Long-term efficacy of house dust mite sublingual immunotherapy on clinical and pulmonary function in patients with asthma and allergic rhinitis

Background

A previous study reported that house dust mite (HDM) sublingual immunotherapy (SLIT) for 48 weeks was effective as add-on treatment for allergic asthma; however, data regarding its long-term efficacy are scarce.

Objective

We sought to evaluate the effect of HDM SLIT on asthma control, pulmonary function, and airway inflammation and remodeling throughout the 5-year treatment period.

Methods

A total of 140 patients with asthma and allergic rhinitis sensitized to HDM were randomized to receive either drugs alone or drugs plus SLIT for 5 years. The 5-item Asthma Control Questionnaire (ACQ-5), Asthma Quality of Life Questionnaire (AQLQ), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), spirometry, quantitative computed tomography, and type 2 biomarkers were assessed.

Results

An improvement in the ACQ-5, AQLQ, and RQLQ scores was observed in the SLIT group compared with the control group. HDM SLIT increased lung function and reduced the percentage of airway wall area. The levels of fractional exhaled nitric oxide (Feno), blood eosinophil, serum specific IgE for HDM, and total IgE decreased and were sustained during the 5 years. The change in type 2 biomarkers correlated with change in the AQLQ score. On the basis of receiver-operating characteristic analysis for predicting responders, the area under the receiver-operating characteristic curve in FEV1% predicted, airway wall area, Feno, and specific IgE was high. Multivariate regression analysis showed that the strongest predictor of responders was Feno.

Conclusions

HDM SLIT continued to provide sustained efficacy, improve lung function, and prevent progression of airway inflammation and remodeling in asthma throughout the 5-year treatment period.

Efficacy of a house dust mite sublingual immunotherapy tablet as add-on dupilumab in asthma with rhinitis

BACKGROUND

HDM SLIT is one of the disease-modifying treatment for allergic asthma, and has demonstrated efficacy in clinical trials. Dupilumab, blocks IL-4 and IL-13 signaling, key drivers of type 2 inflammation, and is approved for patients with uncontrolled, moderate-to-severe asthma. The aim of this study was to evaluate outcomes after HDM SLIT initiation in asthma with rhinitis not optimally controlled with dupilumab in a real-world setting.

METHODS

At baseline and 48 weeks after treatment, asthma control questionnaire (ACQ)-5, asthma quality of life questionnaire (AQLQ) and rhinoconjunctivitis quality of life questionnaire (RQLQ) were assessed. Spirometry, type 2 inflammatory biomarkers and quantitative computed tomographic parameters of airway remodeling were also collected.

RESULTS

Of 47 patients received HDM SLIT and 41 completed the study. Combined HDM SLIT and dupilumab improved ACQ-5 (p < 0.05), AQLQ (p < 0.05), RQLQ (p < 0.05), and increased lung function and reduced FeNO (p < 0.05) and airway percentage wall area, and wall thickness (each, p < 0.05). The change in ACQ-5 and AQLQ score correlated with both changes in FeNO and FEV₁ percent predicted. Multiple regression analysis showed that the change in FEV₁ percent predicted was independent factor for improvement of AQLQ (r² = 0.510, p = 0.012). Based on ROC analysis for predicting SLIT responders, the baseline area under the curves in serum HDM specific-IgE, total IgE and FEV₁ percent predicted were high (>0.8).

CONCLUSIONS

These results support the benefits of adding HDM SLIT to pharmacotherapy plus dupilumab in uncontrolled asthma with rhinitis.

Serum Periostin as a Biomarker for Predicting Clinical Response to House Dust Mite Sublingual Immunotherapy in Allergic Rhinitis

BACKGROUND

House dust mite (HDM) sublingual immunotherapy (SLIT) has proven to be effective for allergic rhinitis (AR), but its efficacy varies among patients. No candidate biomarkers for prediction of response to SLIT are available. Periostin, a matricellular protein, is involved in pathophysiology of AR, and its serum levels reflect airway allergic inflammation.

OBJECTIVE

To evaluate the relationship between serum periostin levels and current rhinitis control before and after standardized quality (SQ)-HDM SLIT, and to investigate the role of periostin in predicting clinical response.

METHODS

One hundred eleven subjects with HDM-induced AR were randomized to receive either SLIT plus pharmacotherapy or pharmacotherapy alone, for 48 weeks. At enrollment and the end of study, clinical characteristics and biomarkers that included serum periostin, serum HDM-specific IgE (s-IgE), total IgE, blood eosinophil counts, and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) were measured. The association between clinical indices or biomarkers and clinical response to SLIT was analyzed.

RESULTS

A response to SLIT was recorded in 64% (32 of 50) patients. High serum periostin levels (>30.2 ng/mL) were associated with an effective response to SLIT, and the magnitude of RQLQ improvement was correlated with the level of serum periostin. The sensitivity and specificity based on receiver operating characteristic analysis for periostin were higher than those of s-IgE. Multivariate regression analysis showed that serum periostin was an independent factor for SLIT responders.

CONCLUSIONS

Serum periostin appears to be a useful biomarker for predicting the response to SQ-HDM SLIT in patients with AR.

Association between biomarkers and house dust mite sublingual immunotherapy in allergic asthma

BACKGROUND

House dust mite (HDM) sublingual immunotherapy (SLIT) has demonstrated efficacy in clinical trials of patients with asthma. Airway inflammation is a characteristic of respiratory allergy, but its relationship to SLIT remains unclear.

OBJECTIVE

We evaluate the association between clinical outcomes with pulmonary function and biomarkers in before and after HDM SLIT (UMIN Number 000022390).

METHODS

One hundred twelve patients with asthma sensitized to HDM were randomized to add-on 6 standardized quality (SQ)-HDM SLIT to pharmacotherapy or pharmacotherapy alone for 48 weeks. At baseline and end of study, biomarkers, blood eosinophils, serum IgE, serum periostin, fractional exhaled nitric oxide (FeNO), and spirometry and clinical symptoms were measured. Association between biomarkers and an increase in FEV₁ of 120 mL or greater were analysed.

RESULTS

Sublingual immunotherapy (SLIT) demonstrated a significant reduction of serum periostin (P < .001), FeNO (P < .01), and increase in HDM-specific IgE (P < .05), FEV₁ (P < .001) and improvement of clinical symptom scores, when compared to pharmacotherapy. The change in FEV₁ correlated with the changes in serum periostin (r = .696, P < .001) and the changes in FeNO (r = .682, P < .001). The independent predictor of improvement in airflow limitation was changed in serum periostin (r²  = .753, P = .013) and FeNO (P = .038). Based on cut-off values derived by receiver operating characteristic analysis (periostin 30.9 ng/mL, FeNO 28.0 ppb), patients were distinguished responders from non-responders, but with no predictive value for blood eosinophils or total IgE. The proportion of patients with both high periostin and FeNO levels was significantly higher in responder than in non-responder (P = .026).

CONCLUSIONS AND CLINICAL RELEVANCE

Adding HDM SLIT to pharmacotherapy resulted in reduced serum periostin and FeNO, and improved pulmonary function. Serum periostin and FeNO may be useful biomarkers for prediction of SLIT.

Comparison between montelukast and tiotropium as add-on therapy to inhaled corticosteroids plus a long-acting β2-agonist in for patients with asthma

Objective: Asthma often remains uncontrolled despite treatment with inhaled corticosteroids (ICS) alone or with ICS plus a long-acting β₂-agonist (LABA). The recommended alternative is the addition of either montelukast or tiotropium. The aim of this study was to compare the effects of montelukast and tiotropium on airway inflammation and remodeling in persistent asthma. Methods: Eighty-seven patients with asthma were treated with budesonide and formoterol (640/18 μg); then, the patients were randomly allocated to three groups to receive oral montelukast (10 mg/day), inhaled tiotropium (5 μg/day), or no add-on to the maintenance therapy for 48 weeks. Fractional exhaled nitric oxide (FeNO) and pulmonary function were measured, and quantitative computed tomography was performed. Results: Compared to the maintenance therapy, add-on montelukast significantly decreased FeNO (p < 0.05) and improved airflow obstruction (p < 0.05), whereas airway dimensions remained unchanged. Changes in FeNO were significantly correlated with changes in FEV₁ (r = -0.71, p < 0.001). In contrast, the addition of tiotropium significantly decreased airway wall area corrected for body surface area (WA/BSA) (p < 0.05), decreased wall thickness (T/√BSA) (p < 0.05) and improved airflow obstruction (p < 0.05) with no change in FeNO. Changes in WA/BSA and T/√BSA were significantly correlated with the change in percentage predicted FEV₁ (r = -0.84, p < 0.001 and r = -0.59, p < 0.01, respectively). Conclusions:Adding either montelukast or tiotropium to ICS/LABA may provide additive benefits with respect to the pulmonary function and airway inflammation or remodeling in patients with asthma.

Effects of the addition of tiotropium on airway dimensions in symptomatic asthma

BACKGROUND

Tiotropium, a once-daily, long-acting anticholinergic bronchodilator, has shown efficacy and safety as an add-on to maintenance therapy in patients with symptomatic asthma.

OBJECTIVE

The aim of the present study was to assess the effect of tiotropium on airway geometry and airway inflammation in patients with asthma who were symptomatic despite treatment with inhaled corticosteroid (ICS) plus a long-acting beta 2agonist (LABA).

METHODS

In total, 53 patients with symptomatic asthma who received ICS plus LABA and who had a prebronchodilator forced expiratory volume in 1 second of 6090% of the predicted value were randomized to the addition of tiotropium 5 g once daily (n = 25) or no add-on (n = 28) to maintenance therapy for 48 weeks. Quantitative computed tomography, fractional exhaled nitric oxide, and pulmonary function were measured.

RESULTS

Compared with maintenance therapy, the addition of tiotropium significantly decreased airway wall area (WA) corrected for body surface area (BSA) (WA/BSA) (p 0.05) and wall thickness (T) (T/BSA, p 0.05), and improved airflow obstruction. No significant difference in the change of fractional exhaled nitric oxide was observed between the two treatment groups. Changes in WA/BSA and T/BSA were significantly correlated with the change in predicted forced expiratory volume in 1 second (r = 0.87, p 0.001, and r = 0.82, p 0.001, respectively).

CONCLUSION

The addition of once-daily tiotropium to maintenance therapy improved airflow limitation and reduced airway T. A triple combination of tiotropium and ICS plus LABA may have additive protective effects of bronchodilation and remodeling.

Association of airway wall thickness with serum periostin in steroid-naive asthma

BACKGROUND

Periostin may be a useful biomarker of T-helper type 2 eosinophilic airway inflammation and has been linked to remodeling in asthma. However, the association between serum periostin and the magnitude of airway wall thickness remains unclear.

OBJECTIVE

We examined the relationship between serum periostin and airway geometry in asthma.

METHODS

Twenty-six patients with steroid-naive asthma, 30 patients with asthma treated with inhaled corticosteroids, and 46 aged-matched healthy controls were studied. Serum periostin levels, lung function, and inflammatory cell counts in sputum were measured. The following parameters of airway dimension were assessed by computed tomography: lumen area, wall area (WA), WA to total area ratio, and wall thickness.

RESULTS

Serum periostin levels were significantly elevated in patients with steroid-naive asthma compared with the controls (p < 0.01) and patients with asthma who were treated with steroids (p < 0.01). In patients who were steroid naive, serum periostin was correlated with air flow limitation (r = -0.62, p < 0.01) and the WA to body surface area (r = 0.71, p < 0.01), and sputum eosinophil percentage (r = 0.60, p < 0.01). Multivariate analysis showed that the percentage of predicted forced expiratory volume in 1 second, WA to body surface area, and sputum eosinophils were independent factors for high serum periostin.

CONCLUSION

Serum periostin may be a candidate for a novel biomarker for not only eosinophilic inflammation but as a marker for airway remodeling in asthma.

Effect of treatment with inhaled corticosteroid on serum periostin levels in asthma

BACKGROUND AND OBJECTIVE

Periostin is a biomarker of eosinophilic airway inflammation and may contribute to airway remodeling in asthma. The anti-inflammatory activity of inhaled corticosteroids (ICS) for asthma control is widely recognized. The aim of this study was to assess the effects of ICS on serum periostin levels and its relationships to inflammation and airway geometry.

METHODS

Forty-two healthy controls and 20 patients with steroid-naïve asthma before and after treatment with fluticasone propionate (800 μg/day for 16 weeks) were examined. Serum periostin, lung function and inflammatory cell counts in sputum were measured. Airway dimensions were determined by quantitative computed tomography (total area of the airway (Ao), wall area (WA), wall thickness (T) and percentage wall area (WA%) ).

RESULTS

Serum periostin concentrations were significantly higher in patients with asthma than in controls. Periostin levels were correlated with airway wall thickness and sputum eosinophilia and inversely correlated with airflow limitation in asthma. ICS significantly decreased serum periostin (P < 0.01), decreased WA corrected for body surface area (WA/BSA, P < 0.05), T/√BSA (P < 0.01) and WA% (P < 0.01), reduced the percentage of sputum eosinophils (P < 0.01) and improved airflow limitation. The decrease in serum periostin levels was associated with an increased per cent predicted forced expiratory volume in 1 s (r = -0.64, P < 0.01), decreased WA/BSA (r = 0.46, P < 0.05) and decreased sputum eosinophils (r = 0.71, P < 0.01).

CONCLUSION

Serum periostin levels respond partially to ICS and may reflect a reduction in airway inflammation and wall thickening in asthma.

Comparison of airway dimensions with once daily tiotropium plus indacaterol versus twice daily Advair(®) in chronic obstructive pulmonary disease

BACKGROUND

Current guidelines recommend combining long-acting bronchodilators with different modes of action in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). We evaluated the effects of airway dimensions and pulmonary function with tiotropium plus indacaterol versus Advair(®).

METHODS

Subjects (n = 46) were randomized to receive tiotropium (18 μg once daily) plus indacaterol (150 μg once daily) or Advair(®) (50/250 μg twice daily) for 16 weeks. Airway geometry was determined by quantitative computed tomography (luminal area, Ai; total area of the airway, Ao; wall area, WA; and percentage wall area, WA/Ao and wall thickness, T). Spirometry (forced expiratory volume in 1 s, FEV1; forced vital capacity, FVC and inspiratory capacity, IC) and St. George's Respiratory Questionnaire (SGRQ) were evaluated.

RESULTS

Tiotropium plus indacaterol significantly increased CT-indices including Ai corrected for body surface area (Ai/BSA), and decreased WA/BSA, WA/Ao and T/√BSA compared with Advair(®) (p < 0.05, respectively). In physiological parameters, mean difference in IC was significantly higher under treatment with tiotropium plus indacaterol than Advair(®) (p < 0.05). The changes in Ai/BSA, WA/BSA, WA/Ao and T/√BSA were significantly correlated with changes in IC (r = 0.535, p = 0.011; r = -0.688, p < 0.001; r = -0.555, p = 0.002 and r = -0.542, p = 0.007; respectively). There were more significant improvements in SGRQ scores after treatment with tiotropium plus indacaterol than Advair(®).

CONCLUSIONS

These findings suggest that dual bronchodilation with tiotropium plus indacaterol is superior in airway geometry and lung function compared with Advair(®) in COPD.

Increased C-reactive protein is associated with airway wall thickness in steroid-naive asthma

BACKGROUND

Asthma is characterized by chronic airway inflammation and remodeling. Levels of serum high-sensitivity C-reactive protein (hs-CRP) reflect airway eosinophilic inflammation. However, the relation between hs-CRP and the development of airway wall thickening remains unknown.

OBJECTIVE

To evaluate whether serum hs-CRP is associated with airway geometry in asthma.

METHODS

Forty-eight steroid-naive patients with asthma, 51 patients with asthma treated with inhaled corticosteroids, and 38 aged-matched healthy controls were studied cross-sectionally. Serum hs-CRP levels, lung function, and inflammatory cell counts in sputum were measured. Quantitative computed tomographic analysis of the apical segment of the right upper lobe was performed.

RESULTS

Serum hs-CRP levels were significantly elevated in steroid-naive patients with asthma compared with controls and steroid-treated patients with asthma and were associated with airflow limitation. In steroid-naive patients, serum hs-CRP levels were correlated with airway wall thickness (r = 0.88, P < .001) and sputum eosinophil percentage (r = 0.75, P < .001). Multivariate analysis showed a significant association between hs-cRP levels and forced expiratory volume in 1 second (percentage predicted; R(2) = 0.65, P = .001).

CONCLUSION

Serum hs-CRP may be a useful systemic biomarker of airway eosinophilia in steroid-naive asthma and has potential utility as a marker for the development of airway wall thickening.

TRIAL REGISTRATION

University Hospital Medical Information Network (www.umin.ac.jp/ctr/index/htm); identifier, UMIN000006724.

Computed tomography assessment of airway dimensions with combined tiotropium and indacaterol therapy in COPD patients

BACKGROUND AND OBJECTIVE

Combining a long-acting muscarinic antagonist with a long-acting β₂-agonist has been shown to be pharmacologically useful in patients with chronic obstructive pulmonary disease (COPD). The aim of the present study was to evaluate the effectiveness of the dual bronchodilator therapy on airway dimensions in COPD.

METHODS

Patients (n = 54) were randomly assigned to receive tiotropium (18 μg once daily), indacaterol (150 μg once daily) or tiotropium plus indacaterol for 16 weeks. Quantitative computed tomography (CT), pulmonary function and health status (St. George's Respiratory Questionnaire) were measured.

RESULTS

Compared with tiotropium or indacaterol alone, combination therapy resulted in a significant decrease in percentage wall area (WA%) and wall thickness, corrected for body surface area, and an increase in luminal area (Ai/BSA). Concurrent treatment was superior to monotherapy in physiological indices, including forced vital capacity, forced expiratory volume in 1 s (FEV₁) and inspiratory capacity. The changes in WA% and Ai/BSA were significantly correlated with changes in FEV₁ (r = -0.44, P < 0.01 and r = 0.37, P < 0.01). There were more significant improvements in SGRQ scores after treatment with combined therapy than with either treatment alone.

CONCLUSIONS

Concurrent therapy with tiotropium and indacaterol is effective for COPD patients to promote reduction in airway wall thickness, bronchodilation, and improvements in lung function compared with a single inhaler.

Effects of budesonide/formoterol combination therapy versus budesonide alone on airway dimensions in asthma

BACKGROUND AND OBJECTIVE

Combination therapy with inhaled corticosteroids and long-acting β(2)-agonists results in improved asthma symptom control compared with the use of inhaled corticosteroids alone. However, the effects of combination therapy on structural changes and inflammation of the airways are still unknown. The aim of this study was to compare the effects of budesonide/formoterol with those of budesonide alone on airway dimensions and inflammation in individuals with asthma.

METHODS

Fifty asthmatic patients were randomized to treatment with budesonide/formoterol (200/6 µg, two inhalations bd) or budesonide (200 µg, two inhalations bd) for 24 weeks. Airway dimensions were assessed using a validated computed tomography technique, and airway wall area (WA) corrected for body surface area (BSA), percentage WA (WA%), wall thickness/Ösquare root BSA, and luminal area (Ai)/BSA at the right apical segmental bronchus, were measured. The percentage of eosinophils in induced sputum, pulmonary function, and Asthma Quality of Life Questionnaires (AQLQ) were also evaluated.

RESULTS

There were significantly greater decreases in WA/BSA (P < 0.05), WA% (P < 0.001) and wall thickness/square root BSA (P < 0.05), and increases in Ai/BSA (P < 0.05), in subjects treated with budesonide/formoterol compared with those treated with budesonide. The reduction in sputum eosinophils and increase in per cent of predicted forced expiratory volume in 1 s (FEV(1) %) were greater for subjects treated with budesonide/formoterol compared with those treated with budesonide alone. In the budesonide/formoterol group, the changes in WA% were significantly correlated with changes in sputum eosinophils and FEV(1%) (r = 0.84 and r = 0.64, respectively). There were improvements in the AQLQ scores after treatment with budesonide/formoterol.

CONCLUSIONS

Budesonide/formoterol combination therapy is more effective than budesonide alone for reducing airway wall thickness and inflammation in individuals with asthma.

Effects of adding omalizumab, an anti-immunoglobulin E antibody, on airway wall thickening in asthma

BACKGROUND

Omalizumab may inhibit allergic inflammation and could contribute to decreasing airway remodeling in patients with asthma.

OBJECTIVE

The aim of this study was to assess the effects of omalizumab on airway wall thickness using computed tomography (CT).

METHODS

Thirty patients with severe persistent asthma were randomized to conventional therapy with (n = 14) or without omalizumab (n = 16) for 16 weeks. The following airway dimensions were assessed by a validated CT technique: airway wall area corrected for body surface area (WA/BSA), percentage wall area (WA%), wall thickness (T)/√BSA, and luminal area (Ai)/BSA at the right apical segmental bronchus. The percentage of eosinophils in induced sputum, pulmonary function and the Asthma Quality of Life Questionnaire (AQLQ) were assessed as well.

RESULTS

Treatment with omalizumab significantly decreased WA/BSA (p < 0.01), WA% (p < 0.01), and T/√BSA (p < 0.01), and increased Ai/BSA (p < 0.05), whereas conventional therapy resulted in no change. In the omalizumab group (n = 14), a significant decrease in the percentage of sputum eosinophils (p < 0.01), improved forced expiratory volume in 1 s (FEV(1)), and an improved AQLQ score were recorded. The changes in FEV(1)% predicted and sputum eosinophils were significantly correlated with changes in WA% (r = 0.88, p < 0.001, and r = 072, p < 0.01, respectively).

CONCLUSIONS

These findings suggest that omalizumab reduced airway wall thickness and airway inflammation. Larger patient studies with longer-term follow-up are needed to show whether omalizumab can truly maintain improved airway wall dimensions.

Effects of adding salmeterol/fluticasone propionate to tiotropium on airway dimensions in patients with chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

Although salmeterol/fluticasone propionate combination (SFC) therapy has been widely used for the treatment of COPD, the relationship between airway dimensions and improvement in pulmonary function remains unknown. The aim of this study was to compare the effects of SFC in combination with tiotropium (Tio) and Tio alone, on airway dimensions and pulmonary function in COPD patients.

METHODS

Thirty COPD patients were randomized to receive inhaled Tio (18 µg once daily) or inhaled SFC (50/250 µg twice daily) plus Tio for 12 weeks. Spirometry and CT were performed, and the St. George's Respiratory Questionnaire (SGRQ) was completed, before and after the trial. Airway dimensions were assessed by a validated CT technique, and airway wall area (WA) corrected for body surface area (BSA), percentage wall area (WA%), absolute wall thickness T/√BSA, and luminal area Ai/BSA at the right apical segmental bronchus, were measured.

RESULTS

Treatment with SFC plus Tio significantly decreased WA/BSA (P < 0.05), WA% (P < 0.01) and T/√BSA (P < 0.01), and increased Ai/BSA (P < 0.01), whereas treatment with Tio alone had no effect. The changes in WA/BSA and Ai/BSA were significantly correlated with increases in FEV1 (r = 0.48, P < 0.05, and r = 0.36, P < 0.05, respectively). There were significant improvements in SGRQ scores after treatment with SFC plus Tio.

CONCLUSIONS

Airway wall thickening and airway narrowing decreased after treatment with SFC plus Tio, and the changes in airway dimensions were proportional to the improvements in FEV1 . These results suggest that SFC plus Tio is more effective than Tio alone in the management of COPD patients.