Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

Household air pollution and COPD: cause and effect or confounding by other aspects of poverty?

SETTING :

Household air pollution (HAP) and chronic obstructive pulmonary disease (COPD) are both major public health problems, reported to cause around 4 million and 3 million deaths every year, respectively. The great majority of these deaths, as well as the burden of disease during life is felt by people in low- and middle-income countries (LMICs).

OBJECTIVE AND DESIGN :

The extent to which HAP causes COPD is controversial; we therefore undertook this review to offer a viewpoint on this from the Global Initiative for COPD (GOLD).

RESULTS :

We find that while COPD is well-defined in many studies on COPD and HAP, there are major limitations to the definition and measurement of HAP. It is thus difficult to disentangle HAP from other features of poverty that are themselves associated with COPD. We identify other limitations to primary research studies, including the use of cross-sectional designs that limit causal inference.

CONCLUSION :

There is substantial preventable morbidity and mortality associated with HAP, COPD and poverty, separately and together. Although it may not be possible to define clear causal links between HAP and COPD, there is a clear urgency to reduce the avoidable burden of disease these inflict on the world’s poor.

The GOLD Summit on chronic obstructive pulmonary disease in low- and middle-income countries

Chronic obstructive pulmonary disease (COPD) is one of the top three causes of death worldwide, but governments and non-governmental organisations have not given its prevention and treatment the priority it requires. This is particularly true in low- and middle-income countries, where most of the people suffering from this disease live. The United Nations (UN) has targeted a reduction of premature deaths from non-communicable diseases (NCDs) by a third by 2030; however, a coordinated UN/World Health Organization (WHO) strategy to address the burden of COPD (one of the most important NCDs) is still lacking. To explore the extent of the problem and inform the development of policies to improve the situation, the Board of Directors of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) held a 1-day Summit. The key themes that emerged were the need to ensure accurate data on prevalence, raise awareness of the disease among the public, healthcare professionals and governments, including the fact that COPD aetiology goes beyond smoking (and other inhaled pollutants) and includes poor lung development in early life, and ensure that spirometry and both pharmacological and non-pharmacological therapies are available and affordable. Here, we present the actions that must be taken to address the impact of COPD. We believe that the WHO is particularly well-positioned to co-ordinate an attack on COPD, and GOLD will do all it can to help and rally support.

Case finding for chronic obstructive pulmonary disease in people attending long-term condition clinics in primary care

Despite increased interest and awareness of chronic obstructive pulmonary disease (COPD), nearly half of the people with COPD remain undiagnosed. Inviting people at risk for screening is unlikely to be effective as many will not attend. Co-morbidities are common in people with COPD but COPD is also a comorbidity of other long-term conditions and people with these conditions are under regular review in primary care clinics. This study aimed to develop a pilot programme to case find people with COPD among patients attending other long-term clinics in primary care. Twenty-three general practices were recruited to participate in South West England. All current or ex-smokers aged ≥35 attending a long-term condition clinic who were not known to have COPD were asked to complete a questionnaire designed to help identify people with COPD and to perform microspirometry. Practices were asked to collect data on up to 100 patients. One thousand three hundred and thirty-three patients were assessed. Four hundred and ten people (31%) were current smokers. Six hundred and thirteen (46%) had high questionnaire scores and 287 (22%) of these also had a forced expiratory volume in 1 second (FEV1) below the lower limit of normal (LLN). The mean FEV1 in these patients was 59.0% of predicted (range 22-79.0%). Two hundred and twenty-four had an FEV1 between 50% and 80% of predicted, 50 had an FEV1 between 30% and 50% of predicted. One hundred and sixteen (40%) of the people with an FEV1 below the LLN were still smoking and 55 accepted referral to cessation services. A total of 56% of the other smokers assessed but not thought to have COPD also accepted referral. Assessing symptoms and performing microspirometry in people attending long-term condition clinics in primary care is feasible and has a high yield of identifying people likely to have previously undiagnosed COPD.

Budesonide/formoterol vs. salmeterol/fluticasone in COPD: a systematic review and adjusted indirect comparison of pneumonia in randomised controlled trials

AIMS

This analysis was designed to provide a comparison between budesonide/formoterol and salmeterol/fluticasone for the relative incidence of pneumonia adverse events, pneumonia serious adverse events and pneumonia-related mortality in patients being treated for chronic obstructive pulmonary disease.

METHODS

An initial literature search revealed no suitable head-to-head trials between budesonide/formoterol and salmeterol/fluticasone and therefore a systematic review was conducted to find randomised controlled trials providing data for input into an adjusted indirect comparison of the two combination treatments using placebo as a common comparator. The Bucher adjusted indirect comparison method was used to calculate odds ratios and 95% confidence intervals.

RESULTS

Eight salmeterol/fluticasone trials and four budesonide/formoterol trials were identified as being relevant for the analyses. The proportion of patients experiencing a pneumonia adverse event was significantly lower with budesonide/formoterol than salmeterol/fluticasone (odds ratio, 0.47; 95% confidence interval, 0.28-0.80). The proportion of patients experiencing a pneumonia serious adverse event was also significantly lower with budesonide/formoterol than salmeterol/fluticasone (odds ratio, 0.41; 95% confidence interval, 0.19-0.86). However, there were too few events to draw any firm conclusions on pneumonia-related mortality.

CONCLUSIONS

The results of the indirect comparison support the hypothesis that budesonide/formoterol is associated with fewer pneumonia events than salmeterol/fluticasone in chronic obstructive pulmonary disease. The limitations of the analysis are that the results from a single study, TORCH, have a large bearing on the overall findings of the analysis, and that there is heterogeneity in the length and the dosing of the included studies, although it does not appear that heterogeneity affected the reported results. Another important limitation is the lack of predefined diagnostic standards for pneumonia in these studies.

Confidence and understanding among general practitioners and practice nurses in the UK about diagnosis and management of COPD

In order to assess the confidence of healthcare professionals in diagnosing and managing COPD telephone interviews were conducted with 60 practice nurses and 46 general practitioners (GPs) in 2001 and 61 nurses and 39 GPs in 2005. The nurses all ran respiratory clinics. 80% of GPs were confident about diagnosing COPD and this had increased from 52% in 2001. Fifty five percent of nurses were confident and there was no change from 2001. In 2005, 79% of GPs and 70% of nurses were confident about differentiating asthma and COPD. Smoking history, breathlessness, age of onset, lack of response to asthma therapy and cough were reported as features differentiating COPD from asthma. Most respondents stated that spirometry is essential to diagnose COPD and in 2005 nearly all practices had access to a spirometry service. GPs were more confident about interpreting spirometry results in 2005 than nurses and their confidence had increased significantly from 2001. In 2005, nearly all respondents had heard of pulmonary rehabilitation, and significantly more had a programme in their area in 2005 than 2001 (69% vs. 49% p=0.05). Fifty four percent of GPs were confident about which patients to refer for long term oxygen therapy in 2005 but nurses were less confident. There had not been any significant change between 2001 and 2005. In 2005 only 35% of respondents had access to a pulse oximeter. When presented with case scenarios, GPs self-reported confidence was not reflected in their diagnoses or investigation and management strategies and they seem to favour cardiac over respiratory diagnoses.

Evaluating the effectiveness of combination therapy to prevent COPD exacerbations: the value of NNT analysis

The effective prevention of exacerbations in patients with chronic obstructive pulmonary disease (COPD) has the potential to improve patients' health-related quality of life, reduce rates of hospitalisation and mortality and lower healthcare costs. Several pharmacological agents, including inhaled corticosteroid/long-acting beta2-agonist combination therapies, have demonstrated beneficial effects on COPD exacerbations. The number needed to treat (NNT) analysis is a simple, concise method that allows physicians to quantify directly the benefits that alternative treatment options have on disease outcomes in terms of the number of patients who need to be treated before a benefit is observed. This review evaluates the applicability and clinical relevance of NNT analysis for determining the effectiveness of combination therapies against COPD exacerbations, focusing on budesonide/ formoterol in the same inhaler. Physicians are encouraged to consider NNT data within the context of their limitations and in conjunction with other analytical methods when selecting treatments for patients with COPD.

Attack context: an important mediator of the relationship between psychological status and asthma outcomes

BACKGROUND

The importance of psychosocial variables in asthma is increasingly recognised, although attempts to relate these to asthma outcomes often produce only weak relationships. This study aimed to identify whether such relationships might be obscured by the effects of recent asthma experience on psychological status.

METHODS

An adult community sample of 37 patients who had suffered a recent attack of asthma and 37 with stable asthma were given measures of panic fear and control confidence. The relationship with subsequent emergency service use was examined using two way ANOVA and correlational analyses. Covariate influences (psychiatric morbidity, age, sex, treatment level, asthma duration, social status) were considered.

RESULTS

Control confidence predicted emergency service use in different ways for recent attack and stable asthma patients. This interaction was highly significant (F(1,69) = 10.32, p<0.005) with high confidence relating to an increased risk of an attack in the recent attack group and low confidence relating to increased risk for the stable asthma group. There was also an interaction between panic fear and attack context (F(1,69) = 11.05, p<0.005) with low panic fear resulting in more attacks for recent attack cases.

CONCLUSIONS

Attack context (having a recent attack) is an important mediator of psychological status. Strong cognitive/affective responses to attacks may motivate improved self-care and this represents a window of opportunity for self-care interventions. Weak cognitive/affective responses to attacks may reflect denial and require different intervention approaches. For those with recently stable asthma the relationships are qualitatively and quantitatively different, and the implications for intervention are also discussed.