Japanese guidelines for adult asthma 2020

The methyl-CpG binding domain 2 regulates peptidylarginine deiminase 4 expression and promotes neutrophil extracellular trap formation via the Janus kinase 2 signaling pathway in experimental severe asthma

OBJECTIVE

The prognosis for severe asthma is poor, and the current treatment options are limited. The methyl-CpG binding domain protein 2 (MBD2) participates in neutrophil-mediated severe asthma through epigenetic regulation. Neutrophil extracellular traps (NETs) play a critical role in the pathogenesis of severe asthma. This study aims to detect if MBD2 can reduce NETs formation and the potential mechanism in severe asthma.

METHODS

A severe asthma model was established in C57BL/6 wild-type mice exposure to house dust mite (HDM), ovalbumin (OVA), and lipopolysaccharide (LPS). Enzyme-linked immunosorbent assay was used to measure the concentrations of IL-4, IL-17A, and IFN-γ in lung tissues. Flow cytometry was employed to determine the percentages of Th2, Th17, and Treg cells in lung tissues. Quantitative real-time polymerase chain reaction was utilized to assess the mRNA expression levels of MBD2, JAK2, and PAD4. Western blotting and immunofluorescence were conducted to detect the protein of MBD2, JAK2, PAD4, and CitH3. HL-60 cells were differentiated into neutrophil-like cells by culturing in a medium containing dimethyl sulfoxide and then stimulated with LPS. KCC-07, Ruxolitinib, and Cl-amidine were used to inhibit the expressions of MBD2, JAK2, and PAD4, respectively.

RESULTS

Severe asthma mice were characterized by pulmonary neutrophilic inflammation and increased formation of neutrophil extracellular traps (NETs). The expression of MBD2, JAK2, and PAD4 was elevated in severe asthma mice. Inhibiting the expression of MBD2, JAK2, and PAD4 reduced NETs formation and decreased airway inflammation scores, total cell counts and neutrophil counts in BALF, and percentage of Th2 and Th17 cell in lung tissues, whereas increasing Treg cell counts. In both severe asthma mice and HL-60-differentiated neutrophil-like cells in vitro, inhibiting MBD2 reduced the mRNA and protein expression of JAK2 and PAD4, and inhibiting JAK2 reduced the expression of PAD4 mRNA and protein.

CONCLUSION

MBD2 regulates PAD4 expression through the JAK2 signaling pathway to promote NETs formation in mice with severe asthma. Further bench-based and bedside-based studies targeting the MBD2, PAD4, and JAK2 signaling pathways will help open new avenues for drug development of severe asthma.

Diagnostic value of EOS count and serum VEGF in bronchial asthma and their correlation with inflammatory factors and lung function indicators

OBJECTIVE

To probe the diagnostic value of direct eosinophils (EOS) count and vascular endothelial growth factor (VEGF) in bronchial asthma (BA) and their correlation with inflammatory factors and lung function indicators.

METHODS

A total of 66 patients with BA (BA group) were retrospectively gathered, who were further divided into mild (n = 25), moderate (n = 31), and severe (n = 10) subgroups based on asthma severity. Additionally, 60 healthy individuals undergoing physical examinations during the same period were enrolled as the normal group. The EOS count, serum VEGF, inflammatory factors [interleukin-6 (IL-6), interleukin-7 (IL-7), interleukin-10 (IL-10)], and lung function indicators [forced expiratory volume in one second (FEV1%) as a percentage of the predicted value, FEV1/forced vital capacity (FVC)] were compared among different groups. Spearman correlation analysis was performed to assess the correlation between EOS count, serum VEGF, and inflammatory factors, as well as lung function indicators in the BA group. Receiver operating characteristic (ROC) curves and Delong's test were adopted to analyze the diagnostic value of EOS and VEGF individually and in combination for BA and the severity of BA.

RESULTS

Versus the normal group, the BA group exhibited higher EOS count and serum levels of VEGF, IL-6, and IL-7, but lower levels of IL-10, FEV1%, and FEV1/FVC. In the severe subgroup, EOS count and serum VEGF, IL-6, and IL-7 levels were higher than those in the moderate and mild subgroups, while the moderate subgroup had higher values than the mild subgroup. IL-10, FEV1%, and FEV1/FVC were lower in the severe subgroup versus the moderate and mild subgroups, and the moderate subgroup had lower levels than the mild subgroup (all p < 0.05). Spearman correlation analysis unveiled positive correlations between EOS count and VEGF with IL-6 and IL-7 (r > 0, p < 0.05), but negative correlations with IL-10, FEV1%, and FEV1/FVC (r < 0, p < 0.05). ROC curve analysis displayed that the areas under the curve (AUCs) for EOS count and serum VEGF individually in diagnosing BA were 0.767 and 0.807. The AUC for the combined diagnosis of both (0.875) was significantly greater than the AUC for each test used alone (p < 0.05). The AUC for using EOS count alone to diagnose the severity of BA in patients was 0.936, while the AUC for using serum VEGF alone was 0.963. The AUC for the combined diagnosis of both (1.000) was significantly greater than the AUC for EOS count alone (p < 0.05).

CONCLUSION

There is a correlation between EOS count, serum VEGF, inflammatory levels, and lung function indicators in patients with BA. The combined detection of EOS count and serum VEGF levels has guiding significance for clinical diagnosis and disease assessment.

CLINICAL TRIAL NUMBER

Not applicable.

Diagnostic value of FeNO, periostin, IL-4, and ECP in patients with acute exacerbation of bronchial asthma

OBJECTIVE

This study aimed to analyze the diagnostic value of fractional exhaled nitric oxide (FeNO), periostin, interleukin (IL)-4, and eosinophil cationic protein (ECP) in patients with acute exacerbation of bronchial asthma (AEBA) and their relationship with lung function.

METHODS

Ninety-six bronchial asthma patients admitted to our hospital from January 2020 to January 2021 were collected and divided into two groups: acute exacerbation group (n = 55) and non-acute-exacerbation group (n = 41). Pulmonary function indices and serum levels of FeNO, IL-4, periostin, ECP, and EOS% were determined. Pearson correlation analysis was used to analyze the relationships between these biomarkers and pulmonary function indices. A receiver operating characteristic (ROC) curve was applied to assess the diagnostic value of these biomarkers for AEBA.

RESULTS

The acute-exacerbation group showed lower percentage of predicted values of peak expiratory flow (PEF%pred), forced expiratory volume in 1 second (FEV1%pred), and forced vital capacity (FVC%pred) while higher levels of FeNO, IL-4, periostin, ECP, and EOS compared to the non-acute-exacerbation group. Pearson correlation analysis indicated that FeNO, IL-4, periostin, and ECP levels were negatively correlated with PEF%pred, FEV1%pred, and FVC%pred, and positively correlated with EOS%. ROC curve analysis revealed that these biomarkers had high predictive value for AEBA.

CONCLUSION

FeNO, IL-4, periostin, and ECP levels are negatively correlated with pulmonary function indices (PEF%pred, FEV1%pred, and FVC%pred) and positively correlated with EOS%. These biomarkers have high predictive value for AEBA.

Impact of taste changes caused by inhalers on adherence to inhalation therapy among patients with asthma and chronic obstructive pulmonary disease

BACKGROUND

Adherence to inhalation therapy impacts treatment outcomes of asthma and chronic obstructive pulmonary disease. Although taste changes induced by inhaled medications may influence adherence, this matter remains underexplored. This study aimed to elucidate the characteristics of taste changes caused by inhaled medications and their association with adherence.

METHODS

Consecutive patients who regularly visited our hospital from August 2023 to December 2023 were recruited. Sweet, bitter, sour, and salty taste changes were assessed using a visual analog scale. Adherence was measured using a structured questionnaire.

RESULTS

Data from 491 inhaler responses (463 patients, aged 68.2 ± 13.5 years) were analyzed. Inhaled corticosteroid (ICS)/long-acting beta2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) therapy promoted the most significant bitter taste change. Besides a long duration of taste changes (over a minute), dry powder inhaler devices (β = 0.19, P < 0.001) were significantly associated with sweet taste changes. Younger age (β = -0.17, P < 0.001), absence of a water rinse before inhalation (β = -0.09, P = 0.027), and inhalers containing LAMA (β = 0.22, P < 0.001) were associated with bitter taste changes. Older age (β = 0.10, P = 0.025) was associated with sour taste changes. Bitter taste changes (β = -0.17, P = 0.027) among users of inhalers containing LAMA and younger age (β = 0.15, P = 0.011) among users of inhalers not-containing LAMA were associated with poor adherence.

CONCLUSIONS

ICS/LABA/LAMA therapy induced the most significant bitter taste changes. The absence of a water rinse before inhalation was associated with bitter taste changes. Bitter taste changes among users of inhalers containing LAMA were correlated with poor adherence, highlighting the need for targeted interventions to improve adherence.

Practical Guidelines for Asthma Management (PGAM): Digest edition

The international and national guidelines for asthma management are typically comprehensive and designed for respiratory specialists, making them less practical for primary care physicians who handle most asthma cases. Recognizing the need for more accessible guidelines, the Japan Asthma Society developed the Practical Guidelines for Asthma Management (PGAM). PGAM aims to provide a concise summary of key asthma management principles, increasing awareness, education, and support among nonspecialists and patients alike. It includes user-friendly tables and lists outlining common symptoms, triggers, diagnostic criteria, and basic management strategies, along with frequently encountered treatable traits and comorbidities. These elements are presented through simple, clinically relevant algorithms. A notable feature of PGAM is the "Basic Roadmap for Asthma Management," which outlines a clear sequence for patient assessment, diagnosis, and treatment from initial consultation onward, offering an easy-to-follow visual guide. Additionally, the guidelines include methods for assessing airway inflammation, enabling patient phenotyping and endotyping. This supports a personalized treatment approach, particularly with biologics, aimed at achieving clinical remission.

Effectiveness of benralizumab in the Tokyo Asthma Study (TOAST): A real-world prospective interventional trial

BACKGROUND

Biologics are integral in the management of severe asthma. As the effectiveness of the anti-IL-5 receptor antibody benralizumab in Japan remains elusive, this study aimed to assess its real-world effectiveness in Japanese patients with severe asthma.

METHODS

This prospective, interventional, single-arm clinical trial was conducted across ten facilities in Japan between September 2020 and July 2022. Adult patients with severe eosinophilic asthma (peripheral blood eosinophil count ≥150 cells/μl) were enrolled and treated with benralizumab. The primary endpoint was the change in ACQ-5 score from baseline to week 24.

RESULTS

Of 103 patients, 98 (mean age: 62.1 years, women: 55.1 %, regular oral corticosteroids [OCS] treatment: 20.4 %) were included in the analysis. From baseline to week 24, benralizumab significantly improved ACQ-5 (-0.67, 95 % CI: -0.94 to -0.39) and AQLQ (0.71, 95 % CI: 0.46 to 0.96) scores with an increase in FEV1 (87 ml, 95 % CI: 15-159 ml). The maintenance OCS dose and the percentage of OCS users decreased from 13.9 mg/day to 6.0 mg/day and from 20.4 % to 9.2 %, respectively. Multivariable analysis identified baseline blood eosinophil count (≥400 cells/μl) and fractional exhaled nitric oxide (≥22 ppb) as independent predictors of therapeutic response to benralizumab. Benralizumab treatment was discontinued due to nonserious adverse events and patient choice in four and three patients, respectively.

CONCLUSIONS

In a real-world setting in Japan, patients with severe eosinophilic asthma treated with benralizumab demonstrated substantial improvements in asthma control, quality of life, and respiratory function with reduced OCS usage.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCTs031190237).

Epidemiology and risk factors of non-esophageal eosinophilic gastrointestinal diseases in Japan: A population-based study

BACKGROUND

Non-esophageal eosinophilic gastrointestinal diseases (non-EoE EGIDs) are allergic conditions where Th-2-predominant inflammation causes symptoms related to gastrointestinal tract dysfunction. No studies have reported the incidence of non-EoE EGIDs. In addition, little is known about the influence of lifestyle factors on the condition.

METHODS

We used a large health claim database from January 2005 to September 2022. Non-EoE EGIDs cases were identified on the basis of the International Classification of Diseases-tenth Revision code, K52.8. The incidence and prevalence of non-EoE EGIDs were estimated by Poisson and binomial distribution, respectively. For each case, 10 controls were randomly selected for a nested case-control study to identify potential risk factors of non-EoE EGIDs.

RESULTS

Of 15,200,895 individuals, 1,368 new cases of non-EoE EGIDs were identified. The incidence and prevalence of non-EoE EGIDs in 2022 were 3.07 (95% CI 2.67-3.52) per 100,000 person-years and 17.23 (95% CI 16.38-18.11) per 100,000 individuals, respectively, which were approximately 6 and 9 times higher than those in 2010. Allergic rhinitis (OR 1.63 (95% CI 1.16-2.29), p = 0.005), chronic sinusitis (OR 2.41 (95% CI 1.58-3.66), p < 0.001), and urticaria (OR 2.32 (95% CI 1.45-3.70), p < 0.001) were related to an increased risk of adult non-EoE EGIDs. Whilst atopic dermatitis (OR 2.28 (95% CI 1.35-3.86), p = 0.006) and the perinatal factors (OR 3.68 (95% CI 1.13-12.02), p = 0.031) were associated with an increased risk of pediatric non-EoE EGIDs. No association was seen with lifestyle factors such as obesity, smoking and alcohol consumption.

CONCLUSIONS

The incidence and prevalence of non-EoE EGIDs have increased over the past two decades.

Association between monocyte-high-density lipoprotein cholesterol ratio and mortality in a population with asthma: a cohort study

BACKGROUND

The monocyte-high-density lipoprotein cholesterol ratio (MHR) serves as an integrated indicator of the pro-inflammatory role of monocytes and anti-inflammatory properties of high-density lipoprotein cholesterol (HDL-C). Research has shown that the MHR is associated with the onset and prognosis of some diseases. However, no study has examined the link between the MHR and prognosis of populations with asthma.

METHODS

This study included data from 2,023 participants with asthma from the National Health and Nutrition Examination Survey (NHANES). This survey applied various statistical models, such as Cox proportional hazards, restricted cubic spline (RCS), threshold effects analysis (TEA), Kaplan-Meier survival analysis, and survival area plots, to assess the correlation between the MHR and mortality in participants with asthma.

RESULTS

According to the Cox hazard models, the MHR and mortality were positively correlated (hazard ratio: 1.93, 95% confidence interval: 1.20-3.11). Additionally, the RCS and TEA demonstrated a positive and linear relationship between the MHR and mortality. Participants with asthma who had a decreased MHR had better survival, compared with those who had an elevated MHR, as per the Kaplan-Meier survival analysis and survival area plots.

CONCLUSIONS

This longitudinal investigation indicated that an increased MHR was associated with elevated mortality in individuals with asthma. Therefore, the MHR may serve as an independent biomarker for predicting the prognosis of individuals with asthma.

The Perception of Asthma, Chronic Obstructive Pulmonary Disease, Asthma and Chronic Obstructive Pulmonary Disease Overlap, and Cough Variant Asthma: A Retrospective Observational Study

Objective The prevalence rates of bronchial asthma (BA) and chronic obstructive pulmonary disease (COPD) are 3%-11% and 8%-16%, respectively, in the general Japanese adult population. Few reports on patients' perceptions of BA, cough variant asthma (CVA), COPD, and asthma and COPD overlap (ACO) are available in Japan, and we aimed to investigate the agreement between the perception and diagnosis of BA and COPD-related diseases. Methods The subjects were 229 datasets matched to the sex and age distribution of the Japanese population of 1,000 adult patients who underwent respiratory function tests and screening for each disease at Nagasaki University Hospital between July 2014 and July 2017. The patients' self-perceptions of diagnosed BA, CVA, COPD, emphysema, chronic bronchitis, and ACO were determined. Results In total, 229 datasets were included in this study. The prevalence of BA was 10.0% (23 cases, including 2 CVA and 6 ACO cases) and 11.8% (27 cases, including 6 ACO cases). The prevalence of ACO was 2.6% (28.6% of BA and 22.2% of COPD), and that of CVA was 0.9% (8.7% of BA). The perception of COPD-related diseases had a much lower sensitivity than that of asthma-related diseases (0.481 vs. 0.995, p<0.0001). Cohen's kappa for asthma-related disease was 0.976, and that for COPD-related disease was 0.621. Conclusion Self-perception of asthma-related disease was adequately high, whereas that of COPD-related disease was low. The prevalence rates of BA, COPD, ACO, and CVA in our study were 10.0%, 11.8%, 2.6%, and 0.9%, respectively. An increase in the perception of COPD may help improve community healthcare for respiratory diseases.

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.

Nebulised high-dose corticosteroids as add-on therapy for adults with asthma exacerbation: a randomised controlled trial

BACKGROUND

Evidence regarding high-dose inhaled corticosteroids (HDICS) in asthma exacerbations in adults is insufficient. This study compares the treatment outcomes of HDICS as add-on therapy to the outcomes of standard treatment in adult patients with acute asthma exacerbation in the ED.

METHODS

This was a single-centre, triple-blind, randomised controlled trial conducted in the ED in Thailand between March 2022 and April 2023. Adult patients with asthma exacerbation were randomly assigned to receive either a placebo (normal saline) or HDICS (budesonide 9000 µg) nebulisation combined with beta agonist and ipratropium within the first hour. The primary endpoints were length of ED stay, hospital admission and ED revisit. The secondary endpoints were dyspnoea scale, pulmonary functions, length of hospital stay and home exacerbation after ED discharge.

RESULTS

A total of 88 patients were randomly assigned to one of two groups: 44 patients received a HDICS and 44 patients were placed in the control group. The HDICS group had a significantly shorter ED length of stay (adjusted mean difference -133.6 min; 95% CI -242.4 to -24.8 min; p=0.016), and a higher proportion of ED discharged home within 8 and 16 hours compared with the control group. However, there were no significant differences between the two groups in hospital admission rates, ED revisit, dyspnoea scale, pulmonary functions, length of hospital stay or home exacerbation after ED discharge.

CONCLUSIONS

HDICS may be useful as an add-on therapy to standard treatment for asthma exacerbation in adults to reduce ED stay.

TRIAL REGISTRATION NUMBER

TCTR20201214001.

Recent Advances and New Therapeutic Goals in the Management of Severe Asthma

Asthma is characterized by chronic airway inflammation as its primary pathological condition, which leads to various respiratory symptoms due to airway narrowing, with type 2 inflammation playing a central role. Asthma treatment, primarily centered on inhaled corticosteroids, aims to suppress type 2 inflammation and improve airway narrowing. However, severe asthma that cannot be controlled with high-dose inhaled corticosteroids or other asthma medications remains a clinical issue. The availability of multiple biological agents has recently improved the management of severe asthma. In addition, the concept of clinical remission has emerged as a treatment goal, further clarifying the objectives of asthma management. However, despite these advancements, the treatment of severe asthma driven primarily by non-type 2 inflammation remains a major challenge, and new biologics are currently being developed to address this issue.

Use and limitations of clinical data in the identification and classification of low molecular weight chemicals (LMWCs) as respiratory sensitizers: recommendations for improvement

While progress has been made in recent years, there are still no suitable and accepted in silico, in vitro, or in vivo models that can be used to accurately predict whether a chemical substance has the intrinsic property to cause immune-mediated chemical respiratory allergy, typically manifested as allergic asthma or allergic rhinitis which represents a severe health hazard. Regulatory authorities have relied primarily on clinical evidence (case reports, clinical databases, worker exposure studies) to classify substances as respiratory sensitizers, but this evidence can lack a proven immunological mechanism which is necessary to identify substances which can cause life-long sensitization and clinically relevant allergic symptoms in the respiratory tract in an exposed population (such respiratory allergens may be considered as "true" sensitizers, in analogy to the definition of skin sensitization, and in contrast to respiratory irritants). In light of this, the European Center for Ecotoxicology and Toxicology of Chemicals convened a Task Force to evaluate the types of clinical methods and data sources and the implications of relying on such data for regulatory decision making from a scientific perspective. Recognizing that there are benefits and important insights from using such data, significant shortcomings were identified. With clinical work being focused on treatment and diagnosis of individual patients, the approaches and methods used for clinical guidance, diagnostics and reporting have serious limitations in proving the respiratory sensitization potential of a specific chemical, definitely restricting their suitability in deriving legally binding hazard classifications for human health protection. Even within the current broader regulatory definition of respiratory sensitization, a robust assessment and sound evidence of causation by a specific chemical seems mandatory in order to avoid misclassifications. Application of a systematic weight-of-evidence approach is considered suitable to determine the level of confidence, including a thorough assessment of the specificity or non-specificity of observed bronchial hyperreactivity. Recommendations proposed in this publication may not only aid industry and regulators in their decision making but also facilitate a further exchange between stakeholders to improve the data used to (a) more precisely identify true respiratory sensitizers to effectively protect human health, (b) aid evaluation of potential predictive models, and (c) encourage regulators to clarify guidance and to consider a re-evaluation of the current regulatory definition of respiratory sensitizers.

Factors associated with uncontrolled severe asthma in the biologic era

BACKGROUND

Despite the development of biologics for severe asthma, individuals with uncontrolled status persist, posing a significant social problem. This multicenter prospective study aimed to identify factors associated with the uncontrolled status of patients with severe asthma in the biologic era assessed using the Asthma Control Questionnaire (ACQ).

METHODS

Subjects with severe asthma diagnosed by respiratory specialists were enrolled from 11 hospitals. Clinical data and questionnaires were collected. We compared controlled (ACQ-5 <1.5) with uncontrolled severe asthma (ACQ-5 ≥1.5) and assessed factors linked to uncontrolled severe asthma using logistic regression analysis.

RESULTS

One hundred fifty-four patients were analyzed (median age, 66 years; 62.3 % female; 52.6 % administered biologics). Among them, 56 patients (36.4 %) had uncontrolled severe asthma (ACQ-5 ≥1.5). The uncontrolled group had more frequent exacerbations (≥2 times in the previous year) and elevated blood neutrophil counts compared with the controlled group. Factors associated with uncontrolled status were analyzed in the overall population, with patients stratified into two groups: those receiving biologics and those not receiving biologics. Multivariate analysis revealed that frequent exacerbations and elevated blood neutrophil counts were associated with uncontrolled status in the overall population and in patients without biologics, whereas elevated blood neutrophil counts were significantly associated with uncontrolled status in patients receiving biologics.

CONCLUSION

Elevated blood neutrophil counts and frequent exacerbations were independently associated with uncontrolled severe asthma. Specifically, elevated blood neutrophil counts were a significant factor related to uncontrolled status irrespective of biologics, suggesting their potential utility as a biomarker in the biologic era.

Organophosphate flame retardants associated with increased oxidative stress biomarkers and elevated FeNO levels in general population of children: The Hokkaido study

Our previous study found that exposure to higher organophosphate flame retardants (PFRs) was associated with increased prevalence of wheeze and type 2 inflammation among school-aged children. It remains unclear whether PFR exposure elevates oxidative stress in these general pediatric population, thereby potentially contributing to the development of allergic diseases. This study examined the associations between individual and mixture exposure to PFRs and oxidative stress in children aged 9-12 years (n = 423). The oxidative stress biomarkers included 4-hydroxynonenal (4-HNE) and hexanoyl-lysine (HEL) for lipid peroxidation, and 8-hydroxy-2'-deoxyguanosine (8-OHdG) for DNA damage. We also examined the mediation effects of oxidative stress on the relationships between PFR exposure and health outcomes: wheeze and type 2 inflammation biomarkers, including fraction of exhaled nitric oxide (FeNO) and blood eosinophils. Higher concentrations of tris(1,3-dichloro-2-propyl) phosphate (TDCIPP), Σ triphenyl phosphate (ΣTPHP), Σ tris(2-butoxyethyl) phosphate (ΣTBOEP), and Σ 2-Ethylhexyldiphenyl phosphate (ΣEHDPHP) metabolites were significantly associated with higher levels of 4-HNE. Elevated concentrations of TDCIPP, ΣTPHP, and ΣTBOEP were positively associated with HEL. Higher ΣTPHP and ΣTBOEP were positively associated with 8-OHdG. The PFR mixture was positively associated with all three oxidative stress biomarkers according to the Quantile g-computation and Bayesian kernel machine regression models. Oxidative stress biomarkers mediated 11.4 % to 15.3 % of the association between PFRs and FeNO ≥35 ppb. PFR exposure was positively associated with oxidative stress markers of DNA damage and lipid peroxidation, which may contribute to elevated type 2 inflammation among school-aged children. These findings, identified in the general pediatric population at low exposure levels, highlight the need for ongoing attention to the allergic symptoms posed by PFR exposure.

Best practice advice for asthma exacerbation prevention and management in primary care: an international expert consensus

Primary care clinicians play a key role in asthma and asthma exacerbation management worldwide because most patients with asthma are treated in primary care settings. The high burden of asthma exacerbations persists and important practice gaps remain, despite continual advances in asthma care. Lack of primary care-specific guidance, uncontrolled asthma, incomplete assessment of exacerbation and asthma control history, and reliance on systemic corticosteroids or short-acting beta2-agonist-only therapy are challenges clinicians face today with asthma care. Evidence supports the use of inhaled corticosteroids (ICS) + fast-acting bronchodilator treatments when used as needed in response to symptoms to improve asthma control and reduce rates of exacerbations, and the symptoms that occur leading up to an asthma exacerbation provide a window of opportunity to intervene with ICS. Incorporating patient perspectives and preferences when designing asthma regimens will help patients be more engaged in their therapy and may contribute to improved adherence and outcomes. This expert consensus contains 10 Best Practice Advice Points from a panel of primary care clinicians and a patient representative, formed in collaboration with the International Primary Care Respiratory Group (IPCRG), a clinically led charitable organization that works locally and globally in primary care to improve respiratory health. The panel met virtually and developed a series of best practice statements, which were drafted and subsequently voted on to obtain consensus. Primary care clinicians globally are encouraged to review and adapt these best practice advice points on preventing and managing asthma exacerbations to their local practice patterns to enhance asthma care within their practice.

Japanese Patients with Severe Asthma Identified as Responders to Omalizumab Treatment at 2 Years Based on the GETE Score Continued Treatment for an Extended Period

Purpose

Omalizumab, the anti-IgE monoclonal antibody used to treat severe asthma, reduces asthma exacerbations, hospitalizations, and corticosteroid use. Although allergic asthma is a therapeutic target of omalizumab, omalizumab is not effective in all patients with severe allergic asthma and is not always available for long-term use. We retrospectively investigated factors related to long-term (≥2 years) use of omalizumab for severe asthma.

Patients and Methods

Of the 116 patients treated with omalizumab for severe asthma at our hospital between 2009 and 2017, 82 were included in this retrospective analysis. Thirty-four were excluded because of adverse events, financial difficulties, or hospital transfers. The number of asthma exacerbations, unscheduled visits, corticosteroid doses, asthma control test scores, pulmonary function test results, and fractional exhaled nitric oxide levels were evaluated.

Results

The median age of the study population was 58 years, with 66% female and 26% taking regular oral corticosteroids. After 2 years of treatment, 52 responders were identified using the global evaluation of treatment effectiveness (GETE) score. Improvements in asthma control test scores, airflow limitation, exacerbations, and oral corticosteroid use were observed in the responders. Multivariate analysis revealed that a peripheral blood eosinophil count of ≥200 or a perennial antigen-specific IgE antibody positivity of ≥2 predicted a response at the 2-year mark. However, Kaplan-Meier analysis demonstrated that neither high eosinophil counts nor perennial antigen-specific IgE positivity influenced the prolongation of treatment beyond 2 years, and responders at 2 years underwent omalizumab treatment for a significantly longer period than non-responders (HR = 9.89, p < 0.001), with GETE at 2 years being the only predictor of long-term omalizumab use.

Conclusion

In this retrospective study the GETE after 2 years of omalizumab therapy emerged as the most meaningful predictor of the long-term effectiveness of omalizumab treatment in patients with severe asthma, highlighting the benefits of prolonged therapy in certain populations. These findings may guide future therapeutic strategies for severe asthma.

Prevalence and characteristics of dysfunctional breathing in patients with asthma in the Japanese population

BACKGROUND

Dysfunctional breathing (DB) is a major asthma comorbidity; however, it is not well recognized in Japan. Moreover, it has rarely been reported in the asthma population, and its clinical characteristics are unclear. We aimed to clarify the clinical characteristics of DB as a comorbidity in patients with asthma in Japan. Questionnaire surveys were conducted among patients with asthma at medical facilities in three regions of Japan (Niigata, Kumamoto, and Tokyo).

METHODS

This cross-sectional questionnaire survey targeting patients with asthma who had regularly visited medical institutions and their doctors was conducted from September to November 2021. The questionnaire addressed the control status and method of treatment. The diagnosis of DB was evaluated using the Nijmegen questionnaire (NQ).

RESULTS

There were 2087 eligible participants. Based on their NQ scores, 217 patients were classified into the DB group (NQ ≥ 19). There were significant differences with respect to sex, disease duration, Asthma Control Test (ACT) scores, Patient Health Questionnaire-9 (PHQ-9) scores, type-2 biomarkers, pulmonary function indices, treatment methods, severity, and asthma exacerbations in the previous year between the DB and non-DB groups. In the multivariate analysis, there were significant differences in sex, disease duration (≥15 y), ACT scores (<20), and PHQ-9 scores (≥10). The cluster analysis of cases with DB classified the population into four clusters.

CONCLUSIONS

The asthma population with DB exhibited several characteristics, including depression and poorly controlled asthma. Further large-scale interventional investigations with longer follow-up periods are necessary to verify these findings.

The association between the use of Shoseiryuto and reduction in intravenous steroid dose among adult inpatients with asthma exacerbation: A national database study in Japan

BACKGROUND

Shoseiryuto, a Japanese herbal medicine, is used to treat asthma exacerbation; however, the effect of Shoseiryuto in a clinical setting is yet to be elucidated. We aimed to examine the effect of Shoseiryuto for inpatients with asthma exacerbation and the reduction in the total amount of intravenous steroids administered during hospitalization, in-hospital mortality, and length of hospital stay using a national inpatient database in Japan.

METHODS

Using data from the Japanese Diagnosis Procedure Combination database (July 2010-March 2022), we identified patients aged ≥18 years who were admitted due to asthma exacerbation. We performed propensity score overlap weighting analyses to estimate the in-hospital outcomes between patients who received Shoseiryuto within 3 days of admission (Shoseiryuto group) and those who did not (control group). The outcomes measured were the dose of intravenous steroids administered, in-hospital mortality, and length of hospital stay for patients alive at discharge.

RESULTS

Among 51,459 eligible patients, 131 received Shoseiryuto. In the propensity score overlap weighting analyses, the use of Shoseiryuto was significantly associated with reduced amount of intravenous steroid during hospitalization (67 mg versus 149 mg, 95% confidence interval [CI]: -68 to -92), but was not associated with reduced in-hospital mortality (1.9% versus 3.5%, 95% CI: -28 to 25) or length of hospital stay (17.3 days versus 18.3 days, 95% CI: -4.2 to 2.4).

CONCLUSIONS

The use Shoseiryuto in inpatients with asthma exacerbation was significantly associated with reduced steroid use. Our results elucidated the potential role of Shoseiryuto in the treatment of asthma exacerbation.

Network pharmacology and experimental verification unraveled the mechanism of Bailing Capsule against asthma

Asthma is a serious public health challenge around the world. Recent studies into traditional Chinese medicine preparations for asthma have yielded promising findings regarding Bailing Capsule's potential in bronchial asthma prevention and treatment. This study aims to initially clarify the potential mechanism of Bailing Capsule in the treatment of asthma using network pharmacology and in vitro experimental approaches. Network pharmacology was adopted to detect the active ingredients of Bailing Capsule via Traditional Chinese Medicine Systems Pharmacology Database, and the key targets and signaling pathways in the treatment of asthma were predicted. Docking and molecular dynamics simulations were conducted to verify the most important interactions formed by these probes within different regions of the binding site. The predicted targets were validated in lipopolysaccharide-induced 16HBE cell experiment. Seven active ingredients were screened from Bailing Capsule, 294 overlapping targets matched with asthma were considered potential therapeutic targets, such as SRC, TP53, STAT3, and E1A binding protein P300. The main functional pathways involving these key targets include phosphatidylinositol 3-kinase/protein kinase B, mitogen-activated protein kinase, renin-angiotensin system and other signaling pathways, which were mainly involved in the inflammatory response, apoptosis, and xenobiotic stimulus. Moreover, molecular docking showed that Cerevisterol have higher affinity for SRC, TP53, STAT3, and E1A binding protein P300 than other main active components, which is close to the docking results of the co-crystallized ligands to proteins. Consequently, Cerevisterol was selected for molecular dynamics simulation and the results show that Cerevisterol can bind most tightly to SRC, TP53, and STAT3. Bailing Capsule can promote the growth of 16HBE cell, reduce the production of IL-4, TNF-α and IL-6, and down-regulate the levels of SRC and STAT3 mRNA. This study preliminarily reveals the potential mechanism of Bailing Capsule against asthma with the aid of network pharmacology and in vitro cell experiment, which provided reference and guidance for in-depth research and clinical application.

Epidemiology and Risk Factors of Eosinophilic Esophagitis in Japan: A Population-Based Study

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) has been increasingly diagnosed globally. However, there have been few general population-based studies in Asia. The aim of this study was to investigate EoE epidemiology in the Japanese general population.

METHODS

We analyzed an employer-based health insurance claim database from January 2005 to September 2022. EoE cases were identified on the basis of the International Statistical Classification of Diseases and Health-related Problems, 10th Revision code, K20.0. We calculated the incidence and prevalence of EoE using Poisson regression and binomial distribution, respectively. Using 10 matched controls for each EoE case, a nested case-control study was performed to identify potential risk factors for EoE.

RESULTS

Of 15,200,895 individuals, 1010 EoE cases were identified. The incidence and prevalence of EoE were 2.82 (95% confidence interval [CI], 2.44-3.26) per 100,000 person-years and 10.68 (95% CI, 10.01-11.37) per 100,000 people in 2022, nearly 3 and 8 times as high as those in 2017, respectively. Smoking was associated with decreased risk of EoE (odds ratio [OR], 0.45, 0.36-0.56, P < .001), whereas alcohol consumption (OR, 1.51, 1.21-1.88, P < .001) was associated with increased risk of EoE along with several allergic conditions and psychiatric disorders. EoE was not related to either body mass index or lifestyle-related diseases such as hypertension, diabetes mellitus, hyperuricemia, and dyslipidemia.

CONCLUSIONS

The incidence and prevalence of EoE in Japan have steadily increased over the past 2 decades. Nevertheless, EoE remains less common in Japan compared with the United States and Western Europe. Factors contributing to the epidemiology of EoE on a global basis may improve our understanding of the contribution of genetic and environmental risk factors.

Efficacy and safety of moxibustion as a complementary and alternative therapy for asthma: A systematic review and meta-analysis

OBJECTIVE

This systematic review of randomized controlled trials (RCTs) aimed to evaluate the efficacy and safety of moxibustion as a complementary or alternative treatment for asthma.

METHODS

Seven databases were searched up to June 23, 2024, to identify RCTs assessing moxibustion for bronchial asthma. The outcomes of interest included response to treatment, asthma control, quality of life, lung function, immunological indicators, and incidence of adverse events (AEs). The treatment effects were measured by proportional odds ratios or mean differences with 95% confidence intervals.

RESULTS

Thirty-seven RCTs (n = 2,879) were included. Moderate- to very low-quality evidence showed that compared with anti-asthmatic drugs alone, moxibustion plus anti-asthmatic drugs led to a significantly better response and greater increases in lung function, asthma control, and IgE levels. However, the combination therapy had no effect on children's quality of life. In the active comparisons, moxibustion resulted in a superior response to treatment and a greater improvement in asthma control and had comparable effects on lung function, quality of life, and IgE levels compared with anti-asthmatic drugs. The effects of moxibustion on the proportions of CD4 + and CD8 + T cells and the eosinophil count were inconsistent between the add-on and active comparisons. All reported AEs related to moxibustion were mild.

CONCLUSIONS

Moxibustion, as an adjunctive treatment or used alone, may improve the response to treatment, lung function, asthma control, and IgE levels in patients with asthma with good safety. Its effects on children's quality of life and immune cell levels remain uncertain.

Prevalence and clinical relevance of comorbid pertussis infection in adult patients with asthma: A prospective, cross-sectional study

BACKGROUND

Viral or atypical bacterial respiratory infections are involved in the new development and the pathogenesis of asthma. Though an association between pertussis and asthma has been expected, few studies have reported it consistently. We assessed the prevalence and clinical relevance of pertussis infection in adult patients with asthma.

METHODS

In this prospective, cross-sectional study, newly referred, adult patients with asthma (n = 107) and with non-asthmatic subacute/chronic cough (n = 31) were enrolled. The prevalence of pertussis in patients with asthma and in those with non-asthmatic subacute/chronic cough was assessed. Next, the prevalence of newly diagnosed asthma was compared between asthmatic patients with and without pertussis. Finally, demographic characteristics of patients, blood test results, pulmonary function test results, and questionnaire scores were compared between the two patient groups.

RESULTS

The prevalence of pertussis infection was significantly higher in patients with asthma than in those with non-asthmatic subacute/chronic cough (36% vs 10%; P = 0.004). The prevalence of newly diagnosed asthma was significantly higher in asthmatic patients with pertussis than in those without (74.4% vs 50.0%; P = 0.014). The physical, psychological, and total scores of the Leicester Cough Questionnaire were significantly lower in asthmatic patients with pertussis than in those without (all P < 0.05). The acid-reflux, dyspeptic, and total scores of the Frequency Scale for Symptoms of Gastroesophageal Reflux Disease (GERD) (FSSG) were significantly higher in asthmatic patients with pertussis than in those without (all P ≤ 0.05). The FSSG acid-reflux score was negatively correlated with the cough-specific quality of life (QOL) score only in asthmatic patients with pertussis (rho = -0.68, P = 0.01).

CONCLUSIONS

The prevalence of pertussis infection was significantly higher in adult patients with asthma than in those with non-asthmatic subacute/chronic cough. In patients with asthma, comorbid pertussis infection may play a role in newly diagnosed asthma and may contribute to impaired cough-specific QOL partly due to worsening acid-reflux symptoms of GERD.

Downregulation of otulin induces inflammasome activation in neutrophilic asthma

BACKGROUND

Neutrophilic asthma (NA) is a severe asthma phenotype associated with steroid resistance and IL-1β overproduction; however, the exact mechanism remains unclear. Moreover, the dysfunction of TNF-α signaling pathway, a regulator of IL-1β production, was associated with the deficiency of ovarian tumor protease deubiquitinase with linear linkage specificity (otulin) in autoimmune patients.

OBJECTIVE

We hypothesized that otulin downregulation in macrophages (Mφ) could trigger Mφ activation via the nucleotide-binding domain, leucine-rich repeat, and pyrin domain-containing protein 3 (NLRP3) inflammasome signaling pathway.

METHODS

We assessed the expressions of otulin in blood monocyte subsets from NA patients and in alveolar Mφ from NA mice. Additionally, we evaluated the functional consequences of otulin deficiency in bone marrow-derived Mφ. The effects of inhibiting receptor-interacting protein kinase (RIPK)-1 and RIPK-3 on neutrophils and group 3 innate lymphoid cells (ILC3s) were assessed in vitro and in vivo.

RESULTS

When comparing nonclassical monocytes, a significant downregulation of otulin in the intracellular components was observed in NA patients compared to healthy controls (P = .005). Moreover, isolated alveolar Mφ from the NA mice exhibited lower otulin expression compared to those from control mice. After otulin knockdown in bone marrow-derived Mφ, we observed spontaneous IL-1β production depending on NLRP3 inflammasome. Moreover, the infiltrated neutrophils and ILC3s were significantly decreased by combined treatment of RIPK-1 and RIPK-3 inhibitors through blocking IL-1β release in NA.

CONCLUSIONS

IL-1β overproduction caused by a deficiency of otulin, an upstream triggering factor, could be a promising diagnostic and therapeutic target for NA.

Cellular senescence-Related genes define the immune microenvironment and molecular characteristics in severe asthma patients

Recent studies have shown that cellular senescence is involved in the pathogenesis of severe asthma (SA). The objective of this study was to investigate the role of cellular senescence-related genes (CSGs) in the pathogenesis of SA. Here, 54 differentially expressed CSGs were identified in SA patients compared to healthy control individuals. Among the 54 differentially expressed CSGs, 3 CSGs (ETS2, ETS1 and AURKA) were screened using the LASSO regression analysis and logistic regression analysis to establish the CSG-based prediction model to predict severe asthma. Moreover, we found that the protein expression levels of ETS2, ETS1 and AURKA were increased in the severe asthma mouse model. Then, two distinct senescence subtypes of SA with distinct immune microenvironments and molecular biological characteristics were identified. Cluster 1 was characterized by increased infiltration of immature dendritic cells, regulatory T cells, and other cells. Cluster 2 was characterized by increased infiltration levels of eosinophils, neutrophils, and other cells. The molecular biological characteristics of Cluster 1 included aerobic respiration and oxidative phosphorylation, whereas the molecular biological characteristics of Cluster 2 included activation of the immune response and immune receptor activity. Then, we established an Random Forest model to predict the senescence subtypes of SA to guide treatment. Finally, potential drugs were searched for each senescence subgroup of SA patients via the Connectivity Map database. A peroxisome proliferator-activated receptor agonist may be a potential therapeutic drug for patients in Cluster 1, whereas a tachykinin antagonist may be a potential therapeutic drug for patients in Cluster 2. In summary, CSGs are likely involved in the pathogenesis of SA, which may lead to new therapeutic options for SA patients.

APPaRENT 3: Asthma Patients' and Physicians' Perspectives on the Burden and Management of Asthma in Seven Countries

INTRODUCTION

Asthma management is strongly dependent on physician and patient beliefs and perceptions about the disease and its long-term treatment. The APPaRENT 3 study was conducted to explore factors influencing treatment choice and to understand patients' and physicians' attitudes and perspectives on the use of controller inhalers in regular versus flexible dosing for asthma management.

METHODS

This cross-sectional survey of patients with asthma and treating physicians was conducted in seven countries: Indonesia, Malaysia, Philippines, Thailand, Vietnam (patient survey only), Saudi Arabia, and the United Arab Emirates. Assessment was carried out through an online/face-to-face questionnaire, where patients' viewpoints were focused on their attitudes and beliefs about asthma and treatment adherence, whereas physicians' viewpoints were gathered on their attitudes and beliefs about asthma management, knowledge of and adherence to asthma treatment guidelines, and asthma treatment regimens.

RESULTS

Overall, 1400 patients (mean age, 34 years) and 599 physicians (mean age, 43 years) were included in the survey. Physicians similarly prioritised symptom control (39%) and exacerbation reduction (40%) in moderate asthma, whereas patients prioritised symptom control (41%) over exacerbation reduction (22%). Although both groups (physicians, 86%; patients, 84%) perceived asthma as well-controlled, poor management was evident based on Asthma Control Test (ACT) scores (mean, 15.7; standard deviation, 4.14; 82% had an ACT score < 20) and high symptom burden (39% reported nighttime awakenings or early mornings ≥ 2 nights/week). Most patients (76%) with moderate asthma were prescribed regular dosing, with the most common treatment being inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) with as-needed inhaled short-acting β2-agonist (SABA; 20%). Among patients on maintenance and reliever therapy, 93% of patients received a separate inhaled reliever.

CONCLUSIONS

Despite high symptom burden, patients overestimated their level of asthma control. Physicians prioritised controlling symptoms and reducing exacerbations as treatment goals for moderate asthma, often prescribing regular dosing with ICS/LABA with as-needed inhaled SABA.

Novel insights into the anti-asthmatic effect of Raphanus sativus L. (Raphani Semen): Targeting immune cells, inflammatory pathways and oxidative stress markers

ETHNOPHARMACOLOGICAL RELEVANCE

Raphanus sativus L. is a well-known medicinal plant with traditional therapeutic applications in various common ailments including inflammation and asthma.

AIMS OF THE STUDY

This study aimed to evaluate the chemical composition and anti-asthmatic potential of the hydro-methanolic extract of the leaves of R. sativus L. (Rs.Cr) using various in vitro and in vivo investigations.

MATERIALS AND METHODS

The Rs.Cr was subjected to preliminary phytochemical analysis and HPLC profiling. The safety was assessed through oral acute toxicity tests in mice. The antiasthmatic effect of the extract was studied using milk-induced leukocytosis and ovalbumin (OVA)-induced allergic asthma models established in mice. While mast cell degranulation and passive paw anaphylaxis models were established in rats. Moreover, effect of the extract was studied on various oxidative and inflammatory makers. The antioxidant effect of the extract was also studied by in vitro DPPH method.

RESULTS

The HPLC profiling of Rs.Cr showed the presence of important polyphenols in a considerable quantity. In toxicity evaluation, Rs.Cr showed no sign of morbidity or mortality with LD50 < 2000 mg/kg. The extract revealed significant mast cell disruption in a dose-dependent manner compared to the intoxicated group. Similarly, treatment with Rs.Cr and dexamethasone significantly (p < 0.001) reduced paw edema volume. Subcutaneous injection of milk at a dose of 4 mL/kg, after 24 h of its administration, showed an increase in the leukocyte count in the intoxicated group. Similarly, mice treated with dexamethasone and Rs.Cr respectively showed a significant decrease in leukocytes and eosinophils count in the ovalbumin-induced allergic asthma model. The extract presented a significant (p˂0.001) alleviative effect on the levels of SOD and GSH, MDA, IL-4, IL-5, and IL-13 in a dose-dependent manner as compared to the intoxicated group. Furthermore, the histological evaluation also revealed a notable decrease in inflammatory and goblet cell count with reduced mucus production.

CONCLUSION

The current study highlights mechanism-based novel insights into the anti-asthmatic potential of R. sativus that also strongly supports its traditional use in asthma.

Changes in fractional exhaled nitric oxide, forced expiratory volume in one second, and forced oscillation technique parameters over three years in adults with bronchial asthma managed under Yokohama Seibu Hospital's coordinated care system

BACKGROUND

In western Yokohama, our hospital and primary care clinics manage adults with asthma via a coordinated care system. We investigated the changes in the fractional expired nitric oxide (FeNO), forced expiratory volume in 1 second (FEV1), and forced oscillation technique (FOT) parameters over 3 years in a cohort of patients in our collaborative system.

METHODS

From 288 adults with well controlled asthma managed under the Yokohama Seibu Hospital coordinated care system between January 2009 and May 2018, we selected 99 subjects to undergo spirometry, FeNO and FOT testing over 3 years and analyzed the changes in these parameters.

RESULTS

Of the 99 patients enrolled, 17 (17.2%) experienced at least one exacerbation (insufficiently controlled (IC)), whereas, 82 (82.8%) remained in well controlled during the 3-year study period. Of well-controlled patients, 54 patients (54.5%) met the criteria for clinical remission under treatment (CR); the remaining 28 patients did not meet the CR criteria (WC). There were no differences in FeNO, FEV1, or FOT parameters at baseline among the IC, WC, and CR groups. The levels of FEV1 decreased gradually, whereas the levels of FeNO decreased significantly over 3 years. The levels of percent predicted FEV1 (%FEV1) significantly increased. We also observed significant improvement in FOT parameters; reactance at 5 Hz (R5), resonant frequency (Fres), and integral of reactance up to the resonant frequency (AX). The CR group demonstrated significant relationships between the change in FeNO and the change in FEV1 and between the change in FEV1 and the change in FOT parameters. No significant correlations emerged in the IC or WC group.

CONCLUSION

The decrease in FeNO and increase in %FEV1, we observed in all study participants suggest that the coordinated care system model benefits patients with asthma. Although it is difficult to predict at baseline which patients will experience an exacerbation, monitoring changes in FeNO and FEV1 is useful in managing patients with asthma. Furthermore, monitoring changes in R5, Fres, and AX via forced oscillation technique testing is useful for detecting airflow limitation.

Changes in disease burden and treatment reality in patients with severe asthma

BACKGROUND

Biologics are clinically available for patients with severe asthma, but changes in asthma control over time are unknown. We examined changes in disease burden and treatment in severe asthma patients.

METHODS

This retrospective study used a Japanese health insurance database (Cross Fact) and included patients aged ≥16 years treated continuously with an inhaled corticosteroid (ICS) for a diagnosis of asthma in each calendar year from 2015 to 2019. Severe asthma was defined as annual use of high-dose ICS plus one or more asthma controller medications four or more times, oral corticosteroids for ≥183 days, or biologics for ≥16 weeks. Changes in asthma exacerbations, prescriptions, and laboratory testing were examined.

RESULTS

Demographic characteristics were similar throughout the study. The number and proportion of patients with severe asthma among those with asthma increased (2724; 15.3% in 2015 vs 4485; 19.0% in 2019). The proportion of severe asthma patients with two or more asthma exacerbations decreased from 24.4% to 21.5%. Odds ratios (95% confidence interval) of ≥2 asthma exacerbations in each year compared with 2015 were 0.96 (0.85-1.08) in 2016 and 0.86 (0.76-0.97) in 2017, with significant reductions observed in subsequent years. Short-acting beta agonists and oral corticosteroid prescriptions for asthma exacerbations decreased and long-acting muscarinic antagonist and biologic prescriptions for maintenance treatment increased.

CONCLUSIONS

This study showed improvements in disease burden and treatment in severe asthma patients. There remains an unmet medical need for patients with severe asthma, given the proportion who continue to have asthma exacerbations.

Association of endometriosis with asthma: a study of the NHANES database in 1999-2006

OBJECTIVE

Asthma is a chronic inflammatory disease of the airways with a gender differences in the prevalence after puberty. Recent studies have reported a relationship between asthma and endometriosis, possibly related to the immune response mechanisms, but the evidences are limited and inconsistent. Herein, this research aimed to investigate the association of endometriosis with asthma based on the representative population in the United States (U.S.) to provide some reference for further exploration on mechanism of gender difference in asthma.

METHODS

In this cross-sectional study, data of women aged ≥ 20 years old were extracted from the National Health and Nutrition Examination Survey (NHANES) database in 1999-2006. Weighted univariate and multivariate logistic regression analyses were utilized to explore the association of endometriosis with asthma. The multivariate models adjusted for covariates including age, race, education level, marital status, poverty income ratio (PIR), body mass index (BMI), waist circumference, smoking, estrogen and progesterone hormones use, uterine fibroids, at least one ovary removed, and birth control pills intake. The evaluation indexes were odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses of age, race, BMI, and pregnancy history were also performed.

RESULTS

Among 5,556 eligible women, 782 had asthma, and 380 had endometriosis. The average age of participants was 37.19 years old, and more than half of them were non-Hispanic White (68.44%). After adjusting for covariates, endometriosis was associated with higher odds of asthma compared with non-endometriosis [OR = 1.48, 95%CI: (1.10-1.99)]. This relationship was also found in 40-49 years old [OR = 2.26, 95%CI: (1.21-4.23)], BMI of 25-29.9 kg/m2 [OR = 2.87, 95%CI: (1.52-5.44)], and pregnancy history [OR = 1.44, 95%CI: (1.01-2.06)] subgroups.

CONCLUSION

Endometriosis had a positive association with asthma in adult women. Females aged 40-49 years old, with BMI of 25-29.9 kg/m2 and had a history of pregnancy should take care about monitoring endometriosis to reduce the potential risk of asthma. Further studies are still needed to clarify the causal association between endometriosis and asthma.

The primary ciliary dyskinesia-related genetic risk score is associated with susceptibility to adult-onset asthma

BACKGROUND

Disturbance of mucociliary clearance is an important factor in the pathogenesis of asthma. We hypothesized that common variants in genes responsible for ciliary function may contribute to the development of asthma with certain phenotypes.

METHODS

Three independent adult Japanese populations (including a total of 1,158 patients with asthma and 2,203 non-asthmatic healthy participants) were studied. First, based on the ClinVar database (https://www.ncbi.nlm.nih.gov/clinvar/), we selected 12 common single-nucleotide polymorphisms (SNPs) with molecular consequences (missense, nonsense, and 3'-untranslated region mutation) in 5 primary ciliary dyskinesia (PCD)-related genes and calculated a PCD-genetic risk score (GRS) as a cumulative effect of these PCD-related genes. Second, we performed a two-step cluster analysis using 3 variables, including PCD-GRS, forced expiratory volume in 1 second (%predicted FEV1), and age of asthma onset.

RESULTS

Compared to adult asthma clusters with an average PCD-GRS, clusters with high and low PCD-GRS had similar overall characteristics: adult-onset, female predominance, preserved lung function, and fewer features of type 2 immunity as determined by IgE reactivity and blood eosinophil counts. The allele frequency of rs1530496, a SNP representing an expression quantitative trait locus (eQTL) of DNAH5 in the lung, showed the largest statistically significant difference between the PCD-GRS-High and PCD-GRS-Low asthma clusters (p = 1.4 x 10-15).

CONCLUSION

Genes associated with PCD, particularly the common SNPs associated with abnormal expression of DNAH5, may have a certain influence on the development of adult-onset asthma, perhaps through impaired mucociliary clearance.

Associations of serum carotenoids with asthma and mortality in the US adults

Objective

This study was to investigate the association between serum carotenoid levels and the prevalence of asthma, as well as the relationship between serum carotenoid levels and the risk of mortality among individuals with asthma.

Methods

Data on five serum carotenoids (α-carotene, β-carotene, β-cryptoxanthin, lutein/zeaxanthin, and lycopene) were obtained from the National Health and Nutrition Examination Survey (NHANES) 2001-2006. Mortality data was extracted from the pertinent mortality records within the NHANES database, up to December 31, 2019. Logistic regression analysis was employed to investigate the association between serum carotenoid concentrations and asthma prevalence. Cox proportional hazards models were used to investigate the connection between serum carotenoids and mortality rates in asthma individuals.

Results

Among the study population, 1569 (12.63 %) individuals were diagnosed with asthma, while 25.01 % of asthma patients died within a median follow-up duration of 15.5 (13.8-17.3) years. After controlling for all other variables, greater serum levels of certain carotenoids, such asα-carotene, β-carotene, β-cryptoxanthin, and lutein/zeaxanthin, were found to be substantially linked with a decreased prevalence of asthma. Furthermore, persons with asthma who had greater levels of serum carotenoids in the fourth quartile had a significantly lower risk of all-cause death compared to those in the first quartile. Specifically, the presence of α-carotene, β-cryptoxanthin, and lutein/zeaxanthin was associated with reductions in all-cause mortality by 45 % (HR = 0.55 [0.36-0.84], Ptrend = 0.002), 38 % (HR = 0.62 [0.42-0.92], Ptrend = 0.004), and 45 % (HR = 0.55 [0.41-0.73], Ptrend<0.001), respectively. The above relationships are mostly linear and remain robust in sensitivity analyses.

Conclusions

Our findings indicate that higher serum carotenoids are related with a reduced likelihood of mortality in asthmatic individuals.

Real-World Safety and Effectiveness of Benralizumab in Japanese Patients with Severe Asthma: A Multicenter Prospective Observational Study

Introduction

This study aimed to demonstrate whether benralizumab maintained the safety and effectiveness profiles established in randomized controlled trials among all patients with severe uncontrolled asthma initially prescribed benralizumab in the real-world setting in Japan.

Methods

This was a prospective, observational, multicenter post-marketing study (ClinicalTrial.gov, NCT03588546). The safety and tolerability of benralizumab over 1 year were assessed by the incidence of adverse events (AEs), serious AEs, adverse drug reactions (ADRs), and serious ADRs. Patient background characteristics indicating a more frequent onset of ADRs with benralizumab were explored. The main effectiveness assessment was the change in Asthma Control Questionnaire-5 (ACQ-5) score from baseline. Patients with baseline ACQ-5 scores ≥1.5 were defined as having severe uncontrolled asthma.

Results

In total, 632 patients were evaluated for safety and 274 for effectiveness; 139 patients were included in the severe uncontrolled asthma subgroup. ADRs were reported in 12.7% and serious AEs in 13.0% of patients. Serious infections occurred in 3.8%, serious hypersensitivity in 0.3%, and malignancy in 0.3% of patients. No helminthic infections occurred. In the effectiveness population, benralizumab improved the mean (standard deviation [95% confidence interval]) ACQ-5 score by -1.16 (1.40 [-1.36, -0.96]) from baseline; forced expiratory volume in 1 second by 0.151 (0.440 [0.09, 0.21]) L; and Mini-Asthma Quality of Life questionnaire score by 1.16 (1.29 [0.94, 1.38]) at the last observation. The annual asthma exacerbation rate was 0.42. A greater ACQ-5 score improvement was observed among patients with eosinophilic asthma characteristics.

Conclusion

No new safety concerns were raised, and patients experienced benefits consistent with previous studies of benralizumab, thus supporting the use of benralizumab for the add-on maintenance treatment of patients with eosinophilic severe uncontrolled asthma.

Exacerbation rates in Japanese patients with obstructive lung disease: A subanalysis of the prospective, observational NOVELTY study

BACKGROUND

Although clinical trials including asthma and COPD patients have revealed much about exacerbation frequencies, most studies are limited in that they recruited patients only with a clear diagnosis of one disease or the other, based on conventional diagnostic criteria, which may exclude many real-world patients with mixed symptoms.

METHODS

NOVELTY is a global prospective observational study of patients with asthma and/or COPD from real-world practice. In this subanalysis, we compared patient characteristics of obstructive pulmonary diseases between the Japanese population (n = 820) and the overall population excluding Japanese patients (n = 10,406).

RESULTS

The Japanese population had fewer exacerbations than the overall population across most of the physician-assessed disease severities and all diagnoses. The difference in exacerbation frequencies was more prominent in patients with COPD and asthma + COPD. The Japanese population was older, had higher former smoking rates, lower BMI, fewer respiratory symptoms, and better health-related quality of life compared with the overall population across all diagnoses.

CONCLUSIONS

We clarified differences in patient characteristics among patients with asthma and/or COPD in Japan compared with non-Japanese patients. Importantly, we found that Japanese patients with asthma and/or COPD had significantly fewer exacerbations compared with patients overall. The results from our study may contribute to the development of precision medicine and guidelines specific to Japan.

Dual biologics for severe asthma and atopic dermatitis: Synopsis of two cases and literature review

The efficacy and safety of the combination of biologic therapies remain unclear with an ineffective and insufficient single biologic for managing asthma. Herein, we report two cases using dual biologics for severe asthma and atopic dermatitis. A 52-year-old male patient who received dupilumab and mepolizumab, benralizumab, or tezepelumab, followed by bronchial thermoplasty, and a 41-year-old male patient who received dupilumab and omalizumab, both experienced improved asthma and atopic dermatitis. To date, 38 cases are using dual biologics for severe asthma. The success rate was 84%, with no major adverse effects. We report the first case of severe asthma receiving dual biologics with tezepelumab and furthermore bronchial thermoplasty, and comprehensive literature review on dual biologics. Dual biologics may be an effective treatment method for severe asthma, requiring further investigation.

Pattern recognition of forced oscillation technique measurement results using deep learning can identify asthmatic patients more accurately than setting reference ranges

No official clinical reference values have been established for MostGraph, which measures total respiratory resistance and reactance using the forced oscillation technique, complicating result interpretation. This study aimed to establish a reference range for MostGraph measurements and examine its usefulness in discriminating participants with asthma from controls (participants without any respiratory diseases). The study also aimed to investigate the effectiveness of deep learning in discriminating between the two aforementioned groups. To establish reference ranges, the MostGraph measurements of healthy controls (n = 215) were power-transformed to distribute the data more normally. After inverse transformation, the mean ± standard deviation × 2 of the transformed values were used to establish the reference ranges. The number of measured items outside the reference ranges was evaluated to discriminate patients with asthma (n = 941) from controls. Additionally, MostGraph measurements were evaluated using deep learning. Although reference ranges were established, patients with asthma could not be discriminated from controls. However, with deep learning, we could discriminate between the two groups with 78% accuracy. Therefore, deep learning, which considers multiple measurements as a whole, was more effective in interpreting MostGraph measurement results than use of reference ranges, which considers each result individually.

Predicting the duration of action of β2-adrenergic receptor agonists: Ligand and structure-based approaches

Agonists of the β2 adrenergic receptor (ADRB2) are an important class of medications used for the treatment of respiratory diseases. They can be classified as short acting (SABA) or long acting (LABA), with each class playing a different role in patient management. In this work we explored both ligand-based and structure-based high-throughput approaches to classify β2-agonists based on their duration of action. A completely in-silico prediction pipeline using an AlphaFold generated structure was used for structure-based modelling. Our analysis identified the ligands' 3D structure and lipophilicity as the most relevant features for the prediction of the duration of action. Interaction-based methods were also able to select ligands with the desired duration of action, incorporating the bias directly in the structure-based drug discovery pipeline without the need for further processing.

Relationship Between Asthma Control Status and Health-Related Quality of Life in Japan: A Cross-Sectional Mixed-Methods Study

INTRODUCTION

There is limited information regarding multidimensional relationships between asthma control and health-related quality of life (HRQoL), work productivity, and asthma symptom burden in Japan. Furthermore, systematic qualitative investigations about asthma burden have not been performed.

METHODS

This cross-sectional, mixed-methods study included Japanese patients (≥ 20 years) with asthma adherent to inhaled corticosteroids/long-acting β2-agonists (ICS/LABA). The primary endpoint was impact of asthma on HRQoL, measured using the Asthma Health Questionnaire-33 (AHQ-33). Secondary endpoints were cough burden (Japanese-adapted Leicester Cough Questionnaire [J-LCQ]) and impact of asthma on work/activities (asthma-specific Work Productivity and Activity Impairment Questionnaire [WPAI:Asthma]). Quantitative data were assessed for the overall population and for well-controlled (WC) and not well-controlled (NWC) asthma subgroups. Qualitative verbal interviews further assessed the impact of NWC asthma on patients' HRQoL; emergent themes were extracted using thematic analyses.

RESULTS

Of 454 patients, 45.2% (n = 205) had NWC asthma. Patients with NWC asthma had significantly worse asthma- and cough-related HRQoL across all AHQ-33 and J-LCQ domains and significantly greater work and activity impairment versus patients with WC asthma, across all assessed WPAI:Asthma domains. AHQ-33 total score was highly correlated with J-LCQ total and domain scores (r = - 0.8132 to r = - 0.7407). Nine themes emerged from qualitative interviews and confirmed that patients with NWC asthma had considerable HRQoL impairment due to asthma symptoms.

CONCLUSIONS

Patients with NWC asthma had higher symptom burden and worse HRQoL than patients with WC asthma, despite ICS/LABA adherence. Cough burden correlated with HRQoL, suggesting cough may be one of the key markers to inform treatment strategy for patients with asthma.

Exposure to organophosphate flame retardants and plasticizers is positively associated with wheeze and FeNO and eosinophil levels among school-aged children: The Hokkaido study

Exposure to organophosphate flame retardants and plasticizers (PFRs) increases the risk of asthma and allergies. However, little is known about its association with type 2 inflammation (T2) biomarkers used in the management of allergies. The study investigated associations among urinary PFR metabolite concentrations, allergic symptoms, and T2 biomarkers. The data and samples were collected between 2017 and 2020, including school children (n = 427) aged 9-12 years living in Sapporo City, Japan, among the participants of "The Hokkaido Study on Environment and Children's Health." Thirteen urinary PFR metabolites were measured by LC-MS/MS. Allergic symptoms were assessed using the International Study of Asthma and Allergies in Childhood questionnaire. For T2 biomarkers, the peripheral blood eosinophil counts, fraction of exhaled nitric oxide level (FeNO), and serum total immunoglobulin E level were measured. Multiple logistic regression analysis, quantile-based g-computation (qg-computation), and Bayesian kernel machine regression (BKMR) were used to examine the associations between the health outcomes of the individual PFRs and the PFR mixtures. The highest concentration of PFR was Σtris(1-chloro-isopropyl) phosphates (ΣTCIPP) (Median:1.20 nmol/L). Tris(1,3-dichloro-2-propyl) phosphate (TDCIPP) was significantly associated with a high odds ratio (OR, 95%CI:1.36, 1.07-1.72) for wheeze. TDCIPP (OR, 95%CI:1.19, 1.02-1.38), Σtriphenyl phosphate (ΣTPHP) (OR, 95%CI:1.81, 1.40-2.37), and Σtris(2-butoxyethyl) phosphate (ΣTBOEP) (OR, 95%:1.40, 1.13-1.74) were significantly associated with increased odds of FeNO (≥35 ppb). ΣTPHP (OR, 95%CI:1.44, 1.15-1.83) was significantly associated with high eosinophil counts (≥300/μL). For the PFR mixtures, a one-quartile increase in all PFRs (OR, 95%CI:1.48, 1.18-1.86) was significantly associated with high FeNO (≥35 ppb) in the qg-computation model. The PFR mixture was positively associated with high FeNO (≥35 ppb) and eosinophil counts (≥300/μL) in the BKMR models. These results may suggest that exposure to PFRs increases the probability of asthma, allergies, and T2 inflammation.

Addressing therapeutic inertia for asthma biologics: Lessons from the KOFU study

Despite evidence-based guidelines and the availability of five biologics in Japan to treat severe asthma, approximately one-third of patients with severe asthma continue to have uncontrolled disease. This lack of appropriate evidence-based treatment is a complex issue resulting from therapeutic inertia, a lack of treatment intensification according to evidence-based guidelines for patients who are considered eligible but not receiving therapy, and is often driven by complex factors involving patients, physicians, and healthcare systems. The KOFU study, the largest cross-sectional Internet Survey for severe asthma in Japan, addressed potential barriers to starting biologic treatment and sought a solution for therapeutic inertia regarding asthma biologics. Although the burden of high medical costs is the largest barrier to initiating biologic treatment for patients, other important barriers were also revealed, including an incorrect perception of asthma severity or a poor recognition of the need for treatment intensification, a lack of proper communication with patients or a lack of confidence in the physicians, initiating biologics together with the complicated process of the insurance systems to ease the burden of high medical costs or strict criteria for the approval of biologics for health care insurance systems. Increased awareness and understanding of these barriers to biologic treatment may facilitate an optimal recommendation process to individualize treatment in patients with severe asthma.

One-day systemic corticosteroid administration for asthma and future "short bursts" risk in real clinical practice

OBJECTIVE

Systemic corticosteroid administration, also called short bursts (SB), is harmful for patients with asthma; however, the actual burden of one-day SB remains unsolved. This study aimed to elucidate the characteristics of patients requiring one-day SB against asthma in clinical practice.

METHODS

Consecutive patients who regularly visited our hospital for asthma treatment between January 2019 and December 2020 were reviewed and followed for one year. SB was defined as ≥3 days of systemic corticosteroid treatment for an exacerbation. One-day SB was defined as one-day of systemic corticosteroid to treat an exacerbation. The one-day SB group included patients who received only one-day SB but no SB during the preceding year. Frequent SB was defined as that occurring ≥2 times/year.

RESULTS

Data on 229 patients were analyzed. Among them, 2.6% (95% confidence interval 1.2-5.6%) were in the one-day SB group. The one-day SB group was female-dominant, obese, non-eosinophilic, and non-atopic. The median one-day SB was 1.5 times/year and almost half of one-day SB were performed by patients themselves. Independent of the low pulmonary function, high blood eosinophil count, and inhaled corticosteroid dose, one-day SB was associated with future frequent SB (adjusted odds ratio = 18.2, 95% confidence interval 1.1-288, P = 0.040, compared to the no SB group).

CONCLUSIONS

Although one-day SB was not frequently experienced, even one-day SB without conventional SB was associated with future frequent SB. It is important to grasp the actual condition of one-day SB and to reinforce the treatment used.

The Link between Periodontal Disease and Asthma: How Do These Two Diseases Affect Each Other?

A growing body of evidence suggests that the effects of poor oral hygiene extend beyond the oral cavity and are associated with a variety of systemic diseases, including asthma. Asthma, which results in symptoms of cough, wheezing, and dyspnoea, and is characterized by airflow limitation with variability and (partial or complete) reversibility, is amongst the most prevalent respiratory diseases with approximately 262 million patients worldwide, and its prevalence and disease burden is on the increase. While asthma can occur at a young age, it can also develop later in life and affects a variety of age groups. Both of these diseases have a chronic course, and various researchers have suggested a link between the two. In this article, we aim to provide a literature review focusing on the association between the two diseases. The results demonstrate that medications (primarily, inhaler medicine), hypoxia induced by asthma, and the breathing behaviour of patients potentially trigger periodontal disease. In contrast, oral periodontopathogenic microorganisms and the inflammatory mediators produced by them may be involved in the onset and/or exacerbation of asthma. Common contributing factors, such as smoking, gastro-oesophageal reflux, and type-2 inflammation, should also be considered when evaluating the relationship between the two diseases.

Neurodevelopmental Outcomes Among Offspring Exposed to Corticosteroid and B2-Adrenergic Agonists In Utero

Importance

Corticosteroids and β2-adrenergic agonists are commonly used during pregnancy to treat asthma. However, offspring neurodevelopmental outcomes following in utero exposure to these medications remain unclear.

Objective

To investigate the association between timing of in utero exposure to corticosteroids and β2-adrenergic agonists and offspring neurodevelopmental milestones during the first 3 years of life.

Design, Setting, and Participants

This cohort study obtained data from the Japan Environment and Children's Study, an ongoing birth cohort study conducted in collaboration with 15 Regional Centers across Japan. Participants were mother-offspring pairs who were recruited between January 1, 2011, and March 31, 2014. Data were analyzed between January and February 2023.

Exposure

Corticosteroids and β2-adrenergic agonists were the exposure of interest. Timing of corticosteroid and β2-adrenergic agonist exposure included early pregnancy (weeks 0-12), mid- to late pregnancy (weeks >12), and both stages of pregnancy.

Main Outcomes and Measures

Offspring neurodevelopmental milestones (communication, gross motor, fine motor, problem-solving, and personal-social skills) were assessed using the Japanese version of the Ages and Stages Questionnaires, 3rd edition, at 6, 12, 18, 24, 30, and 36 months.

Results

In total, 91 460 mother-offspring pairs were analyzed. Among mothers, the mean (SD) age at delivery was 31.20 (5.05) years. Among offspring, 46 596 (50.9%) were males and 44 864 (49.1%) were females, of whom 66.4% had a gestational age of 39 to 41 weeks. During early, mid- to late, and both stages of pregnancy, 401 (0.4%), 935 (1.0%), and 568 (0.6%) offspring, respectively, were exposed to corticosteroids, whereas 170 (0.2%), 394 (0.4%), and 184 (0.2%), respectively, were exposed to β2-adrenergic agonists. No association of corticosteroid exposure during early, mid- to late, and both stages of pregnancy with all 5 neurodevelopmental milestones was found. Similarly, no association between β2-adrenergic agonist use during early pregnancy and all 5 neurodevelopmental milestones was observed. An association was found between β2-adrenergic agonist exposure during mid- to late pregnancy and delayed personal-social skills (adjusted odds ratio, 1.48; 95% CI, 1.01-2.32; P = .045).

Conclusions and Relevance

Results of this study found no association between in utero corticosteroid and β2-adrenergic agonist exposure and offspring neurodevelopmental outcomes, regardless of the timing of exposure. Despite the limitations and low power of the study, the findings suggest that corticosteroids and β2-adrenergic agonists are safe for pregnant individuals with asthma and the neurodevelopment of their offspring.

Real-world impact of dupilumab on asthma disease burden in Japan: The CROSSROAD study

BACKGROUND

Dupilumab, a human monoclonal anti-interleukin (IL)-4Ra antibody blocks the shared receptor component of IL-4 and IL-13, drivers of type 2 inflammation. Dupilumab is approved for severe/refractory asthma inadequately controlled by existing therapies, but knowledge of its effect on real-world disease burden is lacking. This study investigates real-world effects of dupilumab on asthma exacerbation risk and oral corticosteroid (OCS) use in Japanese individuals with asthma.

METHODS

This retrospective, cohort study used a Japanese insurance claims database to identify patients who started dupilumab between 26 March 2019-31 May 2020. Patients were followed for ±365 days from dupilumab initiation. The study primarily assessed the annual incidence rate of severe asthma exacerbations occurring simultaneously with hospitalizations or OCS bursts. Secondary and exploratory endpoints assessed OCS dosage and duration, and healthcare resource utilization (HRU), respectively.

RESULTS

At dupilumab initiation (N = 215), mean age was 57.2 years, 41.9% of patients were aged ≥65 years, and 59.5% were female. Dupilumab significantly reduced the annual incidence of severe asthma exacerbations from 1.29 to 0.74 (95% confidence interval, 0.44-0.76) per patient per year. Mean OCS dosage decreased from 10.4 to 7.2 mg/day in chronic OCS users; median frequency of OCS bursts decreased from 3 to 0. Both unscheduled outpatient visits (35.8% vs 29.8%) and hospitalizations (21.9% vs 12.1%) decreased. Mean (standard deviation) duration of hospitalization also decreased from 6.7 (27.6) to 2.2 (8.1) days.

CONCLUSIONS

Japanese patients with asthma who received dupilumab had reduced incidence rates of severe asthma exacerbations, OCS use, and HRU over 12 months.

Reduced Asthma Exacerbations in Adult Patients Treated With Bronchial Thermoplasty

BACKGROUND

Bronchial thermoplasty (BT) has been shown to be effective in randomized controlled trials of patients with severe asthma who failed to achieve disease control with high-dose inhaled corticosteroids combined with bronchodilators. However, the effectiveness of BT in real-world clinical settings, especially among the Asian population, has not been determined.

OBJECTIVE

To evaluate the effectiveness of BT using a nationwide database.

METHODS

Using the inpatient and outpatient data from the Japanese Diagnosis Procedure Combination database, we applied a self-controlled case series design to evaluate changes in the composite outcome of hospital admissions and emergency department visits, as well as systemic corticosteroid dose, between 1 year before and after BT. We also conducted subgroup analyses based on patients' profiles.

RESULTS

Among the 561 patients with asthma who underwent BT treatment between September 2014 and March 2020, 102 patients with at least 1 outcome were analyzed. Bronchial thermoplasty was significantly associated with an improvement in the composite outcome of hospital admission and emergency department visits (incidence rate ratio 0.53; 95% CI 0.44-0.64). Systemic corticosteroid use was reduced after BT sessions (1931.5 mg [1,341.2-3,725.3 mg] to 641.3 mg [134.2-1,691.1 mg] per person-year; P < .001). Although all groups showed a significant improvement in the composite outcome in the subgroup analyses, BT tended to be less effective among people older than 65 years and those with higher body mass index (>25 kg/m2).

CONCLUSIONS

The present study using real-world data suggests that BT may improve asthma control; however, the effectiveness of BT can vary depending on patient baseline profiles.

Defining the contractile prostanoid component in hyperosmolar-induced bronchoconstriction in human small airways

Exercise-induced bronchoconstriction (EIB) is thought to be triggered by increased osmolarity at the airway epithelium. The aim of this study was to define the contractile prostanoid component of EIB, using an ex vivo model where intact segments of bronchi (inner diameter 0.5-2 mm) isolated from human lung tissue and subjected to mannitol. Exposure of bronchial segments to hyperosmolar mannitol evoked a contraction (64.3 ± 3.5 %) which could be prevented either by elimination of mast cells (15.8 ± 4.3 %) or a combination of cysteinyl leukotriene (cysLT1), histamine (H1) and thromboxane (TP) receptor antagonists (11.2 ± 2.3 %). Likewise, when antagonism of TP receptor was exchanged for inhibition of either cyclooxygenase-1 (8 ± 2.5 %), hematopoietic prostaglandin (PG)D synthase (20.7 ± 5.6 %), TXA synthase (14.8 ± 4.9 %), or the combination of the latter two (12.2 ± 4.6 %), the mannitol-induced contraction was prevented, suggesting that the TP-mediated component is induced by PGD2 and TXA2 generated by COX-1 and their respective synthases.

Prospective Real-World Analysis of Asthma Patients With Preserved and Reduced Physical Activity

BACKGROUND

Asthma is a highly heterogeneous airway disease, and the clinical characteristics of patients with asthma with preserved and reduced physical activity are poorly understood.

OBJECTIVE

We aimed to investigate the risk factors and clinical phenotypes associated with reduced physical activity in a wide range of patients with asthma.

METHODS

We conducted a prospective observational study of 138 patients with asthma, including patients with asthma without chronic obstructive pulmonary disease (COPD) (n = 104) and asthma-COPD overlap (n = 34), and 42 healthy controls. Physical activity levels were measured for 2 weeks using a triaxial accelerometer at baseline and 1 year later.

RESULTS

Higher eosinophils and body mass index (BMI) were associated with reduced physical activity in patients with asthma without COPD. Cluster analysis of asthma without COPD revealed 4 asthma phenotypes. We identified a cluster with preserved physical activity (n = 43) that was characterized by good symptom control and lung function and included a high proportion of biologics users (34.9%). Multivariate regression analysis revealed that patients with late-onset eosinophilic (n = 21), high-BMI noneosinophilic (n = 14), and symptom-predominant asthma phenotypes (n = 26) had lower levels of physical activity than controls. Patients with asthma-COPD overlap also had significantly lower physical activity levels than controls. Similar trends in physical activity levels were observed in each asthma group at 1-year follow-up.

CONCLUSION

This study showed the clinical features of patients with asthma with preserved and reduced physical activity. Reduced physical activity was observed in various asthma phenotypes and in asthma-COPD overlap.

Systemic Corticosteroids for Treating Respiratory Diseases: Less Is Better, but… When and How Is It Possible in Real Life?

Systemic corticosteroids (CSs), a keystone in pulmonology, are drugs with strong antiinflammatory activity. They are cheap, easily available, and accessible, but with common and serious side effects. Moreover, the use of exogenous CSs may suppress the hypothalamic-pituitary-adrenal (HPA) axis, predisposing to adrenal insufficiency. Safe CS treatment is a challenge of pharmacological research. This narrative review examined the indications of CSs in some respiratory diseases, analyzing what types, dosages, and length of treatment are required as the dosage and duration of CS treatments need to be minimized. Chronic maintenance treatments with CSs are associated with poor prognosis, but they are still prescribed in patients with severe asthma, Chronic obstructive pulmonary disease (COPD), and interstitial lung diseases. When CS discontinuation is not possible, all efforts should be made to achieve clinically meaningful reductions. Guidelines suggest the use of methylprednisolone at a dose of 20-40 mg/day or equivalent for up to 10 days in subjects with COVID-19 pneumonia (but not other respiratory viral diseases) and respiratory failure, exacerbations of asthma, and COPD. Some guidelines suggest that CS treatment shorter than 10-14 days can be abruptly stopped, strictly monitoring subjects with unexplained symptoms after CS withdrawal, who should promptly be tested for adrenal insufficiency (AI) and eventually treated. CSs are often used in severe community-acquired pneumonia associated with markedly increased serum inflammation markers, in acute respiratory distress syndrome (ARDS), in septic shock unresponsive to hydro-saline replenishment and vasopressors, and acute exacerbations of interstitial lung diseases. As these cases often require higher doses and longer duration of CS treatment, CS tapering should be gradual and, when useful, supported by an evaluation of HPA axis function.

Serum autophagy protein 5 is positively related to T helper 2/T helper 1 ratio, inflammation, and exacerbation in adult asthma patients

BACKGROUND

Autophagy protein 5 (ATG5) regulates airway epithelial cell autophagy, immune response, and inflammation, which is involved in asthma progression. This study aimed to evaluate ATG5 levels and its clinical roles in adult asthma patients.

METHODS

Totally, 200 adult asthma patients and 100 healthy controls (HCs) were enrolled in this case-control study. Subsequently, serum ATG5 was measured by enzyme-linked immunosorbent assay.

RESULTS

ATG5 was increased in asthma patients compared with HCs [median (interquartile range): 44.2 (31.7-77.8) vs. 23.2 (16.7-39.2) ng/mL] (P < 0.001). In asthma patients, ATG5 was positively related to male gender (P = 0.022), a family history of asthma (P = 0.035), eosinophil count (P < 0.001), and immune globulin E (P < 0.001), while it was negatively correlated with forced expiratory volume in 1 s (FEV1)/forced vital capacity (P < 0.001) and FEV1 (Predicted) (P < 0.001). Meanwhile, ATG5 was inversely associated with T helper (Th) 1 cells (P = 0.008), while it was positively linked with Th2 cells (P < 0.001), Th2/Th1 ratio (P < 0.001), interleukin (IL)-4 (P = 0.002), and IL-4/interferon-γ ratio (P = 0.015). Additionally, ATG5 was positively correlated with tumor necrosis factor-α (P < 0.001), IL-1β (P = 0.001), IL-6 (P = 0.003), and IL-17 (P = 0.029). Notably, ATG5 was elevated in asthma patients at exacerbation compared to those at remission [median (interquartile range): 53.6 (37.6-90.0) vs. 35.6 (28.2-51.5) ng/mL] (P < 0.001). It was also noteworthy that ATG5 was positively linked with exacerbation severity in asthma patients (P = 0.005).

CONCLUSION

Serum ATG5 is related to increased Th2/Th1 ratio, inflammation, exacerbation risk and severity in adult asthma patients, which serves as a candidate marker for the management of asthma. However, further validation is still needed.

Higher Prevalence and Severity of Eosinophilic Otitis Media in Patients with Asthma-COPD Overlap Compared with Asthma Alone

INTRODUCTION

Eosinophilic otitis media (EOM) is well-known to frequently co-exist with adult-onset asthma. Both diseases are similar type 2 inflammation and are considered to have a "one airway, one disease" relationship. Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO), characterized by airway obstruction caused by airway wall thickening (AWT), is a severe condition with a higher incidence of mortality compared to asthma alone or COPD alone. Based on the "one airway, one disease" concept, we hypothesized that the inflammatory pathophysiology of EOM differs depending on its comorbidity with ACO or with asthma alone.

METHODS

A total of 77 chronic rhinosinusitis (CRS) patients with asthma were enrolled in this study. The subjects were divided into 2 groups: a group with comorbid asthma alone (asthma group; 46 patients), and a group with comorbid ACO (ACO group; 31 patients). The 2 groups were compared and assessed with regard to various factors, including the patients' clinical characteristics, prevalence rate of EOM, EOM severity, EOMs relationships with smoking and AWT, and the eosinophil and neutrophil cell counts in the middle ear effusion (MEE).

RESULTS

The ACO group included significantly more males (p < 0.05), was significantly older (p < 0.05), and showed significantly lower lung function values (FEV1 [L], FEV1 [%pred]) (p < 0.01) compared with the asthma group. The ACO group also had a significant history of smoking as shown by the Brinkman index (p < 0.01) and greater AWT as assessed by high-resolution computed tomography (p < 0.05). The EOM prevalence rate was significantly higher in the ACO group (p < 0.05), especially with increased ACO severity (p < 0.05). The EOM severity was also significantly higher in the ACO group (p < 0.05) and also correlated with the ACO severity (p < 0.05). The pretreatment ear clinical characteristics score and the average air conduction hearing level were significantly higher in the ACO group (p < 0.05). The eosinophil percentage in the MEE/otorrhea was significantly lower in the ACO group (25.3%) than in the asthma group (54.7%) (p < 0.05). Conversely, the neutrophil percentage was significantly higher in the ACO group (75.7% vs. 41.9%) (p < 0.05).

CONCLUSIONS

Our findings suggest that, in CRS patients with asthma, comorbidity with ACO may be a clinical factor leading to increased EOM prevalence and severity, as well as a higher neutrophil infiltration percentage in the middle ear. Cessation of smoking and early therapeutic intervention for ACO may mitigate progression of bronchial remodeling (i.e., reduce AWT) and help reduce the prevalence and severity of EOM.