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Domínguez-Ortega J, Delgado Romero J, Muñoz Gall X, Marco A, Blanco-Aparicio M. Uso de glucocorticoides sistémicos para el tratamiento del asma grave: Consenso multidisciplinar español. OPEN RESPIRATORY ARCHIVES 2022. [PMID: 37496970 PMCID: PMC10369533 DOI: 10.1016/j.opresp.2022.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Background and aim Since their effectiveness was initially demonstrated, oral corticosteroids (OCS) have been routinely used to treat asthma. We now know that their usage is linked to the development of side effects such osteoporosis and adrenal insufficiency. This is an observational study based on Delphi methodology. The questionnaire was divided into 4 sections: OCS generalities, maintenance treatment, short-term treatment, and adverse events. Materials and methods Two rounds of a 68-item questionnaire were completed by a panel of 48 allergists and pneumologists. Results Definitions were agreed upon, as was the proper use of OCS in the treatment of severe asthma. The experts agreed that the use of OCS should be minimized as much as possible and that in the event of maintenance treatments, a slow and progressive tapering strategy should be used. They also emphasized the importance of standardizing the technique for measuring the amount of SCG delivered in both cases. Conclusions This consensus document attempts to bring together scientifically supported suggestions from specialists in the management of asthma to reduce the use of OCS in Spain.
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Tsang YP, Marchant JM, Li AM, Chang AB. Stability of sputum inflammatory phenotypes in childhood asthma during stable and exacerbation phases. Pediatr Pulmonol 2021; 56:1484-1489. [PMID: 33713588 DOI: 10.1002/ppul.25347] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Management strategies based on airway inflammation phenotypes are increasingly used for adults with asthma. While sputum-based phenotypes are relatively stable in adults with asthma, there is little such data in childhood asthma. Hence, we aimed to evaluate the stability of sputum inflammatory phenotypes in children with asthma both in the stable and during exacerbation phases. METHODS Sputum cellularity data from two previous prospective studies involving children with asthma were re-evaluated and categorized into two inflammatory phenotypes: eosinophilic (>2.5% eosinophils) and noneosinophilic (≤2.5% eosinophils). Baseline values and follow-up sputum inflammatory phenotype classification were compared in children with asthma during stable and exacerbation phases. RESULTS Thirteen of 32 children (41%) with stable asthma demonstrated a change in sputum inflammatory phenotype 8 weeks later. In a different second cohort, both sputum eosinophils and neutrophils percentages increased and peaked on Day 1 of asthma exacerbation, but compared with baseline, 22% (2/9) and 13% (1/8) of these children had their sputum phenotype categorization changed on Day 1 and Day 3 of exacerbation, respectively. CONCLUSION In children with asthma, sputum inflammatory phenotypes are variable in both stable and exacerbation phases, in contrast to data in adults.
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Affiliation(s)
- Yuk Ping Tsang
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Paediatrics & Adolescent Medicine, United Christian Hospital, Hong Kong SAR
| | - Julie M Marchant
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Queensland, Australia
| | - Albert M Li
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR
| | - Anne B Chang
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Queensland, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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3
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Alahmadi F, Peel A, Keevil B, Niven R, Fowler SJ. Assessment of adherence to corticosteroids in asthma by drug monitoring or fractional exhaled nitric oxide: A literature review. Clin Exp Allergy 2020; 51:49-62. [PMID: 33190234 PMCID: PMC7839457 DOI: 10.1111/cea.13787] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 09/07/2020] [Accepted: 09/24/2020] [Indexed: 01/13/2023]
Abstract
Background Although the efficacy of corticosteroid treatment in controlling asthma is widely accepted, its effectiveness is undermined by poor adherence. However, the optimal method for measuring adherence to asthma therapy remains unclear. Objective To perform a review of the literature reporting biological, objective methods for assessing adherence to inhaled or oral corticosteroids in asthma; we included studies reporting direct measurement of exogenous corticosteroids in blood, or the effect of adherence on exhaled nitric oxide. Design We searched three databases MEDLINE (using both PubMed and Ovid), the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Web of Science for articles published between January 1975 and July 2020. Quality of the studies was assessed using the National Institute of Health checklist. Results From 2850 screened articles, 26 fulfilled the inclusion criteria. Measurement of blood prednisolone with or without cortisol was used in eight studies as a measure of oral corticosteroid adherence, and fractional exhaled nitric oxide (FeNO) in 17 studies for inhaled corticosteroid adherence. Inhaled corticosteroids were measured directly in the blood in one study. By direct measurement of drug levels in the blood, adherence rates to oral corticosteroids ranged from 47% to 92%, although the performance and timing of the test were often not known, making interpretation of findings and serum prednisolone concentrations difficult. FeNO is generally lower in adherent than non‐adherent patients, but no absolute cut‐off can be proposed based on the available data. However, a fall in FeNO following supervised inhaled corticosteroid dosing could indicate previous poor adherence. Conclusions and Clinical Relevance Despite prednisolone and cortisol levels commonly being used as adherence markers in clinical practice, further work is required to assess the influence of the dose and timing on blood levels. The promising findings of FeNO suppression testing should be explored in further prospective studies.
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Affiliation(s)
- Fahad Alahmadi
- Division of Infection, Immunity & Respiratory Medicine, Faculty of Biology, Medicine and Health, School of Biological Sciences, The University of Manchester and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, UK.,Respiratory Therapy Department, College of Medical Rehabilitation Sciences, Taibah University, Madinah, Saudi Arabia
| | - Adam Peel
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Brian Keevil
- Division of Infection, Immunity & Respiratory Medicine, Faculty of Biology, Medicine and Health, School of Biological Sciences, The University of Manchester and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, UK
| | - Rob Niven
- Division of Infection, Immunity & Respiratory Medicine, Faculty of Biology, Medicine and Health, School of Biological Sciences, The University of Manchester and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, UK
| | - Stephen J Fowler
- Division of Infection, Immunity & Respiratory Medicine, Faculty of Biology, Medicine and Health, School of Biological Sciences, The University of Manchester and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Unit and Manchester University NHS Foundation Trust, Manchester, UK
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4
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Ramsahai JM, Wark PA. Appropriate use of oral corticosteroids for severe asthma. Med J Aust 2019; 209:S18-S21. [PMID: 30453868 DOI: 10.5694/mja18.00134] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/25/2018] [Indexed: 12/21/2022]
Abstract
Severe asthma represents a significant burden of disease, particularly in high income nations; oral corticosteroids (OCS) remain an important part of the management toolkit for these patients. Corticosteroids are effective at targeting numerous elements of the type 2/eosinophilic inflammatory pathway and lead to both rapid reduction in eosinophilic inflammation and longer term reduction in airway hyper-responsiveness. Resistance or insensitivity to corticosteroids is a feature of severe asthma, with persistent type 2 inflammation often occurring despite regular use of OCS. OCS remain the only accepted, effective treatment for acute asthma, and also continue to play an important role in the long term management of severe asthma, in spite of their significant side effect profile. Even with the availability of the new biological therapies against IgE and interleukin-5, it is likely that a large proportion of patients will continue to require OCS to control their asthma. Future work should focus on optimising the balance between OCS efficacy and safety, and continued development of agents that allow reduction, or ideally discontinuation of their use, is needed.
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Affiliation(s)
- J Michael Ramsahai
- Centre for Healthy Lungs, Hunter Medical Research Institute University of Newcastle, Newcastle, NSW
| | - Peter Ab Wark
- Centre for Healthy Lungs, Hunter Medical Research Institute University of Newcastle, Newcastle, NSW
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5
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Katsaounou P, Buhl R, Brusselle G, Pfister P, Martínez R, Wahn U, Bousquet J. Omalizumab as alternative to chronic use of oral corticosteroids in severe asthma. Respir Med 2019; 150:51-62. [PMID: 30961951 DOI: 10.1016/j.rmed.2019.02.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/21/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
Systemic/oral corticosteroids (OCS) have been used for decades in the management of acute asthma exacerbations and chronically in patients with uncontrolled severe asthma. However, while OCS are effective at treating acute exacerbations, there is only empirical evidence regarding the efficacy of OCS at reducing the rate of exacerbations. Evidence, although scarce, is suggestive of high exacerbation rates in severe asthma patients even when receiving maintenance treatment with OCS. In addition, use of OCS is associated with undesirable effects. Despite all this, physicians have continued to use OCS for managing severe asthma and acute exacerbation due to the lack of availability of effective alternatives. Fortunately, in the last decade several biologics have been proven safe and effective for patients with uncontrolled severe asthma. This has led to the Global Initiative for Asthma (GINA) recommending the use of biologics, instead of maintenance OCS, in patients with severe asthma (GINA Step 5). These include one biologic targeting immunoglobulin E (IgE) (omalizumab), and different biologics targeting interleukin-5 (IL-5), the IL-5 receptor (IL-5R) or IL-4 receptor α-unit (IL-4R α), including mepolizumab (subcutaneous), reslizumab (intravenous), benralizumab (subcutaneous) and dupilumab (subcutaneous). Omalizumab for the treatment of severe allergic asthma reduces exacerbations, irrespective of blood eosinophil levels. Anti-IL-5/IL-5R biologics are indicated in patients with severe eosinophilic asthma and repetitive exacerbations, irrespective of the presence or absence of allergy. Recently, an anti-IL4Rα biologic has been approved by the FDA for eosinophilic phenotype or oral corticosteroid-dependent asthma. Finally, physicians should consider using biologics as an alternative to chronic OCS therapy.
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Affiliation(s)
- Paraskevi Katsaounou
- School of Medicine, National and Kapodistrian University of Athens, 1st ICU Evangelismos Hospital, Athens, Greece.
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany.
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, De Pintelaan, Ghent, Belgium; Department of Epidemiology and Respiratory Medicine, Erasmus MC Rotterdam, Rotterdam, the Netherlands.
| | - Pascal Pfister
- Global Medical Department, Novartis Pharma AG, Basel, Switzerland.
| | - Rafael Martínez
- Global Medical Department, Novartis Pharma AG, Basel, Switzerland
| | - Ulrich Wahn
- Department of Paediatric Pneumology & Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Jean Bousquet
- Service des Maladies Respiratoires, Hôpital Arnaud de Villeneuve, Montpellier, France.
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Mulholland A, Ainsworth A, Pillarisetti N. Tools in Asthma Evaluation and Management: When and How to Use Them? Indian J Pediatr 2018; 85:651-657. [PMID: 29139062 DOI: 10.1007/s12098-017-2462-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/24/2017] [Indexed: 01/08/2023]
Abstract
The goals of asthma management are accurate diagnosis, prompt initiation of treatment and monitoring of disease progression to limit potential morbidity and mortality. While the diagnosis and management is largely based on history taking and clinical examination, there are an increasing number of tools available that could be used to aid diagnosis, define phenotypes, monitor progress and assess response to treatment. Tools such as the Asthma Predictive Index could help in making predictions about the possibility of asthma in childhood based on certain clinical parameters in pre-schoolers. Lung function measurements such as peak expiratory flow, spirometry, bronchodilator responsiveness, and bronchial provocation tests help establish airway obstruction and variability over time. Tools such as asthma questionnaires, lung function measurements and markers of airway inflammation could be used in combination with clinical assessments to assess ongoing asthma control. Recent advances in digital technology, which open up new frontiers in asthma management, need to be evaluated and embraced if proven to be of value. This review summarises the role of currently available tools in asthma diagnosis and management. While many of the tools are readily available in resource rich settings, it becomes more challenging when working in resource poor settings. A rational approach to the use of these tools is recommended.
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Affiliation(s)
- Anna Mulholland
- Pediatric Respiratory Medicine, Starship Children's Hospital, Park Road, Grafton, Auckland, 1023, New Zealand
| | - Alana Ainsworth
- Pediatric Respiratory Medicine, Starship Children's Hospital, Park Road, Grafton, Auckland, 1023, New Zealand
| | - Naveen Pillarisetti
- Pediatric Respiratory Medicine, Starship Children's Hospital, Park Road, Grafton, Auckland, 1023, New Zealand. .,Department of Pediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand.
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7
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Berthon BS, Gibson PG, Wood LG, MacDonald-Wicks LK, Baines KJ. A sputum gene expression signature predicts oral corticosteroid response in asthma. Eur Respir J 2017; 49:49/6/1700180. [PMID: 28663317 DOI: 10.1183/13993003.00180-2017] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/21/2017] [Indexed: 11/05/2022]
Abstract
Biomarkers that predict responses to oral corticosteroids (OCS) facilitate patient selection for asthma treatment. We hypothesised that asthma patients would respond differently to OCS therapy, with biomarkers and inflammometry predicting response.Adults with stable asthma underwent a randomised controlled cross-over trial of 50 mg prednisolone daily for 10 days (n=55). A six-gene expression biomarker signature (CLC, CPA3, DNASE1L3, IL1B, ALPL and CXCR2) in induced sputum, and eosinophils in blood and sputum were assessed and predictors of response were investigated (changes in forced expiratory volume in 1 s (ΔFEV1), six-item Asthma Control Questionnaire score (ΔACQ6) or exhaled nitric oxide fraction (ΔFeNO)).At baseline, responders to OCS (n=25) had upregulated mast cell CPA3 gene expression, poorer lung function, and higher sputum and blood eosinophils. Following treatment, CLC and CPA3 gene expression was reduced, whereas DNASE1L3, IL1B, ALPL and CXCR2 expression remained unchanged. Receiver operating characteristic (ROC) analysis showed the six-gene expression biomarker signature as a better predictor of clinically significant responses to OCS than blood and sputum eosinophils.The six-gene expression signature including eosinophil and Th2 related mast cell biomarkers showed greater precision in predicting OCS response in stable asthma. Thus, a novel sputum gene expression signature highlights an additional role of mast cells in asthma, and could be a useful measurement to guide OCS therapy in asthma.
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Affiliation(s)
- Bronwyn S Berthon
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Peter G Gibson
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Lisa G Wood
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Lesley K MacDonald-Wicks
- Discipline of Nutrition and Dietetics, School of Health Sciences, University of Newcastle, Newcastle, NSW, Australia
| | - Katherine J Baines
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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8
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Moeller A, Carlsen KH, Sly PD, Baraldi E, Piacentini G, Pavord I, Lex C, Saglani S. Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation. Eur Respir Rev 2016; 24:204-15. [PMID: 26028633 DOI: 10.1183/16000617.00003914] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
This review focuses on the methods available for measuring reversible airways obstruction, bronchial hyperresponsiveness (BHR) and inflammation as hallmarks of asthma, and their role in monitoring children with asthma. Persistent bronchial obstruction may occur in asymptomatic children and is considered a risk factor for severe asthma episodes and is associated with poor asthma outcome. Annual measurement of forced expiratory volume in 1 s using office based spirometry is considered useful. Other lung function measurements including the assessment of BHR may be reserved for children with possible exercise limitations, poor symptom perception and those not responding to their current treatment or with atypical asthma symptoms, and performed on a higher specialty level. To date, for most methods of measuring lung function there are no proper randomised controlled or large longitudinal studies available to establish their role in asthma management in children. Noninvasive biomarkers for monitoring inflammation in children are available, for example the measurement of exhaled nitric oxide fraction, and the assessment of induced sputum cytology or inflammatory mediators in the exhaled breath condensate. However, their role and usefulness in routine clinical practice to monitor and guide therapy remains unclear, and therefore, their use should be reserved for selected cases.
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Affiliation(s)
- Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kai-Hakon Carlsen
- Dept of Paediatrics, Women and Children's Division, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Peter D Sly
- Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Australia
| | - Eugenio Baraldi
- Women's and Children's Health Department, Unit of Respiratory Medicine and Allergy, University of Padova, Padova, Italy
| | - Giorgio Piacentini
- Paediatric Section, Dept of Life and Reproduction Sciences, University of Verona, Verona, Italy
| | - Ian Pavord
- Dept of Respiratory Medicine, University of Oxford, NDM Research Building, Oxford, UK
| | - Christiane Lex
- Dept of Paediatric Cardiology and Intensive Care Medicine, Division of Paediatric Respiratory Medicine, University Hospital Goettingen, Goettingen, Germany
| | - Sejal Saglani
- Leukocyte Biology and Respiratory Paediatrics, National Heart and Lung Institute, Imperial College London, London, UK
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9
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Al-Numani D, Colucci P, Ducharme MP. Rethinking bioequivalence and equivalence requirements of orally inhaled drug products. Asian J Pharm Sci 2015. [DOI: 10.1016/j.ajps.2015.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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10
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Pijnenburg MW, Szefler S. Personalized medicine in children with asthma. Paediatr Respir Rev 2015; 16:101-7. [PMID: 25458797 DOI: 10.1016/j.prrv.2014.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/02/2014] [Indexed: 12/16/2022]
Abstract
Personalized medicine for children with asthma aims to provide a tailored management of asthma, which leads to faster and better asthma control, has less adverse events and may be cost saving. Several patient characteristics, lung function parameters and biomarkers have been shown useful in predicting treatment response or predicting successful reduction of asthma medication. As treatment response to the main asthma therapies is partly genetically determined, pharmacogenetics may open the way for personalized medicine in children with asthma. However, the number of genes identified for the various asthma drug response phenotypes remains small and randomized controlled trials are lacking. Biomarkers in exhaled breath or breath condensate remain promising but did not find their way from bench to bedside yet, except for the fraction of exhaled nitric oxide. E-health will most likely find its way to clinical practice and most interventions are at least non-inferior to usual care. More studies are needed on which interventions will benefit most individual children.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics/ Paediatric Respiratory Medicine, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Stanley Szefler
- The Breathing Institute / Pulmonary Medicine, Department of Pediatrics, Children's Hospital Colorado; University of Colorado Denver School of Medicine, Aurora (CO), USA.
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12
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Vijverberg SJH, Hilvering B, Raaijmakers JAM, Lammers JWJ, Maitland-van der Zee AH, Koenderman L. Clinical utility of asthma biomarkers: from bench to bedside. Biologics 2013; 7:199-210. [PMID: 24009412 PMCID: PMC3762671 DOI: 10.2147/btt.s29976] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Asthma is a chronic disease characterized by airway inflammation, bronchial hyperresponsiveness, and recurrent episodes of reversible airway obstruction. The disease is very heterogeneous in onset, course, and response to treatment, and seems to encompass a broad collection of heterogeneous disease subtypes with different underlying pathophysiological mechanisms. There is a strong need for easily interpreted clinical biomarkers to assess the nature and severity of the disease. Currently available biomarkers for clinical practice - for example markers in bronchial lavage, bronchial biopsies, sputum, or fraction of exhaled nitric oxide (FeNO) - are limited due to invasiveness or lack of specificity. The assessment of markers in peripheral blood might be a good alternative to study airway inflammation more specifically, compared to FeNO, and in a less invasive manner, compared to bronchoalveolar lavage, biopsies, or sputum induction. In addition, promising novel biomarkers are discovered in the field of breath metabolomics (eg, volatile organic compounds) and (pharmaco)genomics. Biomarker research in asthma is increasingly shifting from the assessment of the value of single biomarkers to multidimensional approaches in which the clinical value of a combination of various markers is studied. This could eventually lead to the development of a clinically applicable algorithm composed of various markers and clinical features to phenotype asthma and improve diagnosis and asthma management.
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Affiliation(s)
- Susanne JH Vijverberg
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bart Hilvering
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan AM Raaijmakers
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Jan-Willem J Lammers
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Anke-Hilse Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Leo Koenderman
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
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Kupczyk M, Haque S, Middelveld RJM, Dahlén B, Dahlén SE. Phenotypic predictors of response to oral glucocorticosteroids in severe asthma. Respir Med 2013; 107:1521-30. [PMID: 23993706 DOI: 10.1016/j.rmed.2013.07.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 07/11/2013] [Accepted: 07/12/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Systemic glucocorticosteroids are side-effect prone but often necessary for the treatment of severe asthma (SA). Our goal was to assess the usefulness of medical history, physiological variables and biomarkers as predictors of response to oral steroids. METHODS After 4 weeks of treatment optimization, 84 patients with SA and 62 with mild-to-moderate asthma (MA) underwent a 2 week double-blind placebo-controlled oral prednisolone intervention (0.5 mg/kg BW daily) (NCT00555607). RESULTS Responders had a lower FEV1% (73.7 vs. 88.0), lower FEV1/FVC ratio (0.65 vs. 0.73), lower quality of life (SGRQ score 39.1 vs. 31.4), lower total sputum cell number (1.0 vs. 4.5×10(6)) and higher number of sputum eosinophils (16.8% vs. 6.3%) (p<0.05). For all asthmatics, the degree of improvement in FEV1 correlated with sputum eosinophils, level of asthma control, FeNO, quality of life, age of asthma onset and blood eosinophils. In SA, sputum eosinophils≥3% (OR 9.91), FEV1≤60% (OR 3.7), and SGRQ>42.2 (OR 3.25) were associated with a good response to oral prednisolone. The highest sensitivity and specificity to predict more than 12% increase in FEV1 in SA after oral prednisolone was found for sputum eosinophils≥3% and FeNO>45 ppb. CONCLUSIONS Sputum eosinophils and FeNO were the best predictors of favorable response to oral prednisolone in severe asthmatics. A guided approach to glucocorticosteroid treatment should be recommended as it favors better control of the disease and presumably a lower rate of adverse events. The study has been registered at the site: clinicaltrials.gov with number: NCT00555607.
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Affiliation(s)
- Maciej Kupczyk
- Karolinska Institutet, Stockholm, Sweden; Medical University of Lodz, Poland.
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14
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Vijverberg SJH, Koenderman L, Koster ES, van der Ent CK, Raaijmakers JAM, Maitland-van der Zee AH. Biomarkers of therapy responsiveness in asthma: pitfalls and promises. Clin Exp Allergy 2012; 41:615-29. [PMID: 21488995 DOI: 10.1111/j.1365-2222.2011.03694.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Asthma is one of the most common chronic diseases worldwide. There is a large inter-individual variability in response to asthma treatment. Most patients respond well to standard therapy; however, a small proportion of the patients remain symptomatic despite treatment with high dosages of corticosteroids. Uncontrolled asthma leads to a decreased quality of life. Therefore, it is important to identify individuals who will respond poorly to standard asthma medication, especially to standard maintenance therapy with inhaled corticosteroids, at an early stage. Response to anti-inflammatory therapy is generally monitored by the assessment of clinical symptoms, which only partially correlates with underlying airway inflammation. The identification of specific inflammatory biomarkers might help to guide treatment or predict a corticosteroid response more accurately. Some inflammatory biomarkers are already finding their way into clinical practice (e.g. fraction of nitric oxide in exhaled breath), whereas others are predominantly used as a research tool (e.g. profiles of volatile organic compounds). Currently, there is no inflammatory biomarker used in routine clinical practice to predict a corticosteroid response. More knowledge on the underlying biological mechanism(s) of heterogeneous therapeutic responses could help to identify novel biomarkers. This review will focus on inflammatory patterns and genetic variations that may underlie differences in treatment response in patients with asthma, and will provide an overview of inflammatory biomarkers that could potentially serve as response predictors.
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Affiliation(s)
- S J H Vijverberg
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
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15
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Giudice MM, Pedullà M, Brunese F, Capristo A, Capristo C, Tosca M, Leonardi S, Ciprandi G. Neutrophilic Cells in Sputum of Allergic Asthmatic Children. EUR J INFLAMM 2010; 8:151-156. [DOI: 10.1177/1721727x1000800303] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023] Open
Abstract
Airway inflammation is regarded as a central feature of asthma and is mostly sustained by eosinophilic infiltrate. Recent studies have shown that a co-activation of eosinophil- and neutrophil-dependent inflammatory mechanisms might explain why some asthmatics do not respond to conventional asthma therapy. The aim of our study is to determine whether neutrophilic inflammation was involved in 55 allergic children with mild-moderate persistent asthma and the relationship with the response to steroid treatment. Before the sputum analysis, all children underwent spirometry with the reversibility test, and were divided into two groups on the basis of the response (such as >12% of baseline FEV1): group 1 positive and group 2 negative. Eosinophil cationic protein concentrations were measured by radioimmunoassay and neutrophyl myeloperoxidase (MPO) concentrations were measured by an MPO-EIA. Ten healthy children of comparable ages served as control group. Total IgE, FEV1 and FEV/FVC values were similar in both groups. The sputum macrophage count was higher in controls than in allergic asthmatics, but there was no difference between groups 1 and 2 (59.6% vs 18.3% and 17%; p≤ 0.005). Sputum neutrophils were significantly higher in group 2 both vs controls (62% vs 34%; p≤ 0.005) and vs group 1 (62% vs 37%; p≤ 0.005). Our data suggest that neutrophils are involved in airway allergic inflammation in mild-moderate persistent childhood asthma and a high neutrophil count in sputum may be related to a lower responsiveness to inhaled corticosteroids.
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Affiliation(s)
| | | | | | | | | | - M.A. Tosca
- Pediatric Pneumology and Allergy, Istituto G. Gaslini Genoa
| | - S. Leonardi
- Department of Pediatrics, University of Catania, Catania
| | - G. Ciprandi
- Department of Internal Medicine, Azienda Ospedaliera Universitaria San Martin, University of Genoa, Italy
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16
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Kulkarni NS, Hollins F, Sutcliffe A, Saunders R, Shah S, Siddiqui S, Gupta S, Haldar P, Green R, Pavord I, Wardlaw A, Brightling CE. Eosinophil protein in airway macrophages: a novel biomarker of eosinophilic inflammation in patients with asthma. J Allergy Clin Immunol 2010; 126:61-9.e3. [PMID: 20639010 DOI: 10.1016/j.jaci.2010.03.026] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 03/23/2010] [Accepted: 03/26/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Noneosinophilic asthma is common across asthma severities. However, in patients with moderate-to-severe disease, the absence of sputum eosinophilia cannot distinguish between asthmatic subjects with eosinophilic inflammation controlled by corticosteroids versus those in whom eosinophilic inflammation is not a component of the disease. OBJECTIVES We sought to develop a method to quantify eosinophil proteins in airway macrophages as a novel biomarker of eosinophilic airway inflammation. METHODS Eosinophil proteins in airway macrophages were assessed by means of flow cytometry, immunofluorescence, and cytoplasmic hue change after ingestion of apoptotic eosinophils. Airway macrophage median percentage of red-hued area in stained sputum cytospin preparations was assessed by means of image analysis from (1) subjects with mild-to-severe asthma, subjects with nonasthmatic eosinophilic bronchitis, and healthy control subjects; (2) subjects with eosinophilic severe asthma after treatment with prednisolone; and (3) subject with noneosinophilic asthma before corticosteroid withdrawal. RESULTS Eosinophil proteins were detected in airway macrophages, and cytoplasmic red hue increased after ingestion of apoptotic eosinophils. Airway macrophage percentage redhued area was increased in subjects with moderate-to-severe asthma compared with that seen in subjects with mild asthma and healthy control subjects, was similar in those with or without a sputum eosinophilia, and was increased after corticosteroid therapy. In asthmatic subjects without sputum eosinophilia, the airway macrophage percentage red-hued area was increased in subjects who did versus those who did not have sputum eosinophilia after corticosteroid withdrawal. CONCLUSIONS Eosinophil proteins can be reliably measured in airway macrophages. In combination with sputum eosinophilia, the macrophage eosinophil protein content might further define the asthma phenotype and provide an additional tool to direct therapy.
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Affiliation(s)
- Neeta S Kulkarni
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom.,Children's Community Health Service, Leicester City NHS Primary Care Trust
| | - Fay Hollins
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Amanda Sutcliffe
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Ruth Saunders
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Sachil Shah
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Salman Siddiqui
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Sumit Gupta
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Pranab Haldar
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Ruth Green
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Ian Pavord
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Andrew Wardlaw
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
| | - Christopher E Brightling
- Institute for Lung Health, Glenfield Hospital, Leicester, and the Department of Infection, Immunity and Inflammation, University of Leicester, United Kingdom
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17
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Navarro Merino M, Andrés Martín A, Asensio de la Cruz O, García García ML, Liñán Cortes S, Villa Asensi JR. [Diagnosis and treatment guidelines for difficult-to-control asthma in children]. An Pediatr (Barc) 2009; 71:548-67. [PMID: 19864193 DOI: 10.1016/j.anpedi.2009.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 08/04/2009] [Accepted: 08/05/2009] [Indexed: 11/16/2022] Open
Abstract
Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.
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Affiliation(s)
- M Navarro Merino
- Sección de Neumología Pediátrica, Hospital Universitario Virgen Macarena, Sevilla, España.
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18
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Gruchalla RS, Sampson HA, Matsui E, David G, Gergen PJ, Calatroni A, Brown M, Liu AH, Bloomberg GR, Chmiel JF, Kumar R, Lamm C, Smartt E, Sorkness CA, Steinbach SF, Stone KD, Szefler SJ, Busse WW. Asthma morbidity among inner-city adolescents receiving guidelines-based therapy: role of predictors in the setting of high adherence. J Allergy Clin Immunol 2009; 124:213-21, 221.e1. [PMID: 19615730 DOI: 10.1016/j.jaci.2009.05.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 04/21/2009] [Accepted: 05/26/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND With the expanding effort to provide guidelines-based therapy to adolescents with asthma, attention must be directed to evaluating which factors predict future asthma control when guidelines-based management is applied. OBJECTIVE We evaluated the role of fraction of exhaled nitric oxide in parts per billion, markers of allergic sensitization, airway inflammation, and measures of asthma severity in determining future risk of asthma symptoms and exacerbations in adolescents and young adults participating in the Asthma Control Evaluation study. METHODS Five hundred forty-six inner-city residents, ages 12 through 20 years, with persistent asthma were extensively evaluated at study entry for predictors of future symptoms and exacerbations over the subsequent 46 weeks, during which guidelines-based, optimal asthma management was offered. Baseline measurements included fraction of exhaled nitric oxide in parts per billion, total IgE, allergen-specific IgE, allergen skin test reactivity, asthma symptoms, lung function, peripheral blood eosinophils, and, for a subset, airway hyperresponsiveness and sputum eosinophils. RESULTS The baseline characteristics we examined accounted for only a small portion of the variance for future maximum symptom days and exacerbations--11.4% and 12.6%, respectively. Future exacerbations were somewhat predicted by asthma symptoms, albuterol use, previous exacerbations, and lung function, whereas maximum symptom days were predicted, also to a modest extent, by symptoms, albuterol use, and previous exacerbations, but not lung function. CONCLUSION Our findings demonstrate that the usual predictors of future disease activity have little predictive power when applied to a highly adherent population with persistent asthma that is receiving guidelines-based care. Thus, new predictors need to be identified that will be able to measure the continued fluctuation of disease that persists in highly adherent, well-treated populations such as the one studied.
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Affiliation(s)
- Rebecca S Gruchalla
- University of Texas Southwestern Medical Center, Dallas, Tex 75390-8859, USA.
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Pérez-Yarza EG, Sardón Prado O, Korta Murua J. [Recurrent wheezing in three year-olds: facts and opportunities]. An Pediatr (Barc) 2009; 69:369-82. [PMID: 18928707 DOI: 10.1157/13126564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The 3 year-old group of children has an increased incidence and prevalence of recurrent wheezing episodes. There are different subgroups, who give different inflammatory responses to different triggering agents, and subgroups that differ in aetiopathology and immunopathology. Current diagnostic methods (exhaled nitric oxide in multiple breaths, nitric oxide in exhaled air condensate, induced sputum, broncho-alveolar lavage and endo-bronchial biopsy), enable the inflammatory pattern to be identified and to give the most effective and safe treatment. The various therapeutic options for treatment are reviewed, such as inhaled glucocorticoids when the inflammatory phenotype is eosinophilic, and leukotriene receptor antagonists, when the inflammatory phenotype is predominantly neutrophilic. In accordance with the current recommendations, for the diagnosis as well as for the therapy initiated in children of this age, they must be regularly reviewed, so that if the benefit is not clear, the treatment must be stopped and an alternative diagnosis and treatment considered. The start of treatment should be determined depending on the intensity and frequency of the symptoms, with the aim of decreasing morbidity and increasing the quality of life of the patient.
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Affiliation(s)
- E G Pérez-Yarza
- Unidad de Neumología, Servicio de Pediatría, Hospital Donostia, San Sebastián, España.
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20
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González Pérez-Yarza E. [Childhood asthma: do the answers coincide with the questions?]. Arch Bronconeumol 2008; 43:646-8. [PMID: 18053540 DOI: 10.1016/s1579-2129(07)60149-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
This review focuses on papers published between September 2006 and September 2007 that either answer important clinical questions, or signpost important areas for future research.
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Affiliation(s)
- Jonathan Grigg
- Academic Unit of Paediatrics, Institute of Cell and Molecular Science, Barts and the London Medical School, 4 Newark Street, London E1 2AT, UK.
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22
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The value of FeNO measurement in asthma management: the motion for Yes, it's NO--or, the wrong end of the Stick! Paediatr Respir Rev 2008; 9:127-31. [PMID: 18513673 DOI: 10.1016/j.prrv.2007.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The utility of measurements of exhaled nitric oxide (FeNO) will likely depend on context, being most helpful in moderate and severe asthma, rather than mild asthmatics and community based studies. Atopy on its own is a cause of elevation in FeNO. Adult and paediatric studies have clearly established that measurement of some aspect of airway inflammation is part of state of the art management of asthma, but it is as yet unclear which of several techniques is most useful. The relationship between FeNO and sputum eosinophils is relatively loose, but this does not preclude it being a useful test in clinical practice. In fact, there are only poor correlations between sputum, proximal mucosal, and distal eosinophils, and the importance of these different compartments is unclear. A low FeNO in the setting of supposedly poorly controlled asthma should cast doubt on the diagnosis. We certainly cannot treat an isolated elevation in FeNO, which may be due to a simple viral cold, or constitutional. If FeNO is elevated, particularly if asthma is uncontrolled, it suggests an imbalance between anti-inflammatory therapy and pro-inflammatory environmental influences. Inadequate anti-inflammatory therapy may be due to the prescribed dose being too low; the drug delivery device not being used correctly; or the medication not being taken. Adverse pro-inflammatory environmental influences driving up FeNO include IgE and non-IgE mediated allergen sensitivity in the home, and even in the child's school. Novel technology allows home monitoring of FeNO, but the role of these devices is less clear. Although more data is needed properly to define the role of FeNO measurements in clinical practice, there is sufficient data already published to conclude that 'inflammometry' is an important part of asthma management at the more severe end of the spectrum, and that FeNO measurements are probably the most useful at the moment.
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González Pérez-Yarza E. Asma en la infancia, ¿se corresponden las respuestas con las preguntas? Arch Bronconeumol 2007. [DOI: 10.1157/13112961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Affiliation(s)
- Andrew Bush
- Imperial School of Medicine at National Heart and Lung Institute, UK.
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