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Bourdin A, Brusselle G, Couillard S, Fajt ML, Heaney LG, Israel E, McDowell PJ, Menzies-Gow A, Martin N, Mitchell PD, Petousi N, Quirce S, Schleich F, Pavord ID. Phenotyping of Severe Asthma in the Era of Broad-Acting Anti-Asthma Biologics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:809-823. [PMID: 38280454 DOI: 10.1016/j.jaip.2024.01.023] [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: 10/02/2023] [Revised: 12/20/2023] [Accepted: 01/01/2024] [Indexed: 01/29/2024]
Abstract
Severe asthma is associated with significant morbidity and mortality despite the maximal use of inhaled corticosteroids and additional controller medications, and has a high economic burden. Biologic therapies are recommended for the management of severe, uncontrolled asthma to help to prevent exacerbations and to improve symptoms and health-related quality of life. The effective management of severe asthma requires consideration of clinical heterogeneity that is driven by varying clinical and inflammatory phenotypes, which are reflective of distinct underlying disease mechanisms. Phenotyping patients using a combination of clinical characteristics such as the age of onset or comorbidities and biomarker profiles, including blood eosinophil counts and levels of fractional exhaled nitric oxide and serum total immunoglobulin E, is important for the differential diagnosis of asthma. In addition, phenotyping is beneficial for risk assessment, selection of treatment, and monitoring of the treatment response in patients with asthma. This review describes the clinical and inflammatory phenotypes of asthma, provides an overview of biomarkers routinely used in clinical practice and those that have recently been explored for phenotyping, and aims to assess the value of phenotyping in severe asthma management in the current era of biologics.
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Affiliation(s)
- Arnaud Bourdin
- PhyMedExp, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Simon Couillard
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Merritt L Fajt
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Elliot Israel
- Pulmonary and Critical Care Medicine, Allergy & Immunology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - P Jane McDowell
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Andrew Menzies-Gow
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom; Royal Brompton and Harefield Hospitals, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Neil Martin
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom; University of Leicester, Leicester, United Kingdom
| | | | - Nayia Petousi
- Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Florence Schleich
- Department of Respiratory Medicine, CHU Liege, GIGA I3 Lab, University of Liege, Liege, Belgium
| | - Ian D Pavord
- Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
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van Dijk YE, Rutjes NW, Golebski K, Şahin H, Hashimoto S, Maitland-van der Zee AH, Vijverberg SJH. Developments in the Management of Severe Asthma in Children and Adolescents: Focus on Dupilumab and Tezepelumab. Paediatr Drugs 2023; 25:677-693. [PMID: 37658954 PMCID: PMC10600295 DOI: 10.1007/s40272-023-00589-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/05/2023]
Abstract
Severe asthma in children and adolescents exerts a substantial health, financial, and societal burden. Severe asthma is a heterogeneous condition with multiple clinical phenotypes and underlying inflammatory patterns that might be different in individual patients. Various add-on treatments have been developed to treat severe asthma, including monoclonal antibodies (biologics) targeting inflammatory mediators. Biologics that are currently approved to treat children (≥ 6 years of age) or adolescents (≥ 12 years of age) with severe asthma include: anti-immunoglobulin E (omalizumab), anti-interleukin (IL)-5 (mepolizumab), anti-IL5 receptor (benralizumab), anti-IL4/IL13 receptor (dupilumab), and antithymic stromal lymphopoietin (TSLP) (tezepelumab). However, access to these targeted treatments varies across countries and relies on few and crude indicators. There is a need for better treatment stratification to guide which children might benefit from these treatments. In this narrative review we will assess the most recent developments in the treatment of severe pediatric asthma, as well as potential biomarkers to assess treatment efficacy for this patient population.
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Affiliation(s)
- Yoni E van Dijk
- Pulmonary Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Pediatric Pulmonology, Emma's Childrens Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Niels W Rutjes
- Pulmonary Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Pediatric Pulmonology, Emma's Childrens Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Korneliusz Golebski
- Pulmonary Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Havva Şahin
- Pediatric Pulmonology, Emma's Childrens Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Simone Hashimoto
- Pulmonary Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Pediatric Pulmonology, Emma's Childrens Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anke-Hilse Maitland-van der Zee
- Pulmonary Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Pediatric Pulmonology, Emma's Childrens Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Susanne J H Vijverberg
- Pulmonary Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Pediatric Pulmonology, Emma's Childrens Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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3
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Andrenacci B, De Filippo M, Votto M, Prevedoni Gorone MS, De Amici M, La Grutta S, Marseglia GL, Licari A. Severe pediatric asthma endotypes: current limits and future perspectives. Expert Rev Respir Med 2023; 17:675-690. [PMID: 37647343 DOI: 10.1080/17476348.2023.2254234] [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: 04/21/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Although rare, pediatric severe therapy-resistant asthma (STRA) is a highly heterogeneous, resource-demanding disease that differs significantly from severe adult asthma and whose pathogenesis is still poorly understood. AREAS COVERED This review summarizes the latest 10 years of English-written studies defining pediatric STRA endotypes using lung-specific techniques such as bronchoalveolar lavage and endobronchial biopsy. Results of the studies and limits on the field are discussed, together with some future perspectives. EXPERT OPINION Over the years, it has become increasingly clear that 'one size does not fit all" in asthma. However, "Does an extremely tailored size fit more than one?'. Only using multicentric, longitudinal pediatric studies, will we be able to answer. Three issues could be particularly critical for future research. First, to provide, if existing, a distinction between prepuberal STRA and puberal STRA endotypes to understand the transition from pediatric to adult STRA and to design effective, tailored therapies in adolescents, usually suffering from poorer asthma control. Second, design early treatments for pediatric airway remodeling to preserve lifelong good lung function. Finally, to better characterize inflammation before and during biological therapies, to provide clues on whether to stop or change treatments.
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Affiliation(s)
- Beatrice Andrenacci
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria De Filippo
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Martina Votto
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Sole Prevedoni Gorone
- Pediatric Radiology Unit, Department of Diagnostic and Interventional Radiology and Neuroradiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mara De Amici
- Immuno-Allergology Laboratory, Clinical Chemistry Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefania La Grutta
- Institute of Translational Pharmacology (IFT), National Research Council of Italy (CNR), Palermo, Italy
| | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Institute of Translational Pharmacology (IFT), National Research Council of Italy (CNR), Palermo, Italy
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Pinnock H, Noble M, Lo D, McClatchey K, Marsh V, Hui CY. Personalised management and supporting individuals to live with their asthma in a primary care setting. Expert Rev Respir Med 2023; 17:577-596. [PMID: 37535011 DOI: 10.1080/17476348.2023.2241357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Complementing recognition of biomedical phenotypes, a primary care approach to asthma care recognizes diversity of disease, health beliefs, and lifestyle at a population and individual level. AREAS COVERED We review six aspects of personalized care particularly pertinent to primary care management of asthma: personalizing support for individuals living with asthma; targeting asthma care within populations; managing phenotypes of wheezy pre-school children; personalizing management to the individual; meeting individual preferences for provision of asthma care; optimizing digital approaches to enhance personalized care. EXPERT OPINION In a primary care setting, personalized management and supporting individuals to live with asthma extend beyond the contemporary concepts of biological phenotypes and pharmacological 'treatable traits' to encompass evidence-based tailored support for self-management, and delivery of patient-centered care including motivational interviewing. It extends to how we organize clinical practiceand the choices provided in mode of consultation. Diagnostic uncertainty due to recognition of phenotypes of pre-school wheeze remains a challenge for primary care. Digital health can support personalized management, but there are concerns about increasing inequities. This broad approach reflects the traditionally holistic ethos of primary care ('knowing their patients and understanding their communities'), but the core concepts resonate with all healthcare.
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Affiliation(s)
- Hilary Pinnock
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- Whitstable Medical Practice, Whitstable, Kent, UK
| | - Mike Noble
- Primary Care Research Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Acle Medical Centre, Norfolk, UK
| | - David Lo
- Department of Respiratory Sciences, College of Life Sciences, NIHR Biomedical Research Centre (Respiratory Theme), University of Leicester, Leicester, UK
- Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Viv Marsh
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- CYP Asthma Transformation Black Country Integrated Care Board, Wolverhampton, UK
| | - Chi Yan Hui
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- Deanery of Molecular, Genetic and Population Health Sciences, The University of Edinburgh, Edinburgh, UK
- The UK Engineering Council, London, UK
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Maison N, Omony J, Illi S, Thiele D, Skevaki C, Dittrich AM, Bahmer T, Rabe KF, Weckmann M, Happle C, Schaub B, Meier M, Foth S, Rietschel E, Renz H, Hansen G, Kopp MV, von Mutius E, Grychtol R. T-high asthma phenotypes across life span. Eur Respir J 2022; 60:13993003.02288-2021. [PMID: 35210326 DOI: 10.1183/13993003.02288-2021] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 02/04/2022] [Indexed: 11/05/2022]
Abstract
RATIONALE In adults, personalised asthma treatment targets patients with T2-high and eosinophilic asthma phenotypes. It is unclear whether such classification is achievable in children. OBJECTIVES To define T2-high asthma with easily accessible biomarkers and compare resulting phenotypes across all ages. METHODS In the multicenter clinical ALL Age Asthma Cohort (ALLIANCE), 1125 participants (n=776 asthmatics, n=349 controls) were recruited and followed for 2 years (1 year in adults). Extensive clinical characterisation (questionnaires, blood differential count, allergy testing, lung function and sputum induction (in adults) was performed at baseline and follow-ups. Interleukin (IL)-4, IL-5 and IL-13 were measured after stimulation of whole blood with LPS or anti-CD3/CD28. MEASUREMENTS AND MAIN RESULTS Based on blood eosinophil counts and allergen-specific serum IgE antibodies (sIgE), patients were categorised into four mutually exclusive phenotypes: "Atopy-only", "Eosinophils-only", "T2-high" (eosinophilia+atopy) and "T2-low" (neither eosinophilia nor atopy). The T2-high phenotype was found across all ages, even in very young children in whom it persisted to a large degree even after 2 years of follow-up. T2-high asthma in adults was associated with childhood onset suggesting early origins of this asthma phenotype. In both children and adults, the T2-high phenotype was characterised by excessive production of specific IgE to allergens (p<0.0001) and, from school age onwards, by increased production of IL-5 after anti-CD3/CD28 stimulation of whole blood. CONCLUSIONS Using easily accessible biomarkers, patients with T2-high asthma can be identified across all ages delineating a distinct phenotype. These patients may benefit from therapy with biologicals even at younger age.
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Affiliation(s)
- Nicole Maison
- Institute for Asthma- and Allergy Prevention (IAP), Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Munich, Germany.,Dr von Hauner Children's Hospital, Ludwig Maximilians University, Munich, Germany.,Comprehensive Pneumology Center - Munich (CPC-M; Member of German Center for Lung Research (DZL), Munich, Germany
| | - Jimmy Omony
- Institute for Asthma- and Allergy Prevention (IAP), Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Munich, Germany.,Comprehensive Pneumology Center - Munich (CPC-M; Member of German Center for Lung Research (DZL), Munich, Germany
| | - Sabina Illi
- Institute for Asthma- and Allergy Prevention (IAP), Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Munich, Germany.,Comprehensive Pneumology Center - Munich (CPC-M; Member of German Center for Lung Research (DZL), Munich, Germany
| | - Dominik Thiele
- Institute of Medical Biometry and Statistics (IMBS), University Medical Center Schleswig-Holstein, Luebeck, Germany.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Chrysanthi Skevaki
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps-University Marburg, Marburg, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), Philipps University Marburg, German Center for Lung Research (DZL), Marburg, Germany
| | - Anna-Maria Dittrich
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Thomas Bahmer
- University Hospital Schleswig-Holstein, Campus Kiel, Internal Medicine Department I, Pneumology, Kiel, Germany.,LungenClinic Grosshansdorf GmbH, Grosshansdorf, Germany.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Klaus Friedrich Rabe
- LungenClinic Grosshansdorf GmbH, Grosshansdorf, Germany.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Markus Weckmann
- Division of Pediatric Pneumology and Allergology, University Medical Center Schleswig-Holstein, Luebeck, Germany.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Christine Happle
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Bianca Schaub
- Dr von Hauner Children's Hospital, Ludwig Maximilians University, Munich, Germany.,Comprehensive Pneumology Center - Munich (CPC-M; Member of German Center for Lung Research (DZL), Munich, Germany
| | - Meike Meier
- Faculty of Medicine, University Children's Hospital, University of Cologne, Cologne, Germany
| | - Svenja Foth
- Universities of Giessen and Marburg Lung Center (UGMLC), Philipps University Marburg, German Center for Lung Research (DZL), Marburg, Germany.,University Children's Hospital Marburg, University of Marburg, Marburg, Germany
| | - Ernst Rietschel
- Faculty of Medicine, University Children's Hospital, University of Cologne, Cologne, Germany
| | - Harald Renz
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps-University Marburg, Marburg, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), Philipps University Marburg, German Center for Lung Research (DZL), Marburg, Germany.,Department of Clinical Immunology and Allergology, Sechenov University, Moscow, Russia
| | - Gesine Hansen
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Matthias Volkmar Kopp
- Division of Pediatric Pneumology and Allergology, University Medical Center Schleswig-Holstein, Luebeck, Germany.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Munich, Germany.,Department of Pediatric Respiratory Medicine, Inselspital, University Children's Hospital of Bern, University of Bern, Bern, Switzerland
| | - Erika von Mutius
- Institute for Asthma- and Allergy Prevention (IAP), Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Munich, Germany .,Dr von Hauner Children's Hospital, Ludwig Maximilians University, Munich, Germany.,Comprehensive Pneumology Center - Munich (CPC-M; Member of German Center for Lung Research (DZL), Munich, Germany
| | - Ruth Grychtol
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Member of the German Center for Lung Research (DZL), Hannover, Germany
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Yang Y, Sun Z, Ren T, Lei W. Differential Expression of lncRNA CASC2 in the Serum of Childhood Asthma and Its Role in Airway Smooth Muscle Cells Proliferation and Migration. J Asthma Allergy 2022; 15:197-207. [PMID: 35185342 PMCID: PMC8847142 DOI: 10.2147/jaa.s337236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/15/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yane Yang
- Department of Pediatrics, The Second Affiliated Hospital of Xi‘an Medical University, Xi’an, Shaanxi, People’s Republic of China
| | - Zhihong Sun
- Department of Pediatrics, The Second Affiliated Hospital of Xi‘an Medical University, Xi’an, Shaanxi, People’s Republic of China
- Correspondence: Zhihong Sun, Department of Pediatrics, The Second Affiliated Hospital of Xi‘an Medical University, 167 Fang Dong Street, Xi’an, 710038, People’s Republic of China, Tel/Fax +86-2983553606, Email
| | - Tingting Ren
- Department of Pediatrics, The Second Affiliated Hospital of Xi‘an Medical University, Xi’an, Shaanxi, People’s Republic of China
| | - Wei Lei
- Department of Pediatrics, Chang ‘an District Hospital, Xi‘an, Shaanxi, People’s Republic of China
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Eller MCN, Pierantozzi Vergani K, Saraiva-Romanholo BM, de Souza Xavier Costa N, de Brito JM, Antonangelo L, Faria CS, Rodrigues JC, Mauad T. Bronchial eosinophils, neutrophils, and CD8 + T cells influence asthma control and lung function in schoolchildren and adolescents with severe treatment-resistant asthma. Respir Res 2022; 23:335. [PMID: 36494835 PMCID: PMC9733356 DOI: 10.1186/s12931-022-02259-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Studies in adult severe treatment-resistant asthma (STRA) have demonstrated heterogeneous pathophysiology. Studies in the pediatric age group are still scarce, and few include bronchial tissue analysis. OBJECTIVE We investigated 6-18-year-old patients diagnosed with STRA in Sao Paulo, Brazil, by characterizing the different lung compartments and their correlations with asthma control and lung function. METHODS Inflammatory profiles of 13 patients with a confirmed diagnosis of STRA were analyzed using blood, induced sputum, bronchoalveolar lavage, viral and bacterial screens and endobronchial biopsy. Inflammatory cells, cytokines, and basement membrane thickening were tested for correlations with the asthma control test (ACT) and spirometry and plethysmography parameters. RESULTS Endobronchial biopsy specimens from 11 patients were viable for analysis. All biopsies showed eosinophilic infiltration. Submucosal (SM) eosinophils and neutrophils were correlated with worse lung function (pre-BD FEV1), and SM neutrophils were correlated with fixed obstruction (post-BD FEV1). Intraepithelial (IE) neutrophils were positively correlated with lung function (pre-BD sGaw). CD8 + T cells had the highest density in the IE and SM layers and were positively correlated with ACT and negatively correlated with the cytokines IL1β, IL2, IL5, IL7, IL10, IL12, IL17, GCSF, MCP-1, INF-δ, and TNFα in sputum supernatant. The ASM chymase + mast cell density correlated positively with quality-of-life score (pAQLQ) and ACT. CONCLUSION Eosinophils and SM neutrophils correlated with worse lung function, while IE neutrophils correlated with better lung function. Most importantly, CD8 + T cells were abundant in bronchial biopsies of STRA patients and showed protective associations, as did chymase + mast cells.
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Affiliation(s)
- Miriam Cardoso Neves Eller
- grid.11899.380000 0004 1937 0722Unidade de Pneumologia Pediátrica, Instituto da Criança, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneias de Carvalho Aguiar, 647, São Paulo, SP CEP 05403-000 Brazil
| | - Karina Pierantozzi Vergani
- grid.11899.380000 0004 1937 0722Unidade de Pneumologia Pediátrica, Instituto da Criança, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneias de Carvalho Aguiar, 647, São Paulo, SP CEP 05403-000 Brazil
| | | | - Natália de Souza Xavier Costa
- grid.11899.380000 0004 1937 0722Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil
| | - Jôse Mára de Brito
- grid.11899.380000 0004 1937 0722Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil ,grid.411180.d0000 0004 0643 7932Departamento de Patologia E Parasitologia, Universidade Federal de Alfenas, Alfenas, MG Brazil
| | - Leila Antonangelo
- grid.11899.380000 0004 1937 0722Divisao de Patologia Clinica, Departamento de Patologia, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, SP Brazil ,grid.11899.380000 0004 1937 0722Laboratorio de Investigacao Clinica (LIM03), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil
| | - Caroline Silvério Faria
- grid.11899.380000 0004 1937 0722Laboratorio de Investigacao Clinica (LIM03), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil
| | - Joaquim Carlos Rodrigues
- grid.11899.380000 0004 1937 0722Unidade de Pneumologia Pediátrica, Instituto da Criança, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneias de Carvalho Aguiar, 647, São Paulo, SP CEP 05403-000 Brazil
| | - Thais Mauad
- grid.11899.380000 0004 1937 0722Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil
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8
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Novosad J, Krčmová I. Evolution of our view on the IgE molecule role in bronchial asthma and the clinical effect of its modulation by omalizumab: Where do we stand today? Int J Immunopathol Pharmacol 2021; 34:2058738420942386. [PMID: 32689848 PMCID: PMC7375718 DOI: 10.1177/2058738420942386] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Bronchial asthma is a heterogeneous disease whose definition and treatment are based on evidence of variable airway obstruction and airway inflammation. Despite the enormous increase in the amount of information on the pathogenesis of this disease, diagnosis is still an unresolved problem, as we still lack sensitive and specific biomarkers. On the other hand, at the turn of the 20th and 21st century, there was a rapid development of therapeutic modalities based on the principle of biological therapy. The first authorized drug matching these characteristics was omalizumab – a monoclonal antibody directed against immunoglobulin E (IgE). It has been used for the treatment of severe forms of bronchial asthma for more than 15 years, which is a sufficient time to acquire ways of its effective use and to assess whether the treatment with omalizumab has met our expectations. However, we continue to discover new and surprising facts about the effects of omalizumab treatment which leads to widening of therapeutic indications. In this work, a basic overview of the very complex role of the IgE molecule in the organism (with a special emphasis on allergic asthma) is discussed, and the most important practical and clinical consequences resulting from its modulation by targeted therapy with omalizumab are summarized.
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Affiliation(s)
- Jakub Novosad
- Institute of Clinical Immunology and Allergology, University Hospital Hradec Králové, Hradec Králové, Czech Republic.,Faculty of Medicine in Hradec Králové, Charles University in Prague, Prague, Czech Republic
| | - Irena Krčmová
- Institute of Clinical Immunology and Allergology, University Hospital Hradec Králové, Hradec Králové, Czech Republic.,Faculty of Medicine in Hradec Králové, Charles University in Prague, Prague, Czech Republic
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9
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Montamat G, Leonard C, Poli A, Klimek L, Ollert M. CpG Adjuvant in Allergen-Specific Immunotherapy: Finding the Sweet Spot for the Induction of Immune Tolerance. Front Immunol 2021; 12:590054. [PMID: 33708195 PMCID: PMC7940844 DOI: 10.3389/fimmu.2021.590054] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/04/2021] [Indexed: 01/16/2023] Open
Abstract
Prevalence and incidence of IgE-mediated allergic diseases have increased over the past years in developed and developing countries. Allergen-specific immunotherapy (AIT) is currently the only curative treatment available for allergic diseases that has long-term efficacy. Although AIT has been proven successful as an immunomodulatory therapy since its beginnings, it still faces several unmet needs and challenges today. For instance, some patients can experience severe side effects, others are non-responders, and prolonged treatment schedules can lead to lack of patient adherence and therapy discontinuation. A common strategy to improve AIT relies on the use of adjuvants and immune modulators to boost its effects and improve its safety. Among the adjuvants tested for their clinical efficacy, CpG oligodeoxynucleotide (CpG-ODN) was investigated with limited success and without reaching phase III trials for clinical allergy treatment. However, recently discovered immune tolerance-promoting properties of CpG-ODN place this adjuvant again in a prominent position as an immune modulator for the treatment of allergic diseases. Indeed, it has been shown that the CpG-ODN dose and concentration are crucial in promoting immune regulation through the recruitment of pDCs. While low doses induce an inflammatory response, high doses of CpG-ODN trigger a tolerogenic response that can reverse a pre-established allergic milieu. Consistently, CpG-ODN has also been found to stimulate IL-10 producing B cells, so-called B regulatory cells (Bregs). Accordingly, CpG-ODN has shown its capacity to prevent and revert allergic reactions in several animal models showing its potential as both preventive and active treatment for IgE-mediated allergy. In this review, we describe how CpG-ODN-based therapies for allergic diseases, despite having shown limited success in the past, can still be exploited further as an adjuvant or immune modulator in the context of AIT and deserves additional attention. Here, we discuss the past and current knowledge, which highlights CpG-ODN as a potential adjuvant to be reevaluated for the enhancement of AIT when used in appropriate conditions and formulations.
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Affiliation(s)
- Guillem Montamat
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Cathy Leonard
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Aurélie Poli
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Ludger Klimek
- Centre for Rhinology and Allergology, Wiesbaden, Germany
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
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Pijnenburg MW, Fleming L. Advances in understanding and reducing the burden of severe asthma in children. THE LANCET RESPIRATORY MEDICINE 2020; 8:1032-1044. [PMID: 32910897 DOI: 10.1016/s2213-2600(20)30399-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 01/16/2023]
Abstract
Severe asthma in children is rare, accounting for only a small proportion of childhood asthma. After addressing modifiable factors such as adherence to treatment, comorbidities, and adverse exposures, children whose disease is not well controlled on high doses of medication form a heterogeneous group of severe asthma phenotypes. Over the past decade, considerable advances have been made in understanding the pathophysiology of severe therapy-resistant asthma in children. However, asthma attacks and hospital admissions are frequent and mortality is still unacceptably high. Strategies to modify the natural history of asthma, prevent severe exacerbations, and prevent lung function decline are needed. Mechanistic studies have led to the development of several biologics targeting type 2 inflammation. This growing pipeline has the potential to reduce the burden of severe asthma; however, detailed assessment and characterisation of each child with seemingly severe asthma is necessary so that the most effective and appropriate management strategy can be implemented. Risk stratification, remote monitoring, and the integration of multiple data sources could help to tailor management for the individual child with severe asthma.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College, London, UK
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11
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Pamuk G, Le Bourgeois M, Abou Taam R, de Blic J, Delacourt C, Lezmi G. The economic burden of severe asthma in children: a comprehensive study. J Asthma 2020; 58:1467-1477. [PMID: 32820695 DOI: 10.1080/02770903.2020.1802747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The economic burden of severe asthma (SA) in children is poorly described. We aimed to determine the healthcare costs of SA in children for the French national health insurance (NHI). METHODS Children (6-18 years of age) with physician-confirmed diagnoses of SA or non-SA (NSA) were identified. Direct and indirect expenditures related to asthma and associated co-morbidities in the previous six months were determined, based on a physician-guided parental questionnaire and confirmed by medical records. The costs for the French NHI were assessed per child over a six month period. RESULTS Data from 74 children, including 48 with SA (22 requiring omalizumab) and 26 with NSA, were analyzed. The global cost of SA was €3,982 per child over a six-month period, including €3,821 direct costs and €161.9 indirect costs. The global cost was €6,716 (4,220) for those requiring omalizumab vs. €1,669 (3,108) for those who did not (p < 0.01). For children with SA, 65% of direct costs were attributed to medication. Among those on omalizumab, such treatment accounted for 93% of medication costs. The global cost was 10 times higher for children with SA than those with NSA (€3,982 (4,422) vs. €363.2 (352.6), p < 0.01), and 20 times higher for children with SA on omalizumab than those with NSA (p < 0.01). CONCLUSION The economic burden of SA in children for the French NHI is substantial and mainly driven by the most severe children requiring biologics.
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Affiliation(s)
- Gizem Pamuk
- Department of Pediatric Pulmonology and Allergy, AP-HP Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Muriel Le Bourgeois
- Department of Pediatric Pulmonology and Allergy, AP-HP Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Rola Abou Taam
- Department of Pediatric Pulmonology and Allergy, AP-HP Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Jacques de Blic
- Department of Pediatric Pulmonology and Allergy, AP-HP Hôpital Universitaire Necker-Enfants Malades, Paris, France.,Faculty of Medicine, Université Paris Descartes, Paris, France
| | - Christophe Delacourt
- Department of Pediatric Pulmonology and Allergy, AP-HP Hôpital Universitaire Necker-Enfants Malades, Paris, France.,Faculty of Medicine, Université Paris Descartes, Paris, France
| | - Guillaume Lezmi
- Department of Pediatric Pulmonology and Allergy, AP-HP Hôpital Universitaire Necker-Enfants Malades, Paris, France.,Faculty of Medicine, Université Paris Descartes, Paris, France
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12
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A real-world assessment of asthma with chronic rhinosinusitis. Ann Allergy Asthma Immunol 2020; 125:65-71. [PMID: 32171930 DOI: 10.1016/j.anai.2020.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) includes 2 main phenotypes: CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). CRS has been reported to be a comorbidity of asthma. OBJECTIVE This study aimed to investigate the role of CRS in outpatients with asthma visited in real-world setting. METHODS This cross-sectional study enrolled 499 consecutive outpatients with asthma. Age, sex, body mass index, smoking status, lung function, Asthma Control Test, inflammatory type 2 biomarkers (including fractional exhaled nitric oxide, blood eosinophils, serum total immunoglobulin E, and allergy), treatment step according to the Global Initiative for Asthma, and comorbidities (obstructive sleep apnea syndrome, arterial hypertension, bronchiectasis, diabetes mellitus type 2, and osteoporosis) were evaluated. RESULTS A total of 179 (35.87%) patients had CRS, in particular 93 (18.64%) had CRSsNP and 86 (17.23%) had CRSwNP. Type 2 inflammation (defined by at least 1 positive biomarker) was present in 81.44% of patients (fractional exhaled nitric oxide > 30 parts per billion in 46.9%, blood eosinophil count > 300 cell/μL in 39.67%, serum total immunoglobulin E >100 IU/mL in 51.54%, and allergy in 53.71%). By multivariate analysis, type 2 inflammation and blood eosinophils greater than 300 cell/μL were the main predictors (odds ratio [OR] 2.54 and 2.26, respectively) of CRS-asthma association. In particular, CRSwNP comorbidity was predicted by type 2 inflammation (OR 3.4) and blood eosinophils greater than 300 cell/μL (OR 3.0). Smoking had conflicting outcome. CONCLUSION This study confirmed that CRS is a frequent asthma comorbidity because it affects more than one-third of outpatients with asthma. CRSwNP is associated with type 2 inflammation and blood eosinophilia. These outcomes underline that CRSwNP asthma phenotype deserves adequate attention for careful management and optimal identification of the best-tailored therapy.
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Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.
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Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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