal polyposis and atopic dermatitis. Tezepelumab is an anti-TSLP (thymic stromal lymphopoietin) mAb that has recently completed phase 3 trials demonstrating significant reductions in exacerbation rate even at lower T2 biomarker thresholds.Many patients with severe asthma qualify for more than one biologic. To date, there are no head-to-head trials to aid physicians in this choice. However, post-hoc analyses have identified certain clinical characteristics that are associated with superior responses to some therapies. The presence of allergic and/or eosinophilic comorbidities, such as atopic dermatitis, nasal polyposis or eosinophilic granulomatosis with polyangiitis, that may additionally benefit by the choice of biologic should also be taken into consideration, as should patient preferences which may include dosing frequency. To date, all biologics have been shown to have excellent safety profiles.
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18
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Salter B, Lacy P, Mukherjee M. Biologics in Asthma: A Molecular Perspective to Precision Medicine. Front Pharmacol 2022; 12:793409. [PMID: 35126131 PMCID: PMC8807637 DOI: 10.3389/fphar.2021.793409] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/10/2021] [Indexed: 12/11/2022] Open
Abstract
Recent developments in therapeutic strategies have provided alternatives to corticosteroids as the cornerstone treatment for managing airway inflammation in asthma. The past two decades have witnessed a tremendous boost in the development of anti-cytokine monoclonal antibody (mAb) therapies for the management of severe asthma. Novel biologics that target eosinophilic inflammation (or type 2, T2 inflammation) have been the most successful at treating asthma symptoms, though there are a few in the drug development pipeline for treating non-eosinophilic or T2-low asthma. There has been significant improvement in clinical outcomes for asthmatics treated with currently available monoclonal antibodies (mAbs), including anti-immunoglobulin (Ig) E, anti-interleukin (IL)-4 receptor α subunit, anti-IL-5, anti-IL-5Rα, anti-IL-6, anti-IL-33, and anti-thymic stromal lymphopoietin (TSLP). Despite these initiatives in precision medicine for asthma therapy, a significant disease burden remains, as evident from modest reduction of exacerbation rates, i.e., approximately 40-60%. There are numerous studies that highlight predictors of good responses to these biologics, but few have focused on those who fail to respond adequately despite targeted treatment. Phenotyping asthmatics based on blood eosinophils is proving to be inadequate for choosing the right drug for the right patient. It is therefore pertinent to understand the underlying immunology, and perhaps, carry out immune endotyping of patients before prescribing appropriate drugs. This review summarizes the immunology of asthma, the cytokines or receptors currently targeted, the possible mechanisms of sub-optimal responses, and the importance of determining the immune make-up of individual patients prior to prescribing mAb therapy, in the age of precision medicine for asthma.
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Affiliation(s)
- Brittany Salter
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health, St. Joseph’s Healthcare, Hamilton, ON, Canada
| | - Paige Lacy
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Manali Mukherjee
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health, St. Joseph’s Healthcare, Hamilton, ON, Canada
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19
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Lourenço LO, Ribeiro AM, Lopes FDTQDS, Tibério IDFLC, Tavares-de-Lima W, Prado CM. Different Phenotypes in Asthma: Clinical Findings and Experimental Animal Models. Clin Rev Allergy Immunol 2021; 62:240-263. [PMID: 34542807 DOI: 10.1007/s12016-021-08894-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
Asthma is a respiratory allergic disease presenting a high prevalence worldwide, and it is responsible for several complications throughout life, including death. Fortunately, asthma is no longer recognized as a unique manifestation but as a very heterogenic manifestation. Its phenotypes and endotypes are known, respectively, as pathologic and molecular features that might not be directly associated with each other. The increasing number of studies covering this issue has brought significant insights and knowledge that are constantly expanding. In this review, we intended to summarize this new information obtained from clinical studies, which not only allowed for the creation of patient clusters by means of personalized medicine and a deeper molecular evaluation, but also created a connection with data obtained from experimental models, especially murine models. We gathered information regarding sensitization and trigger and emphasizing the most relevant phenotypes and endotypes, such as Th2-high asthma and Th2-low asthma, which included smoking and obesity-related asthma and mixed and paucigranulocytic asthma, not only in physiopathology and the clinic but also in how these phenotypes can be determined with relative similarity using murine models. We also further investigated how clinical studies have been treating patients using newly developed drugs focusing on specific biomarkers that are more relevant according to the patient's clinical manifestation of the disease.
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Affiliation(s)
- Luiz Otávio Lourenço
- Department of Biosciences, Federal University of São Paulo, Campus Baixada Santista, Santos, SP, Brazil
| | - Alessandra Mussi Ribeiro
- Department of Biosciences, Federal University of São Paulo, Campus Baixada Santista, Santos, SP, Brazil
| | | | | | - Wothan Tavares-de-Lima
- Department of Pharmacology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Carla Máximo Prado
- Department of Biosciences, Federal University of São Paulo, Campus Baixada Santista, Santos, SP, Brazil. .,Department of Medicine, School of Medicine, University of São Paulo, São Paulo, SP, Brazil.
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20
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Lanario JW, Burns L. Use of Health Related Quality of Life in Clinical Trials for Severe Asthma: A Systematic Review. J Asthma Allergy 2021; 14:999-1010. [PMID: 34408445 PMCID: PMC8367083 DOI: 10.2147/jaa.s320817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/23/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Asthma Health Related Quality of Life (HRQoL) is an outcome important to patients with severe asthma and can provide clinicians with additional insight into the benefits of treatment. The aim of this systematic review is to examine the use and reporting of HRQoL questionnaires within randomised controlled trials (RCTs) of biologics, fevipiprant and bronchial thermoplasty. METHODS We followed the guidelines on the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement. Of the 2380 retrieved articles, 52 studies were identified for inclusion. RESULTS Sixty-three percent included an asthma HRQoL questionnaire. It was a secondary outcome in the majority of cases (73%). The proportion of studies including an asthma HRQoL questionnaire did not change significantly over a 20-year period. While the Asthma Quality of Life Questionnaire (AQLQ) was used in 45% of studies, 55% used a variety of 4 questionnaires. Most (70%) of the studies that included a HRQoL questionnaire did not report its subscale scores. Approximately half (52%) of studies that used HRQoL reported this in the abstract of the paper. A higher proportion of studies used an asthma control questionnaire compared to a HRQoL questionnaire (71% vs 63%). CONCLUSION In order to increase the use of asthma HRQoL questionnaires in RCTs of severe asthma treatments, the drivers and barriers to their use must first be understood. At present, the patients' perspective is underrepresented in RCTs of biologics, fevipiprant and bronchial thermoplasty for severe asthma.
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Affiliation(s)
| | - Lorna Burns
- Faculty of Health, University of Plymouth, Plymouth, UK
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21
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Jung JW, Park HS, Park CS, Cho SH, Choi IS, Moon HB, Kwon SS, Yoon HJ, Park JW, Lee JM, Choi DC, Choi BW. Effect of omalizumab as add-on therapy to Quality of Life Questionnaire for Korean Asthmatics (KAQLQ) in Korean patients with severe persistent allergic asthma. Korean J Intern Med 2021; 36:1001-1013. [PMID: 34237826 PMCID: PMC8273830 DOI: 10.3904/kjim.2020.549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/16/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND/AIMS Omalizumab is the first biologic known to be effective in patients with severe allergic asthma. METHODS This study was conducted as a multicenter, single-group, open trial to evaluate the improvement in the quality of life with the additional administration of omalizumab for 24 weeks in Korean patients with severe persistent allergic asthma. RESULTS Of the 44 patients, 31.8% were men and the mean age was 49.8 ± 11.8 years. A score improvement of 0.5 points or more in the Quality of Life Questionnaire for Korean Asthmatics (KAQLQ) was noted in 50.0% (22/44) of the patinets. In the improved group, the baseline total immunoglobulin E (IgE) level and the amount of omalizumab used were higher, and the day and night asthma symptoms were more severe, compared to those in the non-improved group. According to the Global Evaluation of Treatment Effectiveness, favorable outcomes were found in 78.6% of patients. The Korean asthma control test (p < 0.005) and forced expiratory volume in 1 second % predicted (FEV1%; p < 0.01) improved significantly in patients who received omalizumab treatment, compared to that at week 0, and the total dose of rescue systemic corticosteroids significantly decreased (p < 0.05). The improved group on KAQLQ showed a significant improvement in FEV1% (p < 0.001). CONCLUSION Omalizumab can be considered a biological treatment for Korean patients with severe allergic asthma. It is recommended to consider omalizumab as add-on therapy in patients with high baseline total IgE levels and severe asthma symptoms.
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Affiliation(s)
- Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon,
Korea
| | - Choon-Sik Park
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon,
Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Inseon S. Choi
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
| | - Hee-Bom Moon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Soon Seog Kwon
- Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Korea
| | - Jung Won Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Jong-Myung Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu,
Korea
| | - Dong-Chull Choi
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Byoung Whui Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
- Department of Internal Medicine, Chung-Ang University H.C.S. Hyundae Hospital, Namyangju,
Korea
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Campo P, Soto Campos G, Moreira A, Quirce S, Padilla‐Galo A, Martínez‐Moragón E, Mardones A, Dávila I. Real-life study in non-atopic severe asthma patients achieving disease control by omalizumab treatment. Allergy 2021; 76:1868-1872. [PMID: 33220106 DOI: 10.1111/all.14668] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 01/11/2023]
Affiliation(s)
- Paloma Campo
- Allergy Unit IBIMA‐Regional University Hospital of Málaga ARADyAL, Málaga Spain
| | | | | | - Santiago Quirce
- Department of Allergy La Paz Hospital Institute for Health Research (IdiPAZ), Centro de investigación en red de enfermedades respiratorias (CIBERES) Madrid Spain
| | | | | | - Aizea Mardones
- Pneumology Service University Hospital Basurto Bilbao Spain
| | - Ignacio Dávila
- Allergy Service University Hospital of Salamanca and Institute for Biomedical Research of Salamanca (IBSAL), Biomedical and Diagnosis Science Department, Salamanca University School of Medicine Salamanca Spain
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23
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Total IgE Variability Is Associated with Future Asthma Exacerbations: A 1-Year Prospective Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2812-2824. [PMID: 33991705 DOI: 10.1016/j.jaip.2021.04.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Few prospective studies have investigated the relationship between IgE variability and risk for asthma exacerbations (AEs). OBJECTIVE To explore the relationship between IgE variability and AEs. METHODS Recruited patients with stable asthma underwent two serum total IgE tests within a month (at screening [baseline IgE] and at 1 month) to obtain the coefficient of variation (CV) of base 10 log-transformed IgE. Patients with IgE CV were divided into IgE CV-high and IgE CV-low cohorts based on the CV median and were observed within 12 months, during which the association between IgE variability and AEs was explored using a negative binomial regression model. RESULTS The IgE CV levels obtained from 340 patients classified patients into two groups (n = 170 for the IgE CV-high and IgE CV-low groups, respectively) based on the serum total IgE CV median of 2.12% (quartiles 1 and 3: 0.98% and 3.91%, respectively). The IgE CV-high patients exhibited worse asthma control and lung function and more marked airway inflammation, and received more intensive medication use compared with IgE CV-low patients. The IgE CV-high patients exhibited increased rates of moderate-to-severe (adjusted rate ratio = 2.88; 95% confidence interval, 1.65-5.03; P < .001) and severe (adjusted rate ratio = 2.16; 95% confidence interval, 1.08-4.32; P = .029) AEs during the follow-up year compared with IgE CV-low patients. Furthermore, sputum IL-6 partially mediated the associations between IgE CV with moderate-to-severe and severe AEs. CONCLUSIONS Variability in total serum IgE levels is an easily obtained and practical measure for predicting AEs. Future studies are needed to investigate whether IgE variability can be used to guide precision medicine in asthma.
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Blanco-Aparicio M, Calvo-Alvarez U, González-Barcala FJ. Biologics in Asthma: Don't Let the Magic Bullets Sink the Boat. Arch Bronconeumol 2021; 57:383-384. [PMID: 34088387 DOI: 10.1016/j.arbr.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/31/2020] [Indexed: 10/21/2022]
Affiliation(s)
| | | | - Francisco-Javier González-Barcala
- Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain; Facultad de Medicina-Universidad de Santiago de Compostela, Santiago de Compostela, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Spain
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25
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Abstract
The global COVID-19 pandemic has brought respiratory disease to the forefront of public health, but asthma prevalence has been rising globally for decades. Asthma is mediated by errant immune activation and airway remodeling, but the influences of environment, nutrition, and comorbidities (e.g., asthma-chronic obstructive pulmonary disorder-overlap [ACO]) are still poorly understood. Even as a new generation of biologic-based treatments offer better airway control and reductions in mortality, a lack of prophylactic treatments and mechanistic understanding complicates efforts to prevent pathogenesis. This review will explicate and synthesize current knowledge on the effect of ACO and biologics (omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab) on pathogenesis, treatment, and prognosis.
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26
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Kariyawasam HH, James LK. Chronic Rhinosinusitis with Nasal Polyps: Targeting IgE with Anti-IgE Omalizumab Therapy. Drug Des Devel Ther 2020; 14:5483-5494. [PMID: 33328726 PMCID: PMC7735718 DOI: 10.2147/dddt.s226575] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/24/2020] [Indexed: 12/28/2022] Open
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex, clinically heterogeneous and persistent inflammatory disorder of the upper airway. Detailed mechanistic insights into disease pathogenesis are lacking, but it is now accepted that local tissue IgE driven T2-high inflammatory pathways are critical to disease. The recent CRSwNP Phase 3 POLYP1 and POLYP2 replicate studies of blocking IgE with omalizumab confirmed rapid improvements in all clinical parameters of sinonasal disease, confirming a pivotal role for IgE driven inflammatory pathways in CRSwNP. This review summarises the biology of IgE in relation to CRSwNP. Insight into how IgE may drive CRSwNP is evaluated in the context of clinical improvements seen with omalizumab. The need for further studies using a broader patient and biomarker specific groups to aid more precise drug-patient selection alongside more detailed mechanistic studies of omalizumab in CRSwNP is highlighted.
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Affiliation(s)
- Harsha H Kariyawasam
- Specialist Allergy and Clinical Immunology, Royal National ENT Hospital, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Rhinology, Royal National ENT Hospital, University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Louisa K James
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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27
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Flora M, Perna F, Abbadessa S, Garziano F, Maffucci R, Maniscalco M, Mollica M, Pelaia C, Tremante E, Maffei M, Calabrese C. Basophil activation test for Staphylococcus aureus enterotoxins in severe asthmatic patients. Clin Exp Allergy 2020; 51:536-545. [PMID: 33131112 DOI: 10.1111/cea.13772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 10/08/2020] [Accepted: 10/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several studies have shown an association between severe asthma and serum immunoglobulins E (IgE) against Staphylococcus aureus enterotoxins (SEs). SEs-the prototypes being types A (SEA), B (SEB) and toxic shock syndrome toxin 1 (TSST-1)-can induce both polyclonal and specific IgE responses. OBJECTIVE The aim of the study was to evaluate the ability of SEs to induce basophil activation in severe asthmatic patients using the basophil activation test (BAT). METHODS 57 severe asthmatic patients were enrolled. BAT in response to SEA, SEB and TSST-1 was performed in all patients, while serum IgE to SEA, SEB and SEC was available in 49 patients. BAT was considered positive when CD203c+ basophils to SEs were ≥5%, and the stimulation index (SI, ratio between % of CD203c+ basophils to SEs and to negative control) was >2. Two threshold values (>0.1 kU/L and >0.35 kU/L, respectively) were used to assess serum SEsIgE. RESULTS 36.8% of severe asthmatic patients had a BAT positive for at least one SE (BAT SEs+). Serum SEsIgE >0.35 kU/L (SEs IgE+) was associated with BAT SEs positivity. Among patients with negative skin prick test, 35% were BAT SEs+, 30% SEs IgE+, 55% BAT or IgE- SEs+. A negative correlation between SI of BAT to SEs and both clinical (ACT score) and functional parameters was observed, together with a positive correlation of BAT with asthma exacerbations. CONCLUSIONS The positivity of BAT for SEs in a subgroup of severe asthmatic patients further supports the pathogenic role of Staphylococcus aureus in severe asthma.
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Affiliation(s)
- Martina Flora
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Perna
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Salvatore Abbadessa
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Federica Garziano
- Clinical Biochemistry Unit, A.O.R.N. Ospedali dei Colli, Naples, Italy
| | - Rosalba Maffucci
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mauro Maniscalco
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA, IRCCS, TeleseTerme, Italy
| | - Mariano Mollica
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Corrado Pelaia
- Department of Health Sciences, University "Magna Graecia" of Catanzaro, Italy
| | - Eugenio Tremante
- Otolaryngology Head and Neck Surgery Unit, A.O.R.N. Ospedali dei Colli, Naples, Italy
| | - Marianna Maffei
- Otolaryngology Head and Neck Surgery Unit, A.O.R.N. Ospedali dei Colli, Naples, Italy
| | - Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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28
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Frøssing L, Silberbrandt A, Von Bülow A, Backer V, Porsbjerg C. The Prevalence of Subtypes of Type 2 Inflammation in an Unselected Population of Patients with Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1267-1275. [PMID: 33039645 DOI: 10.1016/j.jaip.2020.09.051] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 09/07/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND With the introduction of different targeted therapies for type 2 (T2)-high asthma, there is an urgent need for markers to guide the choice of treatment. T2-high asthma includes different clinical phenotypes of asthma, but the prevalence and impact of activation of different T2 inflammatory pathways is unknown. OBJECTIVE To describe the level of coexpression of clinically available T2 inflammatory markers in patients with severe asthma, and the relationship with clinical characteristics and comorbidities. METHODS Patients with severe asthma according to European Respiratory Society/American Thoracic Society guidelines were examined prospectively including sputum induction and grouped according to T2 biomarkers: blood eosinophilia (≥0.3 × 109/L), total IgE (≥150 U/mL), and fractional exhaled nitric oxide (≥25 parts per billion). RESULTS We found 116 (70%) of the 166 patients to have at least 1 T2 biomarker elevated: 39% had 2 or more elevated biomarkers, whereas 31% had only 1 biomarker elevated. Concomitant airway and systemic eosinophilia was present in 28% of all patients, corresponding to half (53%) of the patients with either. Expression patterns of the T2 biomarkers were associated with differences in allergic sensitization and the coexistence of nasal polyposis. CONCLUSIONS Most patients with severe asthma showed at least 1 T2 inflammatory trait. Coexpression of T2 biomarkers was highly heterogeneous, and different expression patterns were associated with distinct clinical characteristics.
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Affiliation(s)
- Laurits Frøssing
- Respiratory Research Unit, Department of Respiratory Medicine L, Copenhagen University Hospital, Bispbjerg and Frederiksberg, Denmark.
| | - Alexander Silberbrandt
- Respiratory Research Unit, Department of Respiratory Medicine L, Copenhagen University Hospital, Bispbjerg and Frederiksberg, Denmark
| | - Anna Von Bülow
- Respiratory Research Unit, Department of Respiratory Medicine L, Copenhagen University Hospital, Bispbjerg and Frederiksberg, Denmark
| | - Vibeke Backer
- Center for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Celeste Porsbjerg
- Respiratory Research Unit, Department of Respiratory Medicine L, Copenhagen University Hospital, Bispbjerg and Frederiksberg, Denmark
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30
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Efficacy of Omalizumab Therapy in an Asthmatic with Low IgE. Case Rep Pulmonol 2020; 2020:8898454. [PMID: 33014501 PMCID: PMC7520673 DOI: 10.1155/2020/8898454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/21/2020] [Accepted: 09/04/2020] [Indexed: 11/18/2022] Open
Abstract
Asthma is one of the most common respiratory diseases encountered in clinical practice. Although the vast majority of asthmatics can be adequately controlled with inhaled steroids and other preventer medications, a small proportion remain uncontrolled. Anti-IgE treatment with omalizumab has been proposed in patients as a preferred approach in step 5 asthma therapy according to GINA guidelines. Although therapy with this molecule is approved for patients with atopic asthma and pretreatment serum IgE levels of 30-1500 only, there have been a few reports of its efficacy in subjects outside this reference IgE range. We report the case of a middle-aged lady with severe corticosteroid-dependent asthma and low serum IgE levels who was successfully treated with 9 months of omalizumab therapy. She gained good asthma control and was tapered off steroid use by the fifth month of therapy with omalizumab. The case report stresses the need for further investigation into expanding the spectrum of omalizumab usage in asthma beyond the current IgE suitability range.
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31
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Caminati M, Bagnasco D, Rosenwasser LJ, Vianello A, Senna G. Biologics for the Treatments of Allergic Conditions: Severe Asthma. Immunol Allergy Clin North Am 2020; 40:549-564. [PMID: 33012319 DOI: 10.1016/j.iac.2020.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
By selectively targeting specific steps of the immune inflammation cascade, biologic drugs for severe asthma have substantially contributed to increase the standard of care, to reduce drug-related morbidity. and most importantly to ameliorate patients' quality of life. Upcoming molecules are going to provide a chance for severe phenotypes besides Th2 high through the interaction with epithelial and innate immunity. Some practical aspects including optimal treatment duration, the possibility of a dose treatment modulation, the place and relevance of ICS in best responders are still under debate. Long-term safety, especially when interacting with innate immunity needs to be further investigated.
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Affiliation(s)
- Marco Caminati
- Department of Medicine, Allergy and Clinical Immunology Section, University of Verona and Verona University Hospital, Piazzale Scuro 10, Verona 37134, Italy.
| | - Diego Bagnasco
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Largo Rosanna Benzi, 10, Genoa 16132, Italy
| | | | - Andrea Vianello
- Respiratory Pathophysiology Division, University of Padua, Padua, Italy; Dipartimento di Scienze CardioToraco Vascolari e Sanità Pubblica, Via Nicolo` Giustiniani, 2, Padua 35128, Italy
| | - Gianenrico Senna
- Department of Medicine, Allergy and Clinical Immunology School, University of Verona & Asthma Center and Allergy Unit, Verona University Hospital, Piazzale Scuro 10, Verona 37134, Italy
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32
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Lommatzsch M, Marchewski H, Schwefel G, Stoll P, Virchow JC, Bratke K. Benralizumab strongly reduces blood basophils in severe eosinophilic asthma. Clin Exp Allergy 2020; 50:1267-1269. [PMID: 32762056 DOI: 10.1111/cea.13720] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/06/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Marek Lommatzsch
- Department of Pneumology and Critical Care Medicine, University of Rostock, Rostock, Germany
| | - Hannes Marchewski
- Department of Pneumology and Critical Care Medicine, University of Rostock, Rostock, Germany
| | - Georg Schwefel
- Department of Pneumology and Critical Care Medicine, University of Rostock, Rostock, Germany
| | - Paul Stoll
- Department of Pneumology and Critical Care Medicine, University of Rostock, Rostock, Germany
| | | | - Kai Bratke
- Department of Pneumology and Critical Care Medicine, University of Rostock, Rostock, Germany
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33
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Fu Z, Xu Y, Cai C. Efficacy and safety of omalizumab in children with moderate-to-severe asthma: a meta-analysis. J Asthma 2020; 58:1350-1358. [PMID: 32602383 DOI: 10.1080/02770903.2020.1789875] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of omalizumab in children with moderate-to-severe asthma.Data sources: We systematically searched MEDLINE, EMBASE, and Cochrane for randomized controlled trials (RCTs ) (inception to January 2020).Study selections: All RCTs which were conducted in childhood and adolescence with asthma and compared the efficacy or safety of omalizumab were adopted. RESULTS Three studies with four publications including 1380 pediatric patients met our criteria. For children with moderate-to-severe asthma, omalizumab decreased asthma exacerbations rate (OR 0.51, 95% CI: 0.44-0.58, p < 0.001) compared with placebo with no evidence of heterogeneity. Omalizumab reduced the rate of asthma exacerbations 0.58) with treatment period ≥30 weeks (p for heterogeneity = 0.03). Omalizumab treated patients had an excellent or good response rate of treatment effectiveness assessed by physicians (2.75, 2.45-3.09) and a bigger reduction in the dosage of inhaled corticosteroid (ICS) at the end of follow-up. For children with severe asthma, omalizumab also reduced the likelihood of asthma exacerbations and increased the odd of treatment effectiveness rated as excellent or good. Patients receiving omalizumab had a lower incidence of severe adverse events (0.36, 0.22-0.57). CONCLUSIONS These findings suggested that omalizumab had beneficial effects on moderate-to-severe asthma in children. Patients may benefit more from long-term use of omalizumab. In addition, omalizumab reduces the rate of serious adverse events requiring hospitalizations.
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Affiliation(s)
- Zhuo Fu
- Tianjin Medical University, Tianjin, PR China.,Respiratory Department, Tianjin Children's Hospital, Tianjin, PR China
| | - Yongsheng Xu
- Respiratory Department, Tianjin Children's Hospital, Tianjin, PR China
| | - Chunquan Cai
- Department of Neurosurgery, Tianjin Institute of Pediatrics, Tianjin Children's Hospital, Tianjin, PR China
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34
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Álvarez-Gutiérrez FJ, Blanco-Aparicio M, Plaza V, Cisneros C, García-Rivero JL, Padilla A, Pérez-de Llano L, Perpiñá M, Soto-Campos G. Documento de consenso de asma grave en adultos. Actualización 2020. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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35
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Omalizumab Is an Effective Intervention in Severe Asthma with Fungal Sensitization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3428-3433.e1. [PMID: 32561499 DOI: 10.1016/j.jaip.2020.05.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Severe asthma with fungal sensitization (SAFS) and allergic bronchopulmonary aspergillosis (ABPA) are important complications of severe asthma. The evidence for treating them with omalizumab is limited. OBJECTIVE To determine the effectiveness of treatment with omalizumab in patients with severe allergic asthma comparing those with and without evidence of fungal sensitization using data recorded in the Australian Xolair Registry. METHODS Data from 205 patients who received omalizumab and recorded in the Australian Xolair Registry were analyzed to determine change in the Juniper 5-item Asthma Control Questionnaire (ACQ-5) score, exacerbation frequency, and oral corticosteroid dose over a 24-month period of omalizumab treatment. Patients were grouped into cohorts on the basis of fungal sensitization, and an analysis of improvement in outcomes between baseline and 24 months was conducted within each group. A further subgroup analysis of patients with ABPA was also conducted. RESULTS Patients with SAFS (n = 62), including those with ABPA (ASAFS), were as likely to demonstrate significant improvements in ACQ-5 score and exacerbations and reduced regular oral corticosteroid dose over 24 months as those with severe asthma without sensitization to fungi (n = 156). After adjusting for age, sex, body mass index, smoking history, and baseline FEV1%, the effects still remained. A subgroup analysis of 11 patients with ABPA similarly demonstrated a significant improvement on omalizumab. CONCLUSIONS Omalizumab is an effective therapy in ASAFS, leading to sustained improvements in symptoms and exacerbations for 24 months. The benefit for ABPA is less clear because of the small sample size.
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36
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Lommatzsch M. Immune Modulation in Asthma: Current Concepts and Future Strategies. Respiration 2020; 99:566-576. [PMID: 32512570 DOI: 10.1159/000506651] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 12/20/2022] Open
Abstract
Asthma treatment concepts have profoundly changed over the last 20 years, from standard therapeutic regimens for all patients with asthma towards individually tailored interventions targeting treatable traits ("precision medicine"). A precise and highly effective immune modulation with minimal adverse effects plays a central role in this new concept. Recently, there have been major advances in the treatment of asthma with immune-modulatory compounds. One example is the approval of several highly potent biologics for the treatment of severe asthma. New immune-modulatory strategies are expected to enter clinical practice in the future; these innovations will be especially important for patients with treatment-resistant asthma.
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Affiliation(s)
- Marek Lommatzsch
- Abteilung für Pneumologie/Interdisziplinäre Internistische Intensivstation, Medizinische Klinik I, Zentrum für Innere Medizin, Universitätsmedizin Rostock, Rostock, Germany,
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37
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Hynes G, Pavord ID. Targeted biologic therapy for asthma. Br Med Bull 2020; 133:16-35. [PMID: 32318701 DOI: 10.1093/bmb/ldaa004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/04/2020] [Accepted: 02/09/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Asthma is a common and potentially serious condition affecting 300 million people worldwide. For many years, we have relied on a one-size-fits-all approach to its management, using corticosteroids and bronchodilators for all symptomatic patients. However, with more recent advances, it has become clear that asthma is a heterogeneous condition with multiple different underlying pathways. Understanding the different subtypes will be a key to giving us the ability to intervene in a targeted way to personalize care for patients with asthma. SOURCES OF DATA Key published literature, guidelines and trials from clinicaltrials.gov. AREAS OF AGREEMENT The most widely studied of these subtypes is T2 high eosinophilic asthma, for which there are an increasing number of biologic therapies available. T2 high asthma is associated with the cytokines interleukin (IL)-4, IL-5 and IL-13, for each of which biologics have been developed. AREAS OF CONTROVERSY It is currently unclear which of the available biologics provides superior efficacy. It is also unclear how to select which biologic for which patient. GROWING POINTS Head-to-head trials of the available T2 biologics will be important to determine superiority, and a suggested order for trialling biologics. Going further than this, we would like to see further analyses of available biologics to allow us to predict responders from non-responders in advance of administering therapy. AREAS TIMELY FOR DEVELOPING RESEARCH Non-eosinophilic T2 low asthma is an area that is under-researched and for which there are few treatments available. It is likely that there are different subtypes in this category of asthma and unravelling what these are will be crucial to developing effective treatments.
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Affiliation(s)
- Gareth Hynes
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
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38
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How to compare the efficacy of biologic agents in asthma. Ann Allergy Asthma Immunol 2020; 125:137-149. [PMID: 32387169 DOI: 10.1016/j.anai.2020.04.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The use of biologics in severe asthma has made substantial strides in disease management and fostered a personalized medicine approach; however, how, when, and which biologic to choose are unresolved issues, which form the focus of this review. DATA SOURCES The data sources were published literature, including current guidelines, available through PubMed searches and online resources. STUDY SELECTIONS Studies and randomized controlled trials pertaining to the use of biologics in various phenotypes and/or endotypes of asthma and comparative analyses between biologics in asthma were included. RESULTS Inflammatory constructs in asthma are complex and translate differentially into clinical practice for both disease severity and treatment responsiveness. The utilization of biologics, which target selected components of inflammation, has begun to dramatically improve the course of management for many patients with severe asthma. A retuning of our approach into selecting appropriate patient cohorts or phenotypes for studies and selection of clinically relevant outcomes, which are reflected by existing and novel emerging biomarkers, is enabling a paradigm shift in asthma management. Comparing the efficacy of the available biologics for asthma is challenging as no direct head-to-head studies are available, and indirect comparisons to this query provide varying results. CONCLUSION Significant progress has been achieved in the management of severe asthma with treatment of target-specific biologics. Sophisticated algorithms and trial designs, using a combination of available biomarker profiles and clinical characteristics to stratify patient populations into more precise subphenotypes and endotypes to guide our choice of a biologic or therapy, are critically needed but currently not formulated.
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Bachert C, Humbert M, Hanania NA, Zhang N, Holgate S, Buhl R, Bröker BM. Staphylococcus aureus and its IgE-inducing enterotoxins in asthma: current knowledge. Eur Respir J 2020; 55:13993003.01592-2019. [PMID: 31980492 DOI: 10.1183/13993003.01592-2019] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/31/2019] [Indexed: 02/06/2023]
Abstract
While immunoglobulin (Ig) E is a prominent biomarker for early-onset, its levels are often elevated in non-allergic late-onset asthma. However, the pattern of IgE expression in the latter is mostly polyclonal, with specific IgEs low or below detection level albeit with an increased total IgE. In late-onset severe asthma patients, specific IgE to Staphylococcal enterotoxins (se-IgE) can frequently be detected in serum, and has been associated with asthma, with severe asthma defined by hospitalisations, oral steroid use and decrease in lung function. Recently, se-IgE was demonstrated to even predict the development into severe asthma with exacerbations over the next decade. Staphylococcus aureus manipulates the airway mucosal immunology at various levels via its proteins, including superantigens, serine-protease-like proteins (Spls), or protein A (SpA) and possibly others. Release of IL-33 from respiratory epithelium and activation of innate lymphoid cells (ILCs) via its receptor ST2, type 2 cytokine release from those ILCs and T helper (Th) 2 cells, mast cell degranulation, massive local B-cell activation and IgE formation, and finally eosinophil attraction with consequent release of extracellular traps, adding to the epithelial damage and contributing to disease persistence via formation of Charcot-Leyden crystals are the most prominent hallmarks of the manipulation of the mucosal immunity by S. aureus In summary, S. aureus claims a prominent role in the orchestration of severe airway inflammation and in current and future disease severity. In this review, we discuss current knowledge in this field and outline the needs for future research to fully understand the impact of S. aureus and its proteins on asthma.
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Affiliation(s)
- Claus Bachert
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium .,Division of ENT diseases, CLINTEC, Karolinska Institute, University of Stockholm, Stockholm, Sweden
| | - Marc Humbert
- Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Nan Zhang
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium
| | - Stephen Holgate
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, The Sir Henry Wellcome Research Laboratories, Southampton General Hospital, Southampton, UK
| | - Roland Buhl
- Pulmonary Dept, Mainz University Hospital, Mainz, Germany
| | - Barbara M Bröker
- Dept of Immunology, University Medicine Greifswald, Greifswald, Germany
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40
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McGregor MC, Krings JG, Nair P, Castro M. Role of Biologics in Asthma. Am J Respir Crit Care Med 2020; 199:433-445. [PMID: 30525902 DOI: 10.1164/rccm.201810-1944ci] [Citation(s) in RCA: 277] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Patients with severe uncontrolled asthma have disproportionally high morbidity and healthcare utilization as compared with their peers with well-controlled disease. Although treatment options for these patients were previously limited, with unacceptable side effects, the emergence of biologic therapies for the treatment of asthma has provided promising targeted therapy for these patients. Biologic therapies target specific inflammatory pathways involved in the pathogenesis of asthma, particularly in patients with an endotype driven by type 2 (T2) inflammation. In addition to anti-IgE therapy that has improved outcomes in allergic asthma for more than a decade, three anti-IL-5 biologics and one anti-IL-4R biologic have recently emerged as promising treatments for T2 asthma. These targeted therapies have been shown to reduce asthma exacerbations, improve lung function, reduce oral corticosteroid use, and improve quality of life in appropriately selected patients. In addition to the currently approved biologic agents, several biologics targeting upstream inflammatory mediators are in clinical trials, with possible approval on the horizon. This article reviews the mechanism of action, indications, expected benefits, and side effects of each of the currently approved biologics for severe uncontrolled asthma and discusses promising therapeutic targets for the future.
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Affiliation(s)
- Mary Clare McGregor
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; and
| | - James G Krings
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; and
| | - Parameswaran Nair
- 2 Division of Respirology, Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Ontario, Canada
| | - Mario Castro
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; and
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YALCIN ARZUDIDEM, ONBASI KEVSER, UZUN RUSEN, HERTH FELIX, SCHNABEL PHILIPPALBERT. Human(ized) monoclonal antibodies in atopic patients - state of the art. Cent Eur J Immunol 2020; 45:195-201. [PMID: 33456331 PMCID: PMC7792442 DOI: 10.5114/ceji.2020.97909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 04/13/2017] [Indexed: 02/05/2023] Open
Abstract
Asthma is an important chronic disease affecting a lot of people worldwide. Treatment options for asthma like biological agents are being developed more frequently nowadays. Despite a lot of treatment options, some patients still remain symptomatic. As more and more practitioners choose treatment with biologic agents as a convenient way of therapy, biologic agents and other valuable methods must be discovered in order to cope with a growing number of treatment agents. This manuscript emphasizes on new generation monoclonal human(ized) antibodies in asthmatics and off-label use . The first developed biologic agent is the anti-immunoglobulin E monoclonal antibody called omalizumab. Currently it is an approved treatment option for asthma.
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Affiliation(s)
- ARZU DIDEM YALCIN
- Department of Internal Medicine, Allergy and Clinical Immunology, Genomics Research Center, Academia Sinica, Taipei, Taiwan
- Department of Allergy and Clinical Immunology, Antalya Training and Research Hospital, University of Medical Science, Antalya, Turkey
- Correspondence: Arzu Didem Yalcin, Department of Internal Medicine, Allergy and Clinical Immunology, Genomics Research Center, Academia Sinica, 11529 Tapei,Taiwan, e-mail:
| | - KEVSER ONBASI
- Department of Internal Medicine, Allergy and Clinical Immunology, Dumlupinar University, Kütahya, Turkey
| | - RUSEN UZUN
- Department of Pulmonology, Antalya Training and Research Hospital, University of Medical Science, Antalya, Turkey
| | - FELIX HERTH
- Department of Pulmonary and Critical Care Medicine, Thoraxklinik Translational Lung Research Center, University of Heidelberg, Heidelberg, Germany
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42
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Ledford DK, Casale TB. Can Xolair Be Used in Nonallergic Asthmatic? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:2170. [PMID: 30390909 DOI: 10.1016/j.jaip.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 08/11/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Dennis K Ledford
- Division of Allergy/Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla; James A. Haley Veterans' Hospital, Tampa, Fla.
| | - Thomas B Casale
- Division of Allergy/Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla; James A. Haley Veterans' Hospital, Tampa, Fla
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43
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Martin RJ, Bel EH, Pavord ID, Price D, Reddel HK. Defining severe obstructive lung disease in the biologic era: an endotype-based approach. Eur Respir J 2019; 54:1900108. [PMID: 31515397 PMCID: PMC6917363 DOI: 10.1183/13993003.00108-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 08/19/2019] [Indexed: 11/05/2022]
Abstract
Severe obstructive lung disease, which encompasses asthma, chronic obstructive pulmonary disease (COPD) or features of both, remains a considerable global health problem and burden on healthcare resources. However, the clinical definitions of severe asthma and COPD do not reflect the heterogeneity within these diagnoses or the potential for overlap between them, which may lead to inappropriate treatment decisions. Furthermore, most studies exclude patients with diagnoses of both asthma and COPD. Clinical definitions can influence clinical trial design and are both influenced by, and influence, regulatory indications and treatment recommendations. Therefore, to ensure its relevance in the era of targeted biologic therapies, the definition of severe obstructive lung disease must be updated so that it includes all patients who could benefit from novel treatments and for whom associated costs are justified. Here, we review evolving clinical definitions of severe obstructive lung disease and evaluate how these have influenced trial design by summarising eligibility criteria and primary outcomes of phase III randomised controlled trials of biologic therapies. Based on our findings, we discuss the advantages of a phenotype- and endotype-based approach to select appropriate populations for future trials that may influence regulatory approvals and clinical practice, allowing targeted biologic therapies to benefit a greater proportion and range of patients. This calls for co-ordinated efforts between investigators, pharmaceutical developers and regulators to ensure biologic therapies reach their full potential in the management of severe obstructive lung disease.
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Affiliation(s)
- Richard J Martin
- National Jewish Health and the University of Colorado, Denver, CO, USA
| | - Elisabeth H Bel
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Ian D Pavord
- Respiratory Medicine Unit and NIHR Oxford Respiratory BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
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44
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Varricchi G, Marone G, Spadaro G, Russo M, Granata F, Genovese A, Marone G. Novel Biological Therapies in Severe Asthma: Targeting the Right Trait. Curr Med Chem 2019; 26:2801-2822. [PMID: 29318959 DOI: 10.2174/0929867325666180110094542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 11/09/2017] [Accepted: 11/09/2017] [Indexed: 12/23/2022]
Abstract
Asthma is a heterogeneous disease characterized by chronic airway inflammation that results in a wide spectrum of clinical manifestations. Patients with severe asthma represent a substantial share of consumption of healthcare resources and hospitalization. Moreover, these patients are at risk of increased morbidity and mortality. Recently, several phenotypes and endotypes of asthma have been identified. The identification of specific subtypes of asthma is fundamental for optimizing the clinical benefit of novel treatments. Although in most patients the disease can be controlled by some combination of pharmacologic agents, in some 5-10% of patients the disease remains uncontrolled. Several monoclonal antibodies (mAbs) targeting pathogenetic molecules (e.g., IgE, IL-5, IL- 5Rα, IL-4, IL-13, TSLP) are currently available or under development for the treatment of different forms of severe type 2 asthma. The identification of diagnostic and predictive biomarkers (e.g., IgE, blood eosinophil count, FeNO, periostin, etc.) has revolutioned the field of targeted therapy in severe asthma. Monoclonal antibodies targeting Th2-driven inflammation are generally safe in adult patients with moderate-to-severe asthma. The long-term safety of these biologics is a relevant issue that should be addressed. Unfortunately, little is known about non-type 2 asthma. Further studies are needed to identify biomarkers to guide targeted therapies of different forms of non-type 2 asthma.
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Affiliation(s)
- Gilda Varricchi
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Giancarlo Marone
- Department of Public Health, University of Naples Federico II, Naples, Italy.,Monaldi Hospital, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Michele Russo
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy
| | - Francescopaolo Granata
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Arturo Genovese
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Gianni Marone
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "Gaetano Salvatore", National Research Council (CNR), Naples, Italy
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45
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Campo P, Soto Campos G, Aparicio MB, Jorge AM, González Expósito HM, Quirce S, Dávila I. Severe asthma phenotypes in patients controlled with omalizumab: A real-world study. Respir Med 2019; 159:105804. [PMID: 31704593 DOI: 10.1016/j.rmed.2019.105804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND The appropriate identification of asthma phenotypes of responders to omalizumab would optimize the selection of treatment. OBJECTIVE To describe the most frequent clinical phenotypes in patients with severe asthma responding to omalizumab and their clinical and pulmonary function improvement. METHODS This was an observational, retrospective, multicenter study. Adult patients with severe asthma, who achieved good control after the first year of treatment with omalizumab were included. Omalizumab was prescribed according to clinical routine practice. Responders were assigned to one pre-established phenotype based on the most predominant one before they had started treatment with omalizumab, all according to the physician's criteria. Data about asthma symptoms, number of non-severe asthma exacerbations, medication intake (inhaled and oral corticosteroids and rescue medication), lung function, high fractional exhaled nitric oxide (FeNO) and peripheral eosinophils counts were recorded. RESULTS Among the 345 patients included, the main phenotypes were severe asthma with frequent exacerbations (29.9%), early-onset allergic asthma (23.8%), severe steroid-dependent asthma (18.8%), and severe eosinophilic asthma (13.6%). Clinical and respiratory changes observed after first year of treatment with omalizumab included: reduction in asthma symptoms, reduction in the use and dose of corticosteroids and need for rescue therapy, improvement of pulmonary function, reduction in the number of episodes of non-severe asthma exacerbations regardless of the duration of severe disease since the diagnosis. Increased blood levels of peripheral eosinophils and high FeNO levels were found at baseline. CONCLUSION Several heterogeneous severe asthma phenotypes were observed as good responders to omalizumab.
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Affiliation(s)
- Paloma Campo
- Allergy Unit, IBIMA-Regional University Hospital of Málaga, ARADyAL, Málaga, Spain.
| | | | | | | | | | - Santiago Quirce
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain; CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain.
| | - Ignacio Dávila
- Allergy Service, University Hospital of Salamanca and Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Biomedical and Diagnosis Science Department, Salamanca University School of Medicine, Salamanca, Spain.
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46
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Flora M, Perrotta F, Nicolai A, Maffucci R, Pratillo A, Mollica M, Bianco A, Calabrese C. Staphylococcus Aureus in chronic airway diseases: An overview. Respir Med 2019; 155:66-71. [PMID: 31302581 DOI: 10.1016/j.rmed.2019.07.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 06/22/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023]
Abstract
This review investigates about the role of Staphylococcus Aureus (S. aureus) and S. aureus enterotoxins (SEs) in the pathogenesis of several chronic airway diseases. S. aureus is part of normal human flora and may colonize the skin and the upper airways. SEs acting as superantigens can induce an intense T cell activation and through the release of interleukin (IL) - 4, 5, and 13, can promote a polyclonal IgE response and eosinophilic inflammation. S. aureus can damage epithelial cells inducing the release of the so-called "alarmins" responsible of the activation of Type 2 innate lymphoid cells (ILC-2) linked to an IL-5 mediated airway eosinophilic inflammation. SEs sensitization has been recently associated with the eosinophilic endotypes of both nasal polyps and late onset severe asthma. Studies investigating the effect of biological therapies in SEs sensitized patients should be performed in order to better define the role played by S. aureus in the different endotypes of severe asthma and/or chronic rhinosinusitis.
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Affiliation(s)
- Martina Flora
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Italy
| | - Fabio Perrotta
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Italy
| | - Ambra Nicolai
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Italy
| | - Rosalba Maffucci
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Italy
| | - Anna Pratillo
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Italy
| | - Mariano Mollica
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Italy
| | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Italy
| | - Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Italy.
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47
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Abstract
Severe asthma accounts for only a small proportion of the children with asthma but a disproportionately high amount of resource utilization and morbidity. It is a heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting confirmatory history and objective evidence of asthma and excluding possible masquerading diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled with appropriate management, from asthma that requires the highest level of therapy to maintain control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat asthma includes an assessment of medication delivery, the home environment, and, if possible, the school and other frequented locations, the psychosocial situation, and comorbid conditions. Once identified, aggressive management of issues related to poor adherence and drug delivery, remediation of environmental triggers, and treatment of comorbid conditions is necessary to characterize the degree of control that can be achieved with standard therapies. For the small proportion of patients whose disease remains poorly controlled with these interventions, the clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility for biologic therapies. Management of severe asthma refractory to traditional therapies involves considering the various biologic and other newly approved treatments as well as emerging therapies based on the individual patient characteristics.
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48
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Mokoka MC, McDonnell MJ, MacHale E, Cushen B, Boland F, Cormican S, Doherty C, Doyle F, Costello RW, Greene G. Inadequate assessment of adherence to maintenance medication leads to loss of power and increased costs in trials of severe asthma therapy: results from a systematic literature review and modelling study. Eur Respir J 2019; 53:13993003.02161-2018. [PMID: 30846467 DOI: 10.1183/13993003.02161-2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/20/2019] [Indexed: 01/01/2023]
Abstract
Adherence to inhaled maintenance therapy in severe asthma is rarely adequately assessed, and its influence on trial outcomes is unknown. We systematically determined how adherence to maintenance therapy is assessed in clinical trials of "add-on" therapy for severe asthma. We model the improvement in trial power that could be achieved by accurately assessing adherence.A systematic search of six major databases identified randomised trials of add-on therapy for severe asthma. The relationship between measuring adherence and study outcomes was assessed. An estimate of potential improvements in statistical power and sample size was derived using digitally recorded adherence trial data.87 randomised controlled trials enrolling 22 173 participants were included. Adherence assessment was not reported in 67 trials (n=13 931, 63%). Studies that reported adherence used a range of self-report and subjective methods. None of the studies employed an objective assessment of adherence. Studies that reported adherence had a significantly reduced pooled variance in forced expiratory volume in 1 s (FEV1) compared to those that did not assess adherence: s2=0.144 L2 versus s2=0.168 L2, p<0.0001. Power to detect clinically relevant changes in FEV1 was significantly higher in trials that reported adherence assessment (mean power achieved 59% versus 49%). Modelling suggests that up to 50% of variance in FEV1 outcomes is attributable to undetected variations in adherence. Controlling for such variations could potentially halve the required sample size.Few trials of add-on therapy monitor adherence to maintenance inhaled therapy, resulting in a greater variance in trial outcomes and inadequate power for determining efficacy.
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Affiliation(s)
- Matshediso C Mokoka
- Clinical Research Centre, Smurfit Building, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Elaine MacHale
- Clinical Research Centre, Smurfit Building, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Breda Cushen
- Clinical Research Centre, Smurfit Building, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Christina Doherty
- Beaumont Library, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frank Doyle
- Dept of Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard W Costello
- Dept of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Garrett Greene
- Clinical Research Centre, Smurfit Building, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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49
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Paul AGA, Muehling LM, Eccles JD, Woodfolk JA. T cells in severe childhood asthma. Clin Exp Allergy 2019; 49:564-581. [PMID: 30793397 DOI: 10.1111/cea.13374] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/05/2019] [Accepted: 02/11/2019] [Indexed: 12/17/2022]
Abstract
Severe asthma in children is a debilitating condition that accounts for a disproportionately large health and economic burden of asthma. Reasons for the lack of a response to standard anti-inflammatory therapies remain enigmatic. Work in the last decade has shed new light on the heterogeneous nature of asthma, and the varied immunopathologies of severe disease, which are leading to new treatment approaches for the individual patient. However, most studies to date that explored the immune landscape of the inflamed lower airways have focused on adults. T cells are pivotal to the inception and persistence of inflammatory processes in the diseased lungs, despite a contemporary shift in focus to immune events at the epithelial barrier. This article outlines current knowledge on the types of T cells and related cell types that are implicated in severe asthma. The potential for environmental exposures and other inflammatory cues to condition the immune environment of the lung in early life to favour pathogenic T cells and steroid resistance is discussed. The contributions of T cells and their cytokines to inflammatory processes and treatment resistance are also considered, with an emphasis on new observations in children that argue against conventional type 1 and type 2 T cell paradigms. Finally, the ability for new technologies to revolutionize our understanding of T cells in severe childhood asthma, and to guide future treatment strategies that could mitigate this disease, is highlighted.
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Affiliation(s)
- Alberta G A Paul
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Lyndsey M Muehling
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Jacob D Eccles
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Judith A Woodfolk
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
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50
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Kupczyk M, Bartuzi Z, Bodzenta-Łukaszyk A, Kulus M, Kuna P, Kupryś-Lipińska I, Mazurek H. Polish Society of Allergology statement on the diagnosis and treatment of severe, difficult-to-control bronchial asthma. Postepy Dermatol Alergol 2019; 36:147-157. [PMID: 31320846 PMCID: PMC6627249 DOI: 10.5114/ada.2019.84591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 11/22/2022] Open
Abstract
Severe asthma requires at least high doses of inhaled corticosteroids (ICS) in combination with a long-acting β-agonist (LABA) or systemic corticosteroids (SCS) for more than 50% of days/year to avoid loss of control, or remains uncontrolled despite the treatment described above. The diagnosis of severe asthma should be confirmed in a reference centre as it requires careful differential diagnosis and the exclusion of factors hindering the achievement of optimal control. Severe asthma represents a significant burden for the patient, their family and the healthcare system. This is due to the severity of the symptoms, drug costs, significant impairment of everyday functioning and life quality, and limitation in the professional work. In the case of ineffectiveness of the step 4 GINA treatment, the patient should be referred to a specialist centre to consider additional treatment, including anti-IgE receptor (omalizumab), anti-IL-5 receptor (mepolizumab), or an antibody directed against the α-subunit of receptor for IL-5 (benralizumab). In the case of severe asthma, intensification of therapy should first of all include biological therapy and not the use of SCS. Biological drugs are available in Poland as a part of the therapeutic programme for the treatment of severe asthma. In practice, the therapeutic programme may change with subsequent notices of the Ministry of Health and does not have to be consistent with the Summary of Product Characteristics for individual preparations. The current review presents the basic principles of differential diagnosis of severe asthma and the selection of the optimal biological therapy in Polish conditions.
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Affiliation(s)
- Maciej Kupczyk
- Clinic of Internal Diseases, Asthma and Allergies, N. Barlicki University Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Zbigniew Bartuzi
- Department and Clinic of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Anna Bodzenta-Łukaszyk
- Department of Allergology and Internal Diseases, Medical University of Bialystok, Bialystok, Poland
| | - Marek Kulus
- Clinic of Paediatric Pneumology and Allergology, Paediatric Hospital of the Medical University of Warsaw, Warsaw, Poland
| | - Piotr Kuna
- Clinic of Internal Diseases, Asthma and Allergies, N. Barlicki University Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Izabela Kupryś-Lipińska
- Clinic of Internal Diseases, Asthma and Allergies, N. Barlicki University Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Henryk Mazurek
- Clinic of Pneumology and Cystic Fibrosis, Regional Department of the Institute of Tuberculosis and Pulmonary Diseases, Rabka-Zdroj, Poland
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