International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma

Severe Asthma and Active SARS-CoV-2 Infection: Insights into Biologics

Since the onset of the COVID-19 pandemic, managing asthma has become significantly more challenging. Both national and international guidelines emphasize the importance of continuing prescribed medications to maintain asthma control and prevent exacerbations. However, the emergence of SARS-CoV-2 infection has raised concerns about the safety of biologic therapies during acute COVID-19 episodes, necessitating a careful and individualized approach to their use. Biologic therapies, including omalizumab, dupilumab, mepolizumab, reslizumab, benralizumab, and tezepelumab, which target specific pathways in severe asthma, have revolutionized asthma management by improving symptom control and reducing exacerbation rates. Despite their proven benefits, the intersection of biologic therapy and active SARS-CoV-2 infection has prompted questions regarding potential immunomodulatory effects and risks. This review aimed to synthesize the current literature on the antiviral effects and safety of biologic drugs in severe asthmatic patients with active SARS-CoV-2 infection, encompassing both pediatric and adult populations.

Efficacy of omalizumab after discontinuation: a retrospective single-center observational study in children with severe asthma

Introduction

Several trials documented safety and efficacy of omalizumab, but there are a few data about its effects after discontinuation. This study aims to evaluate the maintenance of efficacy of omalizumab in pediatric asthmatic patients one year after its suspension.

Methods

A retrospective analysis was conducted on 17 subjects aged 6-18 years, divided into two groups: Group A (9 patients) who discontinued omalizumab after 18 months, and Group B (8 patients) who continued the therapy. Data on respiratory function (FEV1%), the number of exacerbations, need for hospitalizations, use of oral corticosteroids, and Asthma Control Test (ACT) scores were collected and analyzed at three time points: baseline (T0), after 18 months of treatment (T1), and 36 months (T2).

Results

In Group A, significant differences were observed between T0 and T1, and T1 and T2, in FEV1% values, the number of exacerbations, the need for oral corticosteroids, and ACT scores. Group B showed significant differences in these parameters over time, with a notable reduction in exacerbations and improvement in ACT scores. The comparative analysis revealed that Group B had a higher number of exacerbations compared to Group A at T0 and greater use of oral cortico-steroids at T1. By T2, Group A had a higher ACT score than Group B at T0, whereas Group B showed higher ACT scores at T2 compared to Group A.

Discussion

The study confirmed the efficacy and safety of omalizumab, with its benefits persisting one year after treatment discontinuation in terms of lung function, reduction in exacerbations, decreased need for oral corticosteroids, and improved quality of life. Further research is necessary.

Patient-centred composite scores as tools for assessment of response to biological therapy for paediatric and adult severe asthma

BACKGROUND

We have previously developed Core Outcome Measures sets for Severe Asthma (COMSA) by multi-stakeholder consensus. There are no patient-centred tools to quantify response to biological therapies for severe asthma. We aimed to develop paediatric and adult CompOsite iNdexes For Response in asthMa (CONFiRM) incorporating clinical parameters and patient-reported quality of life.

METHODS

International expert healthcare professionals and patients with severe asthma were invited to 1) develop consensus levels of clinically relevant changes for each outcome measure within COMSA, 2) use multicriteria decision analysis to develop the CONFiRM scores and 3) assess their internal validity. A separate group of healthcare professionals evaluated CONFiRM's external validity.

RESULTS

Five levels of change for each COMSA outcome were agreed. Severe exacerbations and maintenance oral corticosteroid use were rated as the most important in determining both paediatric and adult CONFiRM scores. There was strong agreement between healthcare professionals and patients, although patients assigned greater importance to quality of life. The CONFiRM score quantified response to a biologic from -31 (deterioration) to 69 (best possible response). Paediatric and adult CONFiRMs had good discriminative ability for a sufficient (area under the curve ≥0.92) and a substantial (area under the curve ≥0.95) response to biologics. Both CONFiRMs demonstrated excellent external validity (Spearman correlation coefficients 0.9 and 0.8 for paediatric and adult, respectively; p<0.0001).

CONCLUSIONS

We have developed novel patient-centred paediatric and adult CONFiRMs that include quality of life measures. CONFiRMs should allow a more holistic understanding of response for the patient and a standardised assessment of the effectiveness of biologics between studies. Further research is needed to prospectively validate CONFiRM scores.

Sputum metagenomics reveals a multidrug resistant Pseudomonas-dominant severe asthma phenotype in an Asian population

BACKGROUND AND OBJECTIVE

While the lung microbiome in severe asthma has been studied, work has employed targeted amplicon-based sequencing approaches without functional assessment with none focused on multi-ethnic Asian populations. Here we investigate the clinical relevance of microbial phenotypes of severe asthma in Asians using metagenomics.

METHODS

Prospective assessment of clinical, radiological, and immunological measures were performed in a multi-ethnic Asian severe asthma cohort (N = 70) recruited across two centres in Singapore. Sputum was subjected to shotgun metagenomic sequencing and patients followed up for a 2-year period. Metagenomic assessment of sputum microbiomes, resistomes and virulomes were related to clinical outcomes.

RESULTS

The lung microbiome in a multi-ethnic Asian cohort with severe asthma demonstrates an increased abundance of Pseudomonas species. Unsupervised clustering of sputum metagenomes identified two patient clusters: C1 (n = 52) characterized by upper airway commensals and C2 (n = 18) dominated by established respiratory pathogens including M. catarrhalis, S. aureus and most significantly P. aeruginosa. C2 patients demonstrated a significantly increased exacerbation frequency on 2-year follow up and an antimicrobial resistome characterized by multidrug resistance. Virulomes appear indistinguishable between severe asthmatics with or without co-existing bronchiectasis, and C2 patients exhibit increased gene expression related to biofilm formation, effector delivery systems and microbial motility. Independent comparison of the C2 cluster to a non-asthmatic bronchiectasis cohort demonstrates analogous airway microbial virulence patterns.

CONCLUSION

Sputum metagenomics demonstrates a multidrug-resistant Pseudomonas-dominant severe asthma phenotype in Asians, characterized by poor clinical outcome including increased exacerbations which is independent of co-existing bronchiectasis.

Global burden of asthma attributable to high body mass index in older adults 1990-2021 and prediction to 2050: An analysis of Global Burden of Disease Study 2021

Background

Previous studies have shown that high body mass index was a primary risk factor for asthma, particularly impacting older adults. This study aimed to assess the spatial and temporal trends for asthma burden attributable to high body mass index in older adults from 1990 to 2021 and to project trends up to 2050.

Method

We extracted data from the Global Burden of Disease Study 2021 for population aged over 60 years with asthma attributable to high BMI. Relevant indicators included number of deaths, disability-adjusted life years, mortality, and disability-adjusted life years rates and the rates were directly standardized. Spearman rank correlation test tested the burden against the Socio-demographic Index (SDI). Decomposition analysis was used to decompose changes in burden according to population structure, population growth, and epidemiologic changes. The Bayesian age-period-cohort model was used to predict the burden.

Results

From 1990 to 2021, despite downward trends in global mortality and disability-adjusted life-year rates, global asthma deaths, and disability-adjusted life years attributable to high body mass index increase by 69% and 46%, rising to 43,628 cases (95% CI: 18,366-71 088) and 1,223,969 years (95% CI: 526,972-1 945,426). Age-standardized mortality rates and disability-adjusted life years rates were more severe in regions with lower SDI, such as Oceania. Mortality rates and disability-adjusted life-year rates increased with age, with a higher burden observed in females compared to males. Population growth had a significant impact on the increase in deaths and disability-adjusted life years from 1990 to 2021, contributing approximately 158% and 222%, respectively. Asthma deaths and disability-adjusted life years attributable to high body mass index will continue to rise to 101,252 cases and 2,941,172 years up to 2050.

Conclusion

The global asthma burden due to high body mass index in older adults has risen significantly and is expected to continue this trend, highlighting the importance of developing public health strategies to address this issue.

Perturbations in the airway microbiome are associated with type 2 asthma phenotype and severity

BACKGROUND

Airway microbiome has been linked to asthma heterogeneity, yet little is known about the associations between airway microbiota and type 2 (T2) asthma phenotype and severity.

OBJECTIVE

To determine the relationship of nasopharyngeal (NP) and induced sputum (IS) microbiota to the phenotypic features of T2 asthma.

METHODS

NP and IS samples from subjects with T2 mild-to-moderate asthma (n = 23), subjects with severe asthma (n = 21), and healthy controls (n = 16) were analyzed. Bacterial microbiota and functional profiles were compared. The correlation between microbial communities and clinical and inflammatory features was evaluated in individuals with asthma of 2 statuses.

RESULTS

Differences in NP and IS microbiota were associated with T2 asthma phenotype. Alterations in NP microbiota were more reflective of T2 inflammation and severity, with additional stratification of a subgroup characterized by significant elevations in T2 inflammatory biomarkers and reductions in bacterial richness and diversity (P < .05). Burkholderia-Caballeronia-Paraburkholderia, Ralstonia, and Rhodococcus were identified as hub taxa within NP microbial network in T2 severe asthma, which were prevalent in the entire airway and involved in bacterial functions including inflammatory and steroid responses (P < .05). The composition and diversity of IS microbiota were complex, with Veillonella as the most altered genus, having an increase with increasing asthma severity.

CONCLUSION

Our work revealed the significant associations of microbiota perturbations throughout the entire respiratory tract to the extent of T2 inflammation, phenotype and severity in T2 asthma. The specific taxa identified invite further mechanistic investigations to unravel their possibility as biomarkers and therapeutic targets for T2 severe asthma.

Relationships Between Chronic Cough and Asthma Control and Quality of Life in Patients With Severe Asthma: A 6-Month Longitudinal Analysis

BACKGROUND

The prevalence and clinical implications of chronic cough (CC) in patients with severe asthma receiving asthma treatment remain relatively unknown.

OBJECTIVE

This study aimed to evaluate the relationships between CC and asthma control and quality of life (QoL) in patients with severe asthma through longitudinal analysis.

METHODS

Baseline and 6-month follow-up data from the Korean Severe Asthma Registry were analyzed. CC was defined as a cough visual analog scale (VAS) score of ≥40 at both baseline and 6 months. Demographic parameters and clinical outcomes were compared between patients with severe asthma and CC and those without CC. Generalized estimating equation (GEE) analysis was performed to identify associations of CC with asthma control and QoL scores.

RESULTS

Of the total 286 participants with severe asthma, 116 (40.6%) were defined as having CC. Patients with CC had higher baseline cough and wheeze severity VAS scores (all P < .001), poorer asthma control (P < .001), and worse QoL (Severe Asthma Questionnaire [SAQ] and Euro-QoL 5-Dimension [EQ-5D] index, all P < .001) than those without CC. During the follow-up, patients with CC were more frequently exposed to oral corticosteroids (58.6% vs 38.6%, P = .010) and experienced more frequent asthma exacerbations (48.3% vs 28.6%, P = .009) than those without CC. GEE analysis revealed that CC was independently associated with poor asthma control, lower SAQ scores, and a lower EQ-5D index after adjusting for confounders.

CONCLUSION

The presence of CC was associated with worse asthma control and QoL in patients with severe asthma. Further studies are warranted to better evaluate and manage CC in these patients.

Computed tomography-based measurements associated with rapid lung function decline in severe asthma

BACKGROUND

Patients with severe asthma are susceptible to lung function decline (LFD), but biomarkers that reliably predict an accelerated LFD have not been fully recognized.

OBJECTIVE

To identify variables associated with previous LFD occurrences in patients with severe asthma by exploring the computed tomography (CT) imaging features within predefined LFD groups.

METHODS

We obtained inspiratory and expiratory CT images of 102 patients with severe asthma and derived 2 airway structural parameters (wall thickness [WT] and hydraulic diameter) and 2 parenchymal variables (functional small airway disease and emphysema). We retrospectively calculated the annual changes in forced expiratory volume in 1 second and grouped participants by their values determined. The 4-imaging metrics, along with levels of several biomarkers, were compared among the LFD groups.

RESULTS

Patients with severe asthma with enhanced LFD exhibited significantly lower WT and smaller hydraulic diameter compared with those with minimal change or slight decline in lung function, after an adjustment of smoking status. Conversely, CT-based percentages of emphysema and functional small airway disease did not significantly differ according to LFD. Furthermore, fractional exhaled nitric oxide (FeNO) level and the blood matrix metalloproteinase-9/TIMP metallopeptidase inhibitor 1 ratio were significantly higher in patients with severe asthma with enhanced LFD compared with those in the others.

CONCLUSION

Lower WT on CT scans with increased FeNO that may represent increased airway inflammation significantly correlated with enhanced LFD in patients with severe asthma. Consequently, active management plans may help to attenuate LFD for patients with severe asthma with lower WT and high FeNO.

Sputum Metabolomic Signature and Dynamic Change of Cough Variant Asthma

Cough variant asthma (CVA), a common reason for chronic cough, is a globally prevalent and burdensome condition. The heterogeneity of CVA and a lack of knowledge concerning the exact molecular pathogenesis has hampered its clinical management. This study presents the first sputum metabolome of patients with CVA, revealing the dynamic change during treatment and exploring biomarkers related to the occurrence and treatment response of CVA. We found that arginine biosynthesis, purine metabolism, and pyrimidine metabolism pathways were enriched in CVA compared with healthy controls. Part of the metabolic disturbances could be reversed by antiasthmatic medication. The levels of dipeptides/tripeptides (alanyl tyrosine, Gly-Tyr-Ala, Ala-Leu, and Thr-Leu) were significantly associated with sputum neutrophil or eosinophil percentages in patients with CVA. Differential metabolites before treatment between effective and ineffective treatment groups were enriched in purine metabolism, thiamine metabolism, and arginine metabolism. 2-Isopropylmalate was downregulated in CVA and increased after treatment, and the effective treatment group had a lower 2-isopropylmalate level before treatment. Random forest and logistic regression models identified glutathione, thiamine phosphate, alanyl tyrosine, and 2'-deoxyadenosine as markers for distinguishing CVA from healthy controls (all areas under the curve >0.8). Thiamine phosphate might also be promising for predicting therapy responsiveness (area under the curve, 0.684). These findings imply that disturbed mitochondrial energy metabolism and imbalanced oxidation-reduction homeostasis probably underlay the metabolic pathogenesis of CVA.

Natural killer cells in the lung: novel insight and future challenge in the airway diseases

Natural killer (NK) cells are innate lymphoid cells which are present in the lung as circulating and resident cells. They are key players both in airway surveillance and in crosstalk with (COPD) pathogenesis, and they seem to contribute to the development of bronchiectasis. In asthma, NK cell dysfunction was observed mainly in severe forms, and it can lead to a biased type-2 immune response and failure in the resolution of eosinophilic inflammation that characterise both allergic and eosinophilic phenotypes. Moreover, aberrant NK cell functions may interfere with antimicrobial immune response contributing to the frequency and severity of virus-induced exacerbations. In COPD, lung NK cells exhibit increased cytotoxicity against lung epithelium contributing to lung tissue destruction and emphysema. This cell destruction may be exacerbated by viral infections and cigarette smoke exposure through NKG2D-dependent detection of cellular stress. Lastly, in bronchiectasis, the airway NK cells might both promote neutrophil survival following stimulation by proinflammatory cytokines and promote neutrophil apoptosis. Systemic steroid treatment seemingly compromises NK activity, while biologic treatment with benralizumab could enhance NK cell proliferation, maturation and activation. This narrative review gives an overview of NK cells in airway diseases focusing on pathophysiological and clinical implications. Together, our findings emphasise the pleiotropic role of NK cells in airway diseases underscoring their possible implications as to therapeutical approaches.

Effectiveness of anti-IL-5/5Rα biologics in severe asthma in real-world studies: a systematic review and meta-analysis

Background

Three biologics targeting interleukin 5 (anti-IL-5) or its receptor-α (anti-IL-5Rα) are approved for patients with severe asthma.

Methods

We systematically searched the literature published in Medline and Embase up to 1 May 2023 to identify observational studies and nonrandomised trials that assess the response to anti-IL-5/5Rα in real-life patients with severe eosinophilic asthma. We also performed random-effects meta-analyses.

Results

We identified 6401 studies, of which 92 with 9546 patients were analysed. Biologics use was associated with a 62% reduction in severe exacerbations (risk ratio 0.38, 95% CI 0.29-0.50) and a 54% reduction in hospitalisations (risk ratio 0.46, 95% CI 0.35-0.61) at 12 months of treatment, compared to pre-treatment. Biologics improved asthma control (decrease in asthma control questionnaire score by 1.11 points (95% CI -1.29--0.94) and increase in asthma control test score by 6.41 points (95% CI 5.66-7.16)) and increased the asthma quality of life questionnaire score by 1.08 points (95% CI 0.88-1.28) and forced expiratory volume in 1 s by 0.21 L (95% CI 0.15-0.27) at 12 months. There was a significant reduction in oral corticosteroids use of 51% (risk ratio 0.49, 95% CI 0.42-0.56), with a mean dose reduction of 6.01 mg·day-1 (95% CI -7.55--4.48) at 12 months of treatment. Similar findings were observed at 3-4, 6 and 24 months. A biomarker-related response to treatment was also noted.

Conclusions

This comprehensive meta-analysis summarises the significant clinical response to anti-IL-5/5Rα biologics in real-life studies, providing important insights for their use in clinical practice.

Adherence to Mediterranean diet and asthma control. Results from a small study among asthmatic patients in Greece

OBJECTIVES

Current variations in asthma prevalence and clinical characteristics suggest that lifestyle choices including dietary habits, may affect the pathogenesis and/or clinical expression of the disease. The purpose of this study is to evaluate the association between adherence to Mediterranean diet (MD) and asthma control, considering disease severity.

METHODS

Adherence to MD was assessed through a questionnaire, the MD Adherence Screener (MEDAS), previously validated in Mediterranean populations. Each participant received a score ranging from 0 to 14. A score higher than 10 indicates high MD adherence. The level of asthma control was assessed by the Asthma Control Test and two groups were formed (controlled vs. partly controlled/uncontrolled).

RESULTS

The study sample included 105 participants (34% males). About 45% of participants were severe asthmatics. Adherence to MD was associated with 14% higher, though not statistically significant, probability of controlled asthma in the overall study sample (OR = 1.14; 95% CI = 0.46-2.81) and 60% higher probability of controlled asthma among severe asthmatics (OR = 1.60, 95% CI = 0.46-5.59).

CONCLUSIONS

These results indicate a possible association between adherence to MD and asthma control, but findings are restricted by the study's small sample size which does not allow asserting the inference.

Characteristics of patients with severe asthma reported to be eligible or non-eligible for biologic therapy in Poland: Results from the international observational study RECOGNISE

PURPOSE

To analyze characteristics of real-world patients with severe asthma in Poland and identify factors determining clinicians' opinion on the eligibility for biologics.

METHODS

In this retrospective, multi-national, single-visit study (NCT03629782), investigators were asked whether the patient might benefit from a referral for further clinical assessment and potentially biologic therapy. Asthma exacerbations and healthcare resource utilization (HCRU) in the last 12 months were documented by the investigators. Patient-reported outcomes included St George's Respiratory Questionnaire (SGRQ) and Asthma Control Questionnaire (ACQ-6).

RESULTS

Of 1025 patients, 146 were enrolled in Poland. Investigators considered 77.4 ​% of patients eligible for biologics and 22.6 ​% non-eligible. Patients considered eligible were diagnosed at younger age than non-eligible (median 39 vs 45 years; p ​= ​0.0113) and more frequently had a history of atopy (46 ​% vs 21.2 ​%; p ​= ​0.0106). Eligible patients had a higher frequency (93.8 ​% vs 66.7 ​%, p ​< ​0.0001) and number of exacerbations (median 2 vs 1, p ​= ​0.0003). Among eligible patients, 81.4 ​% and among non-eligible, 66.7 ​% had not well-controlled asthma; long-term oral corticosteroids were used by 46.0 ​% and 51.5 ​%, respectively. Short-term corticosteroid use was more frequent in biologics-eligible than in non-eligible patients (82.3 ​% vs 48.5 ​%, p ​< ​0.0001). Patients eligible for biologics had a higher median SGRQ total score (64.7 vs 48.4; p ​= ​0.0075) and HRCU (63.7 ​% vs 9.1 ​%; p ​< ​0.0001).

CONCLUSIONS

In Poland, 3 in 4 patients with severe asthma are recognized by clinicians as potential candidates for biologics. However, eligibility is not associated with long-term oral corticosteroid use, highlighting the need to better inform the physicians about the benefits of biologic therapy.

Vascular remodeling and TSLP/angiogenin overexpression in severe mixed asthma

BACKGROUND

Asthma with neutrophilic/mixed inflammation is a difficult-to-control clinical phenotype. Currently, vascular and matrix airway remodeling in asthma with neutrophilic/mixed inflammation is not well known. We aimed to evaluate the differences in vascular/smooth muscle/matrix related asthma remodeling in eosinophilic (EOS) and mixed/neutrophilic (MIXED) bronchial phenotypes in relation to asthma severity and exacerbation frequency.

METHODS

In this cross-sectional study, α-SMA+ cells (100µM beneath the basement membrane [BM]), BM thickness, vascular remodeling-related biomarkers (angiogenin, vascular endothelial growth factor [VEGF], CD31 and Protease-activated receptor 2 [PAR2]), alarmins (TSLP and Interleukin (IL)-33) were evaluated in bronchial sections from 40 mild-to-severe asthmatics (EOS: N = 19 and mixed/neutrophilic: N = 19/2) and 7 control subjects (CTRL).

RESULTS

The number of CD31+ and angiogenin+ cells was higher in MIXED than in EOS asthmatics (p < 0.05). In severe MIXED CD31+, TSLP+, α-SMA+, and angiogenin+ cells increased compared to mild MIXED/EOS or severe EOS (p < 0.05), but BM thickness was higher in severe vs. mild EOS (p < 0.05). MIXED frequent exacerbators had higher numbers of CD31+ and TSLP+ cells, whereas MIXED non-exacerbators had increased PAR2+ cells. CD31+ cells correlated with impairment of pulmonary functions, number of exacerbations, ICS dose, bronchial neutrophils, angiogenin, α-SMA, TSLP and IL-33 (p < 0.05). Finally, CD31 > 97.17 cells/mm2, angiogenin > 35.36 cells/mm2, and functional parameters such as FEV1, FEV1/FVC, TLC and FRC (%pred.) were found to be predictors of severe MIXED asthma.

CONCLUSION

The severe or frequent exacerbator asthmatics with bronchial mixed inflammatory profile are characterized by increased number of vessels and overexpression of TSLP and angiogenin, suggesting a pathogenetic link between mixed eosinophilic and neutrophilic inflammation and vascular remodeling.

Eosinophil-Driven vs. Eosinophil-Associated Severe Asthma: Practical Implications for Target Treatment

Severe asthma (SA) is a chronic inflammatory condition affecting approximately 10% of asthmatic patients, and eosinophils are considered key pathogenetic actors in a significant number of patients. Biological therapies have been demonstrated to improve asthma control by decreasing exacerbation rates and reducing the use of oral corticosteroids. In this context, phenotyping and endotyping patients with SA is essential for selecting the most effective therapeutic approach. For this purpose, biomarkers such as IgE, absolute blood eosinophil count, and fractional exhaled nitric oxide (FeNO) are crucial in defining a patient's inflammatory profile. Their integration provides a framework for classifying asthma into T2-high, T2-mild, or T2-low categories, guiding personalized treatment strategies. By incorporating multiple biomarkers into a unified model, it is possible to better stratify patients and optimize biologic therapy selection, paving the way for improved outcomes in SA management. This review aims to evaluate the role of phenotyping and endotyping SA patients, with particular attention to the impact of eosinophilic inflammation and combinatory biomarkers on decision-making processes for the selection of biological therapies.

Benralizumab Outcomes in Patients with Severe Eosinophilic Asthma Treated in Real-Life Settings: Results of the BREEZE Study in 5 Countries From Central Eastern Europe and Baltics

Purpose

To describe real-world clinical characteristics, treatment patterns and outcomes of severe eosinophilic asthma (SEA) patients initiated on benralizumab after treatment authorization in Central Eastern Europe and Baltic Area.

Patients and Methods

BREEZE was a retrospective, medical chart review with a pre-post design conducted in 42 clinical centers from Bulgaria, Czech Republic, Hungary, Lithuania and Romania. Eligibility included diagnosis of SEA and at least one dose of benralizumab administered in real-life settings. Descriptive statistics were used in the full analysis set and key subgroups stratified by blood eosinophils (bEOS) number, maintenance oral corticosteroids (mOCS) use and prior biologics exposure and included calculation of the annualized exacerbation rate (AER) at baseline, and weeks (W) 16 and 48.

Results

Of 381 patients included, 66% were female with overall mean age 56 ±12 years at benralizumab start. At baseline: median bEOS 580 cells/μL (74% bEOS>400), forced expiratory volume in 1 second (FEV1) 1660 mL, mOCS use in 25% of patients (10 mg/day prednisone equivalent, 68% >5 mg/day), AER 3.05 (95% CI 2.9-3.2), and poorly controlled asthma (Asthma Control Test [ACT] <16) in 63% of patients. Median duration of exposure to benralizumab was 11.5 (95% CI 7.7-12.3) months, and discontinuation rate was 1.3% (95% CI 0.4%-3.0%). Median bEOS decreased to 0 at W16 and maintained thereafter; FEV1 increases of +240 mL at W16 and +335 mL at W48 were reported (p <0.001 for both). Overall relative reduction in AER at W16 and W48 was 92% and 93%, respectively, and 82-94% across key subgroups. mOCS dose reduction was 50%, and proportion of patients requiring >5 mg/day decreased constantly (25% at W16, 28% at W48). ACT scores increased from W16 to W56 (p <0.001 for all).

Conclusion

Our findings indicate clinically meaningful benefits of benralizumab across multiple geographies and various subgroups of patients with SEA.

Targeting PGAM5 attenuates airway inflammation in asthma by inhibiting HMGB1 release in bronchial epithelium

Previous studies have demonstrated that high-mobility group box protein 1(HMGB1) was increased and released to the extracellular and participated in the pathogenesis of steroid-insensitive asthma induced by toluene diisocyanate (TDI). Mitochondrial dysfunction of bronchial epithelia is a critical feature in TDI asthma. However, whether mitochondrial dysfunction regulated HMGB1 release in asthma remains unknown. The aim of this study was to explore whether phosphoglycerate mutase family member 5 (PGAM5), a mitochondrial protein, can regulate HMGB1 release in TDI-induced asthma. The gene expression data series (GSE) 67472 from gene expression omnibus (GEO) database was analyzed to compare the levels of PGAM5 in airway epithelial cells from asthma patients and healthy individuals. Male C57BL/6J mice were sensitized and challenged with TDI and treated with the PGAM5 inhibitor LFHP-1c. In vitro, human bronchial epithelial cells(16HBE) were stimulated by TDI-human serum albumin (HSA) and pretreated with PGAM5 siRNA. In this study, we observed PGAM5 expression was notably increased in airway epithelial cells of asthma patients and TDI-induced asthma mice. In vivo, inhibition of PGAM5 significantly ameliorated airway inflammation, airway hyperresponsiveness (AHR) and mucus hypersecretion, coupled with the decrease of pulmonary HMGB1 expression and release in TDI-exposed mice. In vitro, inhibition of PGAM5 improved mitochondrial dysfunction, decreased the production of reactive oxygen species (ROS) in mitochondrial. Knockdown of PGAM5 reduced the release of cytochrome C (cyt c) and HMGB1 release in TDI-induced asthma. Mechanistically, PGAM5 in bronchial epithelial cells treated by TDI-HSA significantly increased the dephosphorylation of Bax at the S184 residue, promoted the translocation of Bax to mitochondria, and contributed to the activation of mitochondrial-dependent apoptosis in TDI-induced asthma. Based on these findings, we uncovered a novel regulatory mechanism by which high PGAM5 expression promotes airway inflammation by mediating HMGB1 release in TDI-induced asthma, identifying the therapeutic effects of targeting PGAM5 in steroid-insensitive asthma model.

Profiling Blood Hypereosinophilia in Patients on Dupilumab Treatment for Respiratory Conditions: A Real-Life Snapshot

BACKGROUND

A transient and usually asymptomatic increase in blood eosinophil count (BEC) associated with dupilumab treatment has been described. Predicting factors related to the increase in BEC and the occurrence of symptoms are still poorly investigated.

OBJECTIVE

To investigate frequency, timing, duration, clinical relevance, and potential predictors of the increase in BEC in a real-life multicenter cohort of patients affected by asthma and/or chronic rhinosinusitis with nasal polyps (CRSwNP) treated with dupilumab.

METHODS

BEC and clinical conditions at baseline and every 3 months after the start of dupilumab treatment were assessed. Any adverse drug reaction was also recorded. Remission of dupilumab-associated eosinophilia was defined by follow-up BEC values <0.5 × 109 cells/L.

RESULTS

Overall, 108 of 195 (55%) patients experienced an increased BEC after dupilumab initiation, but only 29 of 195 (14.9%) showed hypereosinophilia. BEC peak occurred 6 months after the start of treatment and resolved after 9 months (median time). The probability of developing hypereosinophilia was 3.3 times higher in patients with the baseline BEC between 0.5 × 109 and 1.5 × 109 cells/L. The occurrence of symptoms during BEC peak was higher in patients with comorbidities and in patients showing any increase in BEC.

CONCLUSIONS

In a real-life setting, dupilumab treatment in patients with asthma and/or CRSwNP was often associated with a transient increase in BEC, but hypereosinophilia rarely occurred. Onset of symptoms co-occurring with BEC peak was observed in a minority of subjects. BEC should not preclude dupilumab initiation or continuation but should be monitored for at least 8 months after treatment begins, particularly in the case of baseline eosinophilia/hypereosinophilia and/or comorbidities.

Asthma Phenotypes and Biomarkers

Asthma experienced by both adults and children is a phenotypically heterogeneous condition. Severe asthma, characterized by ongoing symptoms and airway inflammation despite high doses of inhaled and/or systemic corticosteroids, is the focus of research efforts to understand this underlying heterogeneity. Clinical phenotypes in both adult and pediatric asthma have been determined using supervised definition-driven classification and unsupervised data-driven clustering methods. Efforts to understand the underlying inflammatory patterns of severe asthma have led to the seminal discovery of type 2-high versus type 2-low phenotypes and to the development of biologics targeted at type 2-high inflammation to reduce the rates of severe asthma exacerbations. Type 2-high asthma is characterized by upregulation of T helper 2 immune pathways including interleukin (IL)-4, IL-5, and IL-13 along with eosinophilic airway inflammation, sometimes allergic sensitization, and responsiveness to treatment with corticosteroids. Type 2-low asthma is poorly responsive to corticosteroids and is not as well characterized as type 2-high asthma. Type 2-low asthma is limited by being defined as the absence of type 2-high inflammatory markers. Choosing a biologic for the treatment of severe asthma involves the evaluation of a panel of biomarkers such as blood eosinophils, total and specific immunoglobulin E/allergic sensitization, and fractional exhaled nitric oxide. In this review, we focus on the underlying pathobiology of adult and pediatric asthma, discuss the different phenotype-based treatment options for adult and pediatric type 2-high with or without allergic asthma and type 2-low asthma, and describe a clinical phenotyping approach to patients to guide out-patient therapy. Finally, we end with a discussion of whether pediatric asthma exacerbations necessitating admission to an ICU constitute their own high-risk phenotype and/or whether it is a part of other previously defined high-risk subgroups such as difficult-to-control asthma, exacerbation-prone asthma, and severe treatment-resistant asthma.

Social determinants of mental health in asthma: an exploratory study

Introduction

Asthma and mental health problems co-occur at high rates. In context of a holistic approach to health, considering the extent to which social determinants relate to mental health in people with asthma helps identify health inequity and inform population-level preventative strategies. The aim of the current exploratory study was to examine how social determinants are associated with depression, anxiety and resilience in people with mild-moderate and severe asthma.

Methods

A cross-sectional study of 144 adults (aged ≥18 years) with a diagnosis of asthma was conducted. Participants were classified as having mild-moderate asthma or severe asthma based on international guidelines. As part of a multidimensional assessment, participants self-reported age, sex, ethnicity, country of birth, living arrangements, employment, and postcode. They also completed validated self-report questionnaires for depression and anxiety [Hospital Anxiety and Depression Scale (HADS)], and resilience [Resilience Scale (RS-25)]. Bayesian regression analyses were conducted to examine the extent to which social determinants were associated with depression, anxiety and resilience.

Results

74 participants had mild-moderate asthma and 70 participants had severe asthma. Participants were on average 60 years old (SD = 14), 72% were female, 94% were Caucasian, 94% were Australian-born, 26% lived alone, 42% were working full- or part-time, and 83% lived in a major city of Australia. Anxiety and depression were relatively common (35% anxiety; 16% depression using HADS threshold of scores ≥8). Few social determinants were associated with depression, anxiety and/or resilience. Older age was associated with greater resilience. Females had higher levels of anxiety compared to males. Compared to participants currently working full- or part-time, those who were not working or studying due to their health had worse depressive symptoms and those who were not working for other reasons such as retirement had greater resilience.

Discussion

As in the general population, age, sex and employment/student status were associated with components of mental health in people with asthma. Although limited by the small sample size and sociodemographic homogeneity, the findings of this exploratory study contribute to the large body of work fostering a holistic approach to health and striving for health equity in people with asthma, particularly those who experience mental health problems.

Severe asthma in adolescents: Clinical implications and beyond

Severe asthma affects about 6.7% of adolescents worldwide, posing a substantial burden on their physical and psychosocial well-being. The impact of severe asthma on adolescents is multifaceted, with several factors that contribute to this burden, such as comorbidities including obesity, dysfunctional breathing, sleep-disordered breathing and mental health issues. Moreover, daily therapy management is often complex and may require lifestyle modification that could lead to a failure in treatment adherence and to peer-related stressors such as feelings of exclusion. Furthermore, adolescents with severe asthma are prone to risk-taking behaviours, including vaping and substance misuse. While current management strategies often fail to account for their developmental stage, digital technologies offer novel solutions to improve disease management. This narrative review aims to provide a comprehensive overview of the multifaceted impact of severe asthma on adolescents, addressing the main clinical management issues and exploring the role of innovative digital tools to enhance asthma management in this critical population.

Proposal of a New Composite Score (DAMADECO) to Simultaneously Evaluate Asthma and CRSwNP Severity in Comorbid Patients

Background: Asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) are chronic respiratory conditions that frequently coexist. However, an integrated assessment tool for both conditions is currently lacking. This study aimed to develop and preliminarily evaluate a composite score capable of simultaneously assessing asthma and CRSwNP in comorbid patients. Methods: An expert panel comprising three pulmonologists, one allergist/clinical immunologist, and four ear, nose and throat (ENT) specialists developed a tool to capture asthma and CRSwNP severity. The tool (D'Amato-De Corso score, or DAMADECO score) incorporates eight parameters, four specific to asthma and four specific to CRSwNP, to assign individual scores for each condition. A composite score is then calculated to reflect the overall disease burden (ranging from -8: poor control and +8: optimal control). A retrospective pilot study was conducted to evaluate the tool. Results: The DAMADECO composite score was applied to 21 comorbid patients. The mean partial scores for asthma and CRSwNP were -1.57 and -1.67, respectively, with a mean total composite score of -3.24. A total of 13 out of 21 patients had uncontrolled domains in both diseases, while fewer patients had only uncontrolled domains in asthma (1/21) or CRSwNP (6/21). The DAMADECO score also allows researchers to track disease progression and monitor treatment effectiveness. Conclusions: The preliminary results suggest that the DAMADECO score is a promising tool for simultaneously assessing asthma and CRSwNP, addressing the unmet need for an integrated approach to comorbid respiratory diseases. Further validation studies are needed to validate the tool in larger patient populations.

Predictors of revision endoscopic sinus surgery in Finnish patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Although patients with chronic rhinosinusitis with nasal polyps (CRSwNP) may benefit from endoscopic sinus surgery (ESS), some patients will experience polyp recurrence, adding to the overall disease burden of CRSwNP. We aimed to investigate predictors of revision ESS in patients with CRSwNP.

METHODS

A nationwide population-based study including all adults diagnosed with CRSwNP who had surgical procedure codes for ESS (N = 3506), followed up between January 2012 and December 2019. Logistic regression models provided adjusted odds ratios (OR) with 95% confidence intervals (CIs) for the odds of revision surgery within one and 3 years post-index surgery.

RESULTS

559 (15.9%) of the patients had at least one revision surgery during the follow-up. Median time to revision of ESS was 425 days (interquartile range: 213-898). Baseline asthma (OR = 1.58, 95% CI 1.17-2.12) and antibiotic use (OR = 1.61, 95% CI 1.27-2.04) were associated with higher odds of revision ESS, particularly within 3 years post-index surgery, whereas Increasing age was inversely associated with the odds of ESS revision (OR = 0.82, 95% CI 0.76-0.88). The highest odds of revision ESS were observed within 3 years post-index surgery in patients who had undergone extensive surgery at index (OR = 14.13, 95% CI 3.41-95.64) compared with those who had undergone limited surgery. OCS use was frequent among CRSwNP patients, with a higher cumulative dose in patients undergoing multiple ESS revisions (63%, n = 97, median daily dose 3.29 mg, IQR: 1.64-3.70) compared with patients without revisions (49%, n = 1361 and 1.64 mg, IQR: 1.64-3.29, respectively. p-value <0.001).

CONCLUSIONS

A small proportion of CRSwNP patients require revision ESS with associated high cumulative OCS doses, highlighting the need for additional therapies to achieve disease control and reduce the corticosteroid burden. A few simple baseline characteristics can predict the need for recurrent surgery among the patients with CRSwNP.

Allergen Immunotherapy for the Prevention and Treatment of Asthma

Allergic asthma is the predominant phenotype among asthmatics. Although conventional pharmacotherapy is a central component in the management of asthma, it does not enable control of asthma symptoms in all patients. In recent decades, some uncontrolled asthmatic patients, especially those with allergic asthma, have benefited from biological therapies. However, biologics do not address all the unmet needs left by conventional pharmacotherapy. Furthermore, it is noteworthy that neither conventional pharmacotherapy nor biological therapies have disease-modifying properties. In this context, allergen immunotherapy (AIT) represents an indispensable component of the therapeutic arsenal against allergic asthma, due to its disease-modifying immunological effects. In this review article, funded by an AIT manufacturer, we find clinical trials support AIT as the only treatment option able both to improve allergic asthma symptoms and to prevent the onset and worsening of the condition. For patients with severe asthma or other safety concerns, the combination of AIT and biologics offers very promising new treatment modalities for the management of allergic asthma. Trial Registration: clinicaltrials.gov identifier: NCT06027073.

T2-low severe asthma clinical spectrum and impact: The Greek PHOLLOW cross-sectional study

BACKGROUND

Data on type 2 (T2)-low severe asthma (SA) frequency is scarce, resulting in an undefined unmet therapeutic need in this patient population. Our objective was to assess the frequency and characterize the profile and burden of T2-low SA in Greece.

METHODS

PHOLLOW was a cross-sectional study of adult SA patients. Based on a novel proposed classification system, patients were classified as T2-low if blood eosinophil count (BEC; cells/μL) was <150, fractional exhaled nitric oxide (FeNO) < 25 ppb and any allergy status or BEC < 150/FeNO < 50 ppb/no allergy or BEC < 300/FeNO < 25 ppb/no allergy. For patients receiving biologics and/or oral corticosteroids, only those with BEC < 150/FeNO < 25 ppb/no allergy/no response to therapy were classified as T2-low. Secondary outcome measures were: Asthma Control Test (ACTTM), Mini-Asthma Quality of Life Questionnaire (Mini-AQLQ), hospital anxiety and depression scale (HADS), and Work Productivity and Activity Impairment:Respiratory Symptoms (WPAI:RS) questionnaire.

RESULTS

From 22-Mar-2022 to 15-Mar-2023, 602 eligible SA patients were enrolled. The frequency of T2-low asthma was 20.1%. Of those, 71.1% had experienced ≥1 clinically significant exacerbations in the past year, 62.8% had ACT score <20 (uncontrolled asthma), and 22.3% were biologic-treated. Mini-AQLQ score was <6 (impairment) in 79.5% of patients, HADS-total score was ≥15 (clinically significant emotional distress) in 43.8%, while median percent activity impairment and work productivity loss were 30.0 for both domains. Clinical and patient-reported outcomes were worse among patients with ACT-defined uncontrolled asthma.

CONCLUSIONS

One-fifth of SA patients present with a T2-low endotype. These patients frequently have uncontrolled disease and experience impairments in their quality of life, emotions and work ability.

Biologics for eosinophilic otitis media: a retrospective case study in a multidisciplinary center

PURPOSE

Eosinophilic otitis media (EOM) is a difficult-to-treat otitis media characterized by eosinophilic accumulation in the middle ear mucosa and effusion. It is refractory to conventional treatments and is strongly associated with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). The diagnostic criteria for EOM were established by IINO in 2011. With the recognition of type 2 inflammatory diseases, the gold standard of treatment is the systemic and topical administration of corticosteroids. Recently, several retrospective studies have demonstrated the efficacy of biologic treatments in EOM. We aimed to share our experience regarding the response of EOM after the use of biologics.

METHODS

This is a retrospective observational analysis including patients with refractory EOM treated with different biologics (benralizumab, omalizumab, mepolizumab, dupilumab) for concomitant severe asthma, urticaria and/or severe uncontrolled CRSwNP from 2011 to 2023. Treatment effectiveness in terms of EOM severity was measured using medical Global Evaluation of Treatment Effectiveness (GETE).

RESULTS

We illustrated 4 clinical cases of uncontrolled comorbid EOM and demonstrated the complexity of multidisciplinary medical pathway with good response to biologics. We also observed that response to EOM and CRSwNP does not always follow that of asthma.

CONCLUSIONS

The results of our small sample were consistent with those found in the literature and showed control of EOM with biologics. We need a larger multicentric sample and methodology to confirm these results and to compare the efficacy of different biologics.

On-treatment clinical remission of severe asthma with real-world longer-term biologic use

Background

There are limited real-world data describing the proportion of patients with severe asthma (SA) who achieve on-treatment clinical remission with long-term biologic treatment.

Objective

Our aim was to examine the proportion and characteristics of adults with SA who achieved clinical remission with biologic therapy.

Methods

CHRONICLE is an observational study of US subspecialist-treated adults with SA. Sites reported exacerbations and biologic use from 12 months before enrollment forward. Monthly Asthma Control Test scores and 6-monthly specialist assessments of asthma control were collected. Patients who enrolled from February 2018 to February 2023, began taking a biologic during the study observation period, and continued use of that biologic for at least 12 months were evaluated. Incident on-treatment clinical remission was defined in a 12-month interval as the absence of exacerbations and systemic corticosteroid use, a 50% or greater improvement in Asthma Control Test scores of least 20 points in the latest 6 months, and specialist report of asthma control.

Results

Among the evaluable patients (n = 611), the median duration of biologic use was 39.6 months. In at least one 12-month interval during the study, 79.9% of patients had no exacerbations or systemic corticosteroid use and 46.0% met the definition of clinical remission at any point. The point prevalence of clinical remission increased from 22.3% at 12 to 13 months of biologic use to 34.3% at 47 to 48 months of biologic use.

Conclusions

In a real-world cohort of patients with SA with longer-term biologic treatment, almost one-half achieved on-treatment clinical remission. With at least 1 year of biologic therapy, clinical remission is a feasible treatment goal in SA.

Expert opinion on gray areas in asthma management: A lesson from the innovative project "revolution in asthma" of the Italian thoracic society (AIPO-ITS)

BACKGROUND

Despite the availability of numerous guidelines for asthma management, their recommendations are not consistently implemented in clinical practice. This discrepancy between guidelines and real-world practice among Italian healthcare professionals was explored during the "Revolution in Asthma" training program, which identified "gray areas" and barriers preventing clinicians from adopting guideline-based approaches.

OBJECTIVE

This study aims to analyze the key challenges in asthma management and provide evidence-based solutions to improve adherence to guidelines in clinical practice.

METHODS

A group of experts from the Scientific Committee of the Revolution in Asthma project reviewed the program's findings, focusing on three main areas of asthma management: diagnosis, control, and treatment. The experts summarized clinicians' main needs and questions for each area and provided evidence-based responses and practical recommendations.

RESULTS

The study highlights critical challenges in asthma treatment, addressing two key questions: (a) What are the possible uses and indications for short-acting β-agonists in asthma patients? (b) How should asthma treatment be initiated and adjusted based on asthma control? The expert panel developed practical, operational tools to support general practitioners and specialists (pulmonologists and allergists) in optimizing asthma management.

CONCLUSION

This paper serves as a knowledge co-creation initiative, bridging the gap between clinical guidelines and daily practice. By offering concrete recommendations, it aims to enhance the application of guideline-based asthma management among healthcare professionals.

Costs of Oral Corticosteroid Use in Patients with Severe Asthma With/Without Chronic Rhinosinusitis with Nasal Polyps: Data from the Italian SANI Registry

INTRODUCTION

The burden of severe asthma on patients, especially on those with concomitant chronic rhinosinusitis with nasal polyps (CRSwNP), is substantial. Treatment intensification with oral corticosteroids is a common strategy for managing severe asthma exacerbations; however, prolonged exposure to systemic corticosteroids is associated with multisystem toxicity. This study aimed to quantify the association between oral corticosteroid use and annual asthma-related costs in patients with severe asthma with or without CRSwNP.

METHODS

This pharmacoeconomic analysis was based on data from the Severe Asthma Network in Italy (SANI) registry. Asthma-related costs were estimated in the context of the Italian healthcare system and included exacerbations requiring treatment intensification, unplanned visits, admissions to hospital and emergency/intensive care units, and lost workdays. For each item, the mean annual cost per patient was estimated based on national tariffs and the frequency of the event. To quantify the association between oral corticosteroid treatment and costs, the study cohort was stratified according to oral corticosteroid use in the 1-year preceding inclusion in the SANI registry.

RESULTS

A total of 669 patients from the SANI registry were included in the present analysis, 255 of whom had concomitant CRSwNP. Corticosteroid use was associated with significantly higher annual disease-related costs per patient compared with no corticosteroid use. Compared with the overall study cohort and patients without CRSwNP, patients with CRSwNP had higher disease-related costs (higher by €1307 and €1869, respectively).

CONCLUSION

Use of corticosteroids, in particular systemic corticosteroids, is associated with an increase in asthma-related costs. The concomitant presence of CRSwNP impacts negatively on costs. This study suggests that a thorough analysis of costs, expected benefits, and occurrence of adverse events is required when selecting treatment intensification strategies for managing uncontrolled severe asthma.

Effect of mepolizumab in airway remodeling in patients with late-onset severe asthma with an eosinophilic phenotype

BACKGROUND

Clinical trials and real-world experience have provided evidence for the clinical benefits of mepolizumab, an anti-IL-5 biologic, in severe asthma. However, limited data exist regarding the impact of mepolizumab on airway remodeling.

OBJECTIVE

We sought to investigate the effect of mepolizumab on airway structural remodeling in patients treated for severe asthma in routine clinical care.

METHODS

The MESILICO (Efficacy of Mepolizumab in patients with latE-onset Severe eosInophiLic asthma and fIxed obstruCtiOn) study is a multicenter study involving 8 pulmonology departments in Greece. This study focused on patients who initiated mepolizumab for severe asthma with an eosinophilic phenotype and had late-onset disease with obstructive patterns (impaired reversibility). Forty-seven patients were recruited, of whom 41 were enrolled in the bronchoscopy substudy. The findings were related to clinical outcome.

RESULTS

After 12 months, mepolizumab treatment was associated with significant improvements in lung function and Asthma Control Test score, along with a significant decrease in severe exacerbation events (P < .001). Thirty-four of the 41 participants (83%) had paired biopsies for comparative analysis. There was a significant reduction from baseline in sub-basement membrane thickness, airway smooth muscle area, airway smooth muscle layer thickness, extent of epithelial damage, and number of tissue eosinophils (all P < .001). The extent of reduction in airway smooth muscle layer thickness positively correlated with the submucosal eosinophil reduction (r = 0.599; P < .001).

CONCLUSIONS

This study identified that 12 months of mepolizumab treatment in patients with late-onset severe asthma, who are also characterized by eosinophilic and impaired reversibility phenotypes, not only leads to clinical improvement but also reduces indices of airway tissue remodeling suggestive of a disease-modifying effect.

Longitudinal Assessment of Glucocorticoid Toxicity Reduction in Patients With Severe Asthma Treated With Biologic Therapies

BACKGROUND

Toxicities associated with oral corticosteroids (OCS) are well described. Targeted biologics for severe asthma (SA) substantially reduce OCS exposure with the potential to reduce cumulative OCS-related toxicities. The Glucocorticoid Toxicity Index (GTI) systematically assesses OCS-related toxicity; the GTI Aggregate Improvement Score (AIS) is a bidirectional measure of total toxicity change with a minimal clinically important difference (MCID) of ≤-10.

OBJECTIVE

This study was a longitudinal assessment of patients with SA treated with biologic therapies to assess the trajectory of OCS-related toxicity and predictors of toxicity improvement.

METHODS

A total of 89 patients with SA had GTI assessments at baseline and after 1 and 3 years of biologic therapy.

RESULTS

At 3 years, daily prednisolone use continued to decrease (6.9 mg/day [4.0, 9.4] year 1 vs 0.8 mg/day [0.0, 3.7] year 3, P < .001), OCS-related toxicity continued to decline (AIS at 3 years -36 [-94, 19]), and 61% (54 of 89) met the AIS MCID. There was a significant positive correlation between toxicity outcomes at years 1 and 3 (ρ 0.65, P < .001). Nearly half (49%) met the AIS MCID at both years 1 and 3, but 29% of the cohort did not meet the AIS MCID at either time point. Toxicity change at year 1 was predictive of toxicity change at year 3 for 79%. Toxicity reduction was not proportional to OCS reduction; there were no prebiologic characteristics that predicted toxicity reduction.

CONCLUSIONS

After 3 years of biologic treatment, 61% of patients with SA had clinically significant toxicity improvement. Individual toxicity outcomes at year 1 are associated with longitudinal outcomes, suggesting that for some, additional interventions are needed alongside OCS reduction to decrease morbidity.

Small airways dysfunction in severe asthma: Current treatment approaches and future directions

Severe asthma is a significant health concern due to its association with higher mortality rates, reduced quality of life, and increased healthcare costs. These challenges make it a persistent issue for both clinicians and researchers. The small airways, defined as distal airways with a diameter of less than 2 mm and comprising 98.8% of the total lung volume, play a significant role in airway resistance in individuals with asthma. Recent studies demonstrated that small airways dysfunction is found in all asthma severity levels, but it is most pronounced in severe asthma, and greater small airways dysfunction severity correlates with poorer asthma control and a higher frequency of exacerbations. Therefore, therapies aimed at targeting small airways dysfunction are essential for effective asthma management, especially in severe asthma.

Dupilumab Effectiveness in Patients with Severe Allergic Asthma Non-Responsive to Omalizumab

Background/Objectives: Severe allergic asthma is usually treated with omalizumab; however, this drug may not be effective for every patient. By its action, dupilumab could be an alternative in these patients. The objective of this study was to evaluate the efficacy of dupilumab in patients with severe allergic asthma, non-responsive to omalizumab, according to the maintenance of their oral corticosteroid (OCS) dose, an exacerbation rate decrease, or poor control of the disease, despite optimized treatment. Methods: A retrospective analysis of data from severe asthma clinics was performed, observing the efficacy of the switch to dupilumab in patients who experienced a failed treatment with omalizumab. Results: Forty-two patients were included. Dupilumab proved to be effective in patients who experienced a failed omalizumab treatment, with a significant reduction in the exacerbation number and OCS use. Furthermore, remission of the disease, according to the Severe Asthma Network of Italy (SANI) criteria, was achieved in 35 patients, with complete remission in 19 (45%) and partial remission in 16 (38%). The analysis of the predictors of the success of dupilumab therapy in achieving clinical remission, through univariate analysis of the data at baseline, showed that complete remission was more easily reached in patients with concomitant aspirin (ASA) intolerance or in those with nasal polyposis. Conclusions: Dupilumab is an effective drug for the treatment of patients with severe asthma with an allergic component, with better benefits in patients with an ASA intolerance or nasal polyposis.

Molecular allergy diagnosis enabling personalized medicine

Allergic patients are characterized by complex and patient-specific IgE sensitization profiles to various allergens, which are accompanied by different phenotypes of allergic disease. Molecular allergy diagnosis establishes the patient's IgE reactivity profile at a molecular allergen level and has moved allergology into the era of precision medicine. Molecular allergology started in the late 1980s with the isolation of the first allergen-encoding DNA sequences. Already in 2002, the first allergen microarrays were developed for the assessment of complex IgE sensitization patterns. Recombinant allergens are used for a precise definition of personal IgE reactivity profiles, identification of genuine IgE sensitization to allergen sources for refined prescription of allergen-specific immunotherapy and allergen avoidance diagnosis of co- versus cross-sensitization, epidemiologic studies, and prediction of symptoms, phenotypes, and development of allergic disease. For example, molecular IgE sensitization patterns associated with more severe respiratory allergies, severe food allergy, and allergy to honeybee or vespids are already established. The implementation of molecular allergy diagnosis into daily clinical practice requires continuous medical education and training doctors in molecular allergy diagnosis, and may be facilitated by clinical decision support systems such as diagnostic algorithms that may take advantage of artificial intelligence.

Real-world mepolizumab treatment in patients with severe asthma decreased exacerbations, oral corticosteroid use, and healthcare resource utilization and costs over 4 years: a retrospective analysis

OBJECTIVE

Although the efficacy of mepolizumab in reducing exacerbations and oral corticosteroid (OCS) use in severe asthma is well-established, real-world long-term effectiveness data are limited. This study evaluated the real-world impact of mepolizumab treatment in patients with severe asthma over a 4-year follow-up period.

METHODS

This was a retrospective cohort study of patients with asthma initiating mepolizumab (index date: first claim, November 2015-September 2019) using the Merative MarketScan Commercial and Medicare Databases. Outcomes included asthma exacerbations, OCS use, and exacerbation-related healthcare resource utilization (HCRU) and costs, assessed 12-months pre-index (baseline) and annually during the 4-year follow-up period.

RESULTS

Among 189 eligible patients, mean asthma exacerbation rate (AER) declined progressively from baseline during follow-up: AER decreased by 53.8% at Year 1 and 73.8% by Year 4 (p < 0.001). The annual OCS prescription rate reduced from baseline by 41.1% at Year 1 and 62.2% at Year 4 (p < 0.001). The proportion of patients with both no exacerbations and no OCS use progressively increased from 6.4% at baseline to 18.5% at Year 1 and 41.8% at Year 4. Exacerbation-related HCRU including inpatient, emergency room, and outpatient office visits decreased from baseline (9.0%, 21.7%, and 78.8%, respectively), at Year 1 (3.2%, 12.2%, and 49.2%), and Year 4 (0.0%, 4.8%, and 31.8%). Exacerbation-related healthcare costs declined from $4,635 at baseline to $1,487 at Year 1 and $217 at Year 4 (p < 0.001).

CONCLUSION

Patients treated with mepolizumab demonstrated progressive and sustained long-term, real-world reductions in exacerbation frequency, OCS dependency, and exacerbation-related HCRU and costs over 4 years.

A retrospective study on potential drug‒drug interactions in patients with severe asthma receiving biological therapy: a single-center experience

BACKGROUND

Prevalence of potential drug-drug interactions (pDDIs) in adult patients with severe asthma on biological therapy and their clinical significance have not been fully addressed, thus the aim of this study was to investigate them.

METHODS

In this retrospective observational study, patients who were diagnosed with severe asthma and to whom biological therapy was prescribed between September 2015 and December 2020, were enrolled. The study was conducted at the Department of Allergic and Obstructive Pulmonary Diseases, Clinic for Lung Diseases Jordanovac, Clinical Hospital Center Zagreb. Data on demographic characteristics as well as concomitant medication were collected. The analysis of pDDIs was conducted via Lexicomp® online software. Interactions of significance levels A and B were only recorded, while those of levels C, D and X were further analysed. The collected data was processed via Microsoft Excel 365 software.

RESULTS

60 adult patients, 60% female and 40% male, with median age of 56.2 years, were enrolled. The incidence of pDDIs was 86.67%. Total number of pDDIs detected was 518, out of which 43.24%, 45%, 4.44% and 7.3% of clinical significance B, C, D and X. Interactions of level C, D and X were recorded in, as follows: 83.33%, 25% and 33.33% patients with an average of 4.66, 1.53 and 1.9 interactions per patient. Only 13.33% of the patients had none of the potential clinically significant DDI. Most drug pairs contained at least one antiasthmatic drug. Muscarinic receptor antagonists, oral corticosteroids, β2 agonists and methylxanthines showed potential of entering into clinically significant DDIs, while leukotriene antagonists and biologicals showed no potential for the above.

CONCLUSION

Prevalence of potential drug-drug interactions in patients with severe asthma on biological therapy is high. The majority of identified interactions have moderate to high level of clinical significance. Their identification, prevention and resolution could contribute to optimizing therapy, maximizing its therapeutic effect and avoiding undesirable adverse events.

Diabetes-inducing effects of bronchial asthma

BACKGROUND

The relationship between diabetes mellitus (DM) and asthma is complex and can impact disease trajectories.

AIM

To explore the bidirectional influences between the two conditions on clinical outcomes and disease control.

METHODS

We systematically reviewed the literature on the relationship between DM and asthma, focusing on their impacts, mechanisms, and therapeutic implications. Various studies were assessed, which investigated the effect of glycemic control on asthma outcomes, lung function, and exacerbations. The study highlighted the role of specific diabetes medications in managing asthma.

RESULTS

The results showed that poor glycemic control in diabetes can exacerbate asthma, increase hospitalizations, and reduce lung function. Conversely, severe asthma, especially in obese individuals, can complicate diabetes management and make glycemic control more difficult. The diabetes-associated mechanisms, such as inflammation, microangiopathy, and oxidative stress, can exacerbate asthma and decrease lung function. Some diabetes medications exhibit anti-inflammatory effects that show promise in mitigating asthma exacerbations.

CONCLUSION

The complex interrelationship between diabetes and asthma suggests bidirectional influences that affect disease course and outcomes. Inflammation and microvascular complications associated with diabetes may worsen asthma outcomes, while asthma severity, especially in obese individuals, complicates diabetes control. However, the current research has limitations, and more diverse longitudinal studies are required to establish causal relationships and identify effective treatment strategies for individuals with both conditions.

A population of c-kit+ IL-17A+ ILC2s in sputum from individuals with severe asthma supports ILC2 to ILC3 trans-differentiation

In prednisone-dependent severe asthma, uncontrolled sputum eosinophilia is associated with increased numbers of group 2 innate lymphoid cells (ILC2s). These cells represent a relatively steroid-insensitive source of interleukin-5 (IL-5) and IL-13 and are considered critical drivers of asthma pathology. The abundance of ILC subgroups in severe asthma with neutrophilic or mixed granulocytic (both eosinophilic and neutrophilic) airway inflammation, prone to recurrent infective exacerbations, remains unclear. Here, we found by flow cytometry that sputum ILC3s are increased in severe asthma with intense airway neutrophilia, whereas equivalently raised sputum ILC2s and ILC3s were found in severe asthma with mixed granulocytic inflammation. Unbiased clustering analyses identified an "intermediate-ILC2" population displaying markers of both ILC2s (prostaglandin D2 receptor 2; CRTH2, IL-5, and IL-13) and ILC3s (c-kit and IL-17A) that were most abundant in severe asthma with mixed granulocytic airway inflammation. Intermediate ILC2s correlated with airway neutrophilia and were associated with increased amounts of IL-1β and IL-18 in sputum supernatants. Coculture of sort-purified canonical ILC2s with IL-1β and IL-18 in vitro up-regulated c-kit and IL-17A as well as gene expression profiles related to both type 2 and type 17 inflammatory pathways. Together, we have identified an intermediate-ILC2 phenotype in the airways of individuals with severe mixed granulocytic asthma, representing a candidate therapeutic target for controlling neutrophilic airway inflammation.

Connections and Unmet Needs: Severe Asthma Biologics and Osteoporosis

Asthma is a chronic inflammatory disease with the main anti-inflammatory drugs for better disease control being steroids or corticosteroids. The use of steroids in asthma patients, in particular in uncontrolled asthma patients, is associated with an increased risk of osteoporosis and fragility fractures. A single oral corticosteroid course increases the risk of osteoporosis and the continual use of inhaled corticosteroids is correlated over time to an increased risk for both bone conditions. With the use of new, available biologic therapies for asthma, perhaps even anticipating the times of their use in therapeutic management, in the current guidelines and with targeted strategies of prevention it may be possible to improve asthma management, preventing some comorbidities, such as osteoporosis.

Simultaneous treatment with benralizumab and ustekinumab in a patient with severe asthma and ulcerative colitis

The burden of autoimmune diseases is rising worldwide. The expansion of the population of patients eligible for severe asthma biological therapy we are seeing in clinical practice could lead to the simultaneous use of different monoclonal antibodies. We present the case of biological combination therapy with ustekinumab and benralizumab in a patient with ulcerative colitis and severe eosinophilic asthma. The patient, already undergoing biological treatment for colitis, began to suffer from uncontrolled severe asthma. Since benralizumab was administered, the patient has not experienced any exacerbations requiring oral corticosteroids, emergency department visits, or hospital admissions, and the control of asthma symptoms and respiratory function considerably improved. Twelve months after the initiation of the combination, both diseases are well controlled, without any side effects or blood test abnormalities. To our knowledge, this is one of the first reported cases of patients simultaneously receiving a combination of biological therapy for ulcerative colitis and asthma.

Clinical remission in patients with severe eosinophilic asthma treated with mepolizumab: A post-hoc analysis of RELIght study

Background: Remission of asthma can occur as part of the natural history of the disease; however, the use of biologics can result in disease remission in some patients. Objective: In this post hoc analysis of the RELIght study, we aimed to evaluate clinical remission in real life among patients treated with mepolizumab, to detect possible differences between "remitters" and "nonremitters," and to evaluate possible predictors of remission. Methods: Clinical remission was defined as the absence of asthma exacerbations, discontinuation of oral corticosteroids (OCS), achievement of asthma control (Asthma Control Test [ACT] ≥ 20), and stable or improved lung function. Results: A total of 146 patients were evaluated; remission was achieved in 40 (27.4%) and 29 (22%) after 12 and 24 months, respectively. At 12 months, the patients in remission had a better baseline ACT score (17.0 [14.0-19.0] versus 15.0 [12.0-17.0]; p = 0.027), were more rarely using OCS (35% versus 62.2%; p = 0.004), and required a lower baseline dose of OCS (5.0 mg/day [5.0-10.0 mg/day] versus 10.0 mg/day [5.0-15.0 mg/day]; p = 0.042) at baseline, whereas, at 24 months, they less frequently carried a baseline diagnosis of gastroesophageal reflux disease (GERD) (10.3% versus 32%; p = 0.031) and used lower doses of OCS at baseline (5.0 [1.0-5.0] versus 10.0 [5.0-15.0]; p = ≤0.001) versus nonremitters; 52.5% of patients had sustained remission, whereas 42.5% experienced relapse. These patients more frequently had GERD versus patients with sustained remission (52.9% versus 4.8%; p = 0.002). Finally, regression analysis has shown that GERD was the only predictor of relapse. Conclusion: Remitters had better asthma control and needed lower doses or no maintenance OCS at baseline, whereas GERD seems to be an important factor that affects remission and relapse.Clinical trial NCT04084613, www.clinical trials.gov.

Distinct trajectories of treatment response to mepolizumab toward remission in patients with severe eosinophilic asthma

BACKGROUND

Patients with severe eosinophilic asthma, characterised by a high disease burden, benefit from mepolizumab, which improves symptoms and reduces exacerbations, potentially leading to clinical remission in a subgroup. This study aimed to identify treatment response trajectories to mepolizumab for severe eosinophilic asthma and to assess the achievement of clinical remission.

METHODS

Data from the Australian Mepolizumab Registry were used to assess treatment responses at 3, 6 and 12 months. The treatment response trajectories were identified using a group-based trajectory model. The proportions achieving clinical remission at 12 months, which was defined as well-controlled symptoms, no exacerbations and no oral corticosteroid (OCS) use for asthma management, were compared between trajectories, and baseline predictors of the trajectories were identified using logistic regression analysis.

RESULTS

We identified three trajectory groups: Group 1, "Responsive asthma with less OCS use" (n=170); Group 2, "Responsive late-onset asthma" (n=58); and Group 3, "Obstructed and less responsive asthma" (n=70). Groups 1 and 2 demonstrated higher proportions achieving clinical remission at 36.5% and 25.9%, respectively, compared to Group 3 with 5.7% (p<0.001). Baseline predictors for assigned groups included lower OCS dose in Group 1; greater forced expiratory volume in 1 s percentage predicted, higher Asthma Quality of Life Questionnaire score, higher OCS dose and nasal polyps in Group 2; with Group 3 as the reference.

CONCLUSIONS

Treatment response to mepolizumab in severe eosinophilic asthma follows three trajectories with varying proportions achieving clinical remission and differing baseline characteristics. Treatment response variability may influence the achievement of clinical remission with mepolizumab therapy.

Maternal asthma during pregnancy and the likelihood of neurodevelopmental disorders in offspring

INTRODUCTION

Asthma is the most common chronic disease during pregnancy. Maternal asthma has been associated with a multitude of unwanted pregnancy outcomes, in some studies also with neurodevelopmental disorders. Here we investigated associations between maternal asthma and neurodevelopmental disorders.

MATERIAL AND METHODS

We studied a retrospective population-based cohort of 1 271 439 mother-child pairs from singleton live births in Finland between the years 1996-2018. We used multiple high-cover registers for data collection. Adjusted unconditional Cox regression models were used to investigate associations between maternal asthma, asthma medication used during pregnancy, and offspring's neurodevelopmental disorder diagnoses.

RESULTS

We identified 106 163 mother-child pairs affected by maternal asthma. We found that maternal asthma was associated with offspring neurodevelopmental disorders, but the differences in absolute prevalence between the control and exposure groups were small. Attention-deficit hyperactivity disorder (ADHD) was found in 4114 (3.9%) offspring with maternal asthma and in 32 122 (3.0%) controls (adjusted hazard ratio (HR): 1.49; 95% CI 1.44-1.54); autism in 1617 (1.5%) offspring vs 13 701 (1.3%) controls (HR: 1.33; 95% CI 1.26-1.40); motor-developmental disorder in 1569 (1.5%) offspring vs 12 147 (1.1%) controls (HR: 1.37; 95% CI 1.30-1.45); language disorder in 3057 (2.9%) offspring vs 28 421 (2.7%) controls (HR: 1.13; 95% CI 1.08-1.17), learning disabilities in 849 (0.8%) offspring vs 6534 (0.6%) controls (HR: 1.51; 95% CI 1.41-1.62); mixed developmental disorder in 1633 (1.5%) offspring vs 14 434 (1.3%) controls (HR 1.20; 95% CI, 1.14-1.26); and intellectual disability in 908 (0.9%) vs 9155 (0.9%) controls (HR: 1.12; 95% CI 1.04-1.20). No substantial differences were found between allergic and non-allergic asthma phenotypes, and neither allergic tendency nor respiratory infection was associated with a similar likelihood of neurodevelopmental disorders.

CONCLUSIONS

Maternal asthma and allergic and non-allergic phenotypes showed weak associations with the offspring's neurodevelopmental disorders. The association is concerned especially with learning disabilities, ADHD, motor development, and autism.

Biologic Medications for Severe Asthma: Implications for Understanding Pathogenic Heterogeneity and Endotypes

Asthma is a chronic inflammatory disease of the airways long known for phenotypic heterogeneity. Phenotyping studies in asthma have led to a better characterization of disease pathogenesis, yet further work is needed to pair available treatments with disease endotypes. In this review, the biology of targeted pathways is discussed along with the efficacy of biologic therapies targeting those pathways. Results of asthma clinical trials are included, as well as results of trials in related diseases. This review then analyzes how biologics help to inform the complex immunobiology of asthma and further guide their use while identifying areas for future research.

Biologics in severe asthma: a state-of-the-art review

Asthma is considered severe if it remains uncontrolled despite optimal conventional therapy, characterised by poor symptom control, frequent exacerbations and increased exposure to systemic corticosteroids. This has a significant impact on morbidity, mortality and healthcare resource utilisation. Recent advances in the understanding of asthma heterogeneity and immunopathogenesis have helped delineate precise disease pathways. The discovery of these pivotal pathways has led to the development of highly effective biologic therapies. Currently available asthma biologics target immunoglobulin E, interleukin (IL)-5/IL-5Rα, IL-4Rα and thymic stromal lymphopoietin. Identification of specific asthma phenotypes, utilising easily measurable biomarkers, has paved the way towards personalised and precision asthma management. Biologic therapies play a significant role in reducing exacerbations, hospitalisations and the need for maintenance systemic steroids, while also improving the quality of life in patients with severe asthma. The evidence for their clinical efficacy comes from randomised controlled trials (RCTs), extension studies, metanalyses and real-world data. This review synthesises findings from early, pivotal RCTs and subsequent studies following the approval of biologics for severe asthma. The safety and efficacy data from these studies, completed in a variety of settings, provide practical perspectives on their application and enhance their generalisability.

Changes in serum periostin levels in uncontrolled asthma in children (DADO phase 2 study)

OBJECTIVE

Asthma is an inflammatory airway condition and the most common chronic disease in children. However, there is a lack of biological markers for asthma, especially in children. This study aimed to analyze the changes in periostin levels in children with uncontrolled asthma after 12 months of optimized management. The secondary objectives were to evaluate the changes in symptoms, exacerbations, and other biomarkers after 12 months of follow-up.

METHODS

This was an observational, prospective study of children aged 5 to 14 with uncontrolled asthma who visited the Hospital Materno Infantil of Badajoz's Allergy Unit between September 2015 and June 2016. At the first visit and after a 12-month follow-up, lung function, asthma control test (ACT/cACT), quality of life by PAQLQ (Paediatric Asthma Quality of Life Questionnaire), blood eosinophils, total and specific IgE, and serum periostin levels were assessed. Periostin levels were also analyzed in a control group.

RESULTS

After the 12-month follow-up, the percentage of symptoms, the proportion of patients with FEV1 <80%, and the levels of blood eosinophils decreased, whereas ACT and PAQLQ increased. Children with uncontrolled asthma showed high serum periostin concentrations on their first visit (901.48 ng/ml), which decreased after 12 months (67.93 ng/ml) (p<0.001). In the control group, periostin levels were 56.12 ng/ml. The sensitivity and specificity of periostin were 77.8% and 54.8%, respectively, for the diagnosis of controlled and uncontrolled asthma.

CONCLUSION

Our study showed that periostin levels in children with uncontrolled asthma decreased with the correct treatment after asthma control.

Changes in weight secondary to improved odor perception in chronic rhinosinusitis with nasal polyps' patients treated with Dupilumab

PURPOSE

The advent of biologic therapies, notably Dupilumab, has transformed therapeutic approaches to nasal polyposis. This retrospective multicentric study aimed to investigate weight changes in CRSwNP patients undergoing Dupilumab treatment and explore potential correlations with olfactory improvement.

METHODS

Ninety-six patients with CRSwNP were followed for at least 12 months, with assessments including BMI (Body Mass Index), olfactory function, and disease severity.

RESULTS

Significant increases in BMI and olfactory perception were observed after 1 year of Dupilumab treatment (p < .001). Subgroup analysis showed that patients with hyposmia and normosmia at T12 (1-year follow up) experienced significant weight gain (p < .001) alongside improved olfaction (both p < .001). Conversely, patients with anosmia after 1 year of therapy and also patients with stable or worsened olfaction did not show significant BMI changes (respectively p = .201 and p = .107).

CONCLUSION

While these findings suggest a correlation between olfactory improvement and weight gain/BMI, factors like improved nasal airflow and corticosteroid cessation under Dupilumab treatment may also influence weight in CRPwNP patients. The study highlights the need for further research to elucidate the causal relationship and long-term implications of Dupilumab-induced olfactory improvement on weight regulation.