Clinical predictors of remission and persistence of adult-onset asthma

Chronic spontaneous urticaria remission definition and therapy stepping down: World Allergy Organization position paper

BACKGROUND

There is no global agreement on the definition of chronic spontaneous urticaria (CSU) remission.

OBJECTIVE

Our aim was to generate a consensus for clinical definitions of CSU-related terms focused on remission.

METHODS

The World Allergy Organization Urticaria Committee systematically reviewed current available longitudinal articles. On the basis of this review, a consensus agreement was reached for the definition of the term CSU remission. In addition, a scheme specifying when and how therapeutic de-escalation should be performed was constructed.

RESULTS

Almost all of the groups that have carried out longitudinal studies to evaluate the frequency of CSU remission agreed to use the term CSU remission if the patient remains without urticaria signs and symptoms without pharmacologic treatment (omalizumab, cyclosporine, antihistamines, or systemic corticosteroids). According to our systematic review, the available evidence does not specify the best time to consider CSU remission. However, current evidence suggests that there is no significant difference in CSU relapse between 6- and 12-month periods of remission. So far, no evidence exists to propose any biomarkers for defining inflammatory or mechanistic remission in CSU or identifying patients with a high probability of cure. It can be reasonable to consider a reduction of treatment after 6 months of CSU control, with evaluation 2 to 6 months after stepping down treatment.

CONCLUSION

The World Allergy Organization Urticaria Committee proposes defining CSU clinical remission based on the total resolution of urticaria signs and symptoms without pharmacotherapy for at least 6 months. The implications of this definition in clinical practice must be evaluated and validated in future studies.

Baseline forced oscillation technique predicting lack of exacerbations in adult patients with asthma: A 12-month prospective

BACKGROUND

The forced oscillation technique (FOT) is a minimally invasive test to evaluate asthma during resting ventilation. However, its role in longitudinal assessments, such as clinical remission, remains unclear.

OBJECTIVE

To longitudinally assess asthma clinical remission and identify parameters that predict clinical remission at 12 months from baseline FOT.

METHODS

Adult patients with asthma at our university hospital between April 2022 and May 2023 were enrolled in this prospective observational study. They were evaluated for 12 months after enrollment to determine whether they met the following clinical remission criteria: asthma control test score of more than or equal to 20 at enrollment and 12 months, no asthma exacerbations for 12 months, and no regular oral corticosteroid use during the 12 months. FOT parameters at enrollment were analyzed for associations with clinical remission.

RESULTS

A total of 94 patients with asthma completed the study and were categorized into clinical and nonclinical remission groups. Comparison of pulmonary function tests, including the FOT, between the 2 groups revealed significant differences in resistance at 5 Hz and resistance at 20 Hz (R20) but not in forced expiratory volume in 1 second. Multivariate logistic regression analysis revealed that R20 was associated with clinical remission, with adjusted odds ratios of 0.32 (95% CI: 0.12-0.91, P = .033) for R20.

CONCLUSION

R20 can be a useful predictor of future exacerbations in patients with asthma. These findings may assist in evaluating adult patients with asthma and normal forced expiratory volume in 1 second.

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.

Identifying super-responders: A review of the road to asthma remission

Asthma is a chronic respiratory disease marked by heterogeneity and variable clinical outcomes. Recent therapeutic advances have highlighted patients achieving optimal outcomes, termed "remission" or "super-response." This review evaluates the various definitions of these terms and explores how disease burden impedes the attainment of remission. We assessed multiple studies, including a recent systematic review and meta-analysis, on biologic treatments for asthma remission. Our review highlights that type 2 inflammation may be the strongest predictor of biologic response. Key comorbidities (eg, obesity and mood disorders) and behavioral factors (eg, poor adherence, improper inhalation technique, and smoking) were identified as dominant traits limiting remission. In addition, asthma burden and longer disease duration significantly restrict the potential for remission in patients with severe asthma under the current treatment paradigm. We review the potential for a "predict-and-prevent" approach, which focuses on early identification of high-risk patients with type 2 inflammation and aggressive treatment to improve long-term asthma outcomes. In conclusion, this scoping review highlights the following unmet needs in asthma remission: (1) a harmonized global definition, with better defined lung function parameters; (2) integration of nonbiologic therapies into remission strategies; and (3) a clinical trial of early biologic intervention in patients with remission-prone, very type 2-high, moderately severe asthma with clinical remission as a predefined primary end point.

Exploring Definitions and Predictors of Severe Asthma Clinical Remission after Biologic Treatment in Adults

Rationale: There is no consensus on criteria to include in an asthma remission definition in real life. Factors associated with achieving remission after biologic initiation remain poorly understood. Objectives: To quantify the proportion of adults with severe asthma achieving multidomain-defined remission after biologic initiation and identify prebiologic characteristics associated with achieving remission that may be used to predict it. Methods: This was a longitudinal cohort study using data from 23 countries from the International Severe Asthma Registry. Four asthma outcome domains were assessed in the 1 year before and after biologic initiation. A priori-defined remission cutoffs were: 0 exacerbations/yr, no long-term oral corticosteroid (LTOCS), partly/well-controlled asthma, and percent predicted FEV1 ⩾ 80%. Remission was defined using two (exacerbations + LTOCS), three (+control or +lung function), and four of these domains. The association between prebiologic characteristics and postbiologic remission was assessed by multivariable analysis. Measurements and Main Results: A total of 50.2%, 33.5%, 25.8%, and 20.3% of patients met criteria for two-, three- (+control), three- (+lung function), and four-domain remission, respectively. The odds of achieving four-domain remission decreased by 15% for every additional 10 years of asthma duration (odds ratio, 0.85; 95% confidence interval, 0.73-1.00). The odds of remission increased in those with fewer exacerbations per year, lower LTOCS daily dose, better control, and better lung function before biologic initiation. Conclusions: One in five patients achieved four-domain remission within 1 year of biologic initiation. Patients with less severe impairment and shorter asthma duration at initiation had a greater chance of achieving remission after biologic treatment, indicating that biologic treatment should not be delayed if remission is the goal.

Relief of Airflow Limitation and Airway Inflammation by Endoscopic Sinus Surgery in a Patient with Severe Asthma with Eosinophilic Chronic Rhinosinusitis

Although endoscopic sinus surgery (ESS) is beneficial in improving asthma symptoms, its impact on the lung function in patients with asthma and chronic rhinosinusitis remains unclear. We herein report a case of severe asthma with eosinophilic chronic rhinosinusitis, in which ESS substantially improved airflow limitation and concomitantly reduced fractional exhaled nitric oxide and blood eosinophil counts. ESS likely relieved airflow limitation by suppressing type 2 inflammatory pathways. This case highlights ESS as a promising strategy for achieving clinical remission in patients with severe asthma and chronic rhinosinusitis.

Spanish Consensus on Remission in Asthma (REMAS)

The concept of "remission" in asthma has been around for a long time and it has been a controversial topic. Despite the attempts of some studies to characterize this entity, the discussion continues. In the case of asthma there is still no clear definition, either in terms of its meaning or the parameters that should be included or whether it should be divided into clinical or complete remission. To help defining these controversial concepts, SEPAR has advocated the multidisciplinary working group REMAS (REMission in ASthma). Following the Delphi methodology and with the involvement of more than 120 specialists in asthma management, this group has arrived at a consensus on the definitions of remission in asthma and establishing the criteria and characteristics that will be of use in future studies evaluating the efficacy or effectiveness of treatments.

Targeting Asthma Remission as the Next Therapeutic Step Toward Improving Disease Control

The long-term goal of asthma management is to achieve disease control, comprising the assessment of 2 main domains: (1) symptom control and (2) future risk of adverse outcomes. Decades of progress in asthma management have correlated with increasingly ambitious disease control targets. Moreover, the introduction of precision medicines, such as biologics, has further expanded the limits of what can be achieved in terms of disease control. It is now believed that clinical remission, a term rarely associated with asthma, may be an achievable treatment goal. An expert framework published in 2020 took the first step toward developing a commonly accepted definition of clinical remission in asthma. However, there remains a widespread discussion about the clinical parameters and thresholds that should be included in a standardized definition of clinical remission. This review aims to discuss on-treatment clinical remission as an aspirational outcome in asthma management, drawing on experiences from other chronic diseases where remission has long been a goal. We also highlight the integral role of shared decision-making between patients and health care professionals and the need for a common understanding of the individual patient journey to remission as foundational elements in reducing disease burden and improving outcomes for patients with asthma.

Remission in Type 2 Inflammatory Diseases: Current Evidence, Unmet Needs, and Suggestions for Defining Remission in Chronic Rhinosinusitis with Nasal Polyps

PURPOSE OF REVIEW

The development of biological therapies for type 2 inflammatory diseases raises the possibility of addressing remission in those dis-immune conditions. No consensus exists for a definition of remission in chronic rhinosinusitis with nasal polyps (CRSwNP). This review aims to critically evaluate the published data to provide the basis for defining remission in CRSwNP.

RECENT FINDINGS

The published evidence has yet to provide an unequivocal definition on remission in type 2 inflammatory diseases, in part reflecting differences in approaches to diagnosis and follow-up. A multidimensional evaluation is necessary when considering complete remission, including clinical, inflammatory, and histologic criteria, but how to combine or tailor the three perspectives according to disease severity at baseline or timing of assessment of treatment category is yet to reach consensus. We suggest defining remission starting from the approach taken in asthma and eosinophilic esophagitis, that is, including the resolution of symptoms and improvements in objective parameters of disease severity and/or inflammatory activity. Future studies and consensuses should provide validated criteria with cutoffs for the day-to-day definition of remission. The definition of remission in CRSwNP should include the following criteria, to be verified and maintained for a period of ≥ 12 months: absence of symptoms (nasal obstruction, loss of smell, rhinorrhea as the main ones); no impact of symptoms on quality of life; no need of surgery; no chronic or rescue medications (systemic corticosteroids or antibiotics); and recovery of smell function, possibly evaluated by objective test. Assessment of underlying inflammation should also be considered once accurate and feasible biomarkers are available in clinical practice.

Age-related differences in associations between uncontrolled asthma, comorbidities and biomarkers in adult-onset asthma

OBJECTIVE

Adult-onset asthma is a recognized but heterogeneous phenotype and has been described to associate with poor asthma control. Knowledge about associations between clinical characteristics including comorbidities and control of adult-onset asthma is limited, especially in older populations. We aimed to study how clinical biomarkers and comorbidities are associated with uncontrolled asthma among middle-aged and older individuals with adult-onset asthma.

METHODS

Clinical examinations including structured interview, asthma control test (ACT), spirometry, skin prick test (SPT), blood sampling, and measurement of exhaled fractional nitric oxide (FeNO) was performed in a population-based adult-onset asthma cohort in 2019-2020 (n = 227, 66.5% female). Analyses were performed among all included, and separately in middle-aged (37-64 years, n = 120) and older (≥65 years, n = 107) participants.

RESULTS

In bivariate analysis, uncontrolled asthma (ACT ≤ 19) was significantly associated with a blood neutrophil count ≥5/µl, BMI ≥30, and several comorbidities. In multivariable regression analysis, uncontrolled asthma was associated with neutrophils ≥5/µl (OR 2.35; 95% CI 1.11-4.99). In age-stratified analysis, BMI ≥30 (OR 3.04; 1.24-7.50), eosinophils ≥0.3/µl (OR 3.17; 1.20-8.37), neutrophils ≥5/µl (OR 4.39; 1.53-12.62) and allergic rhinitis (OR 5.10; 1.59-16.30) were associated with uncontrolled asthma among the middle-aged. Among the older adults, uncontrolled asthma was only associated with comorbidities: chronic rhinitis (OR 4.08; 1.62-10.31), ischemic heart disease (OR 3.59; 1.17-10.98), malignancy (OR 3.10; 1.10-8.73), and depression/anxiety (OR 16.31; 1.82-146.05).

CONCLUSIONS

In adult-onset asthma, comorbidities were strongly associated with uncontrolled asthma among older adults, while clinical biomarkers including eosinophils and neutrophils in blood were associated with uncontrolled asthma among middle-aged.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Why Current Therapy Does Not Cure Asthma. Is It Time to Move Towards a One Health Approach?

Asthma continues to be a disease for which there is no cure, even if it can be very well controlled with the appropriate therapies, which take into account the specific phenotype. The paradox of asthma is that asthma can heal spontaneously, albeit in a small percentage of cases. This observation is highly relevant, since understanding the mechanisms of spontaneous healing can pave the way for new strategies for treating asthma. It is likely that the lack of cure for asthma is due to the fact that current therapies target downstream mediators of the inflammatory response. Asthma can be considered a response of maladaptation of the airway epithelium to the environment, through the orientation of the innate immunity towards an inflammatory response. The important effect of the environment on asthma progress comes from interventions which help children who live in disadvantaged urban neighborhoods move to higher resourced neighborhoods. It is quite interesting that the magnitude of decrease of exacerbations associated with moving was larger than the effect of inhaled corticosteroids and similar to that observed for the effect of biologic agents. Alpine altitude climate treatment is a natural treatment that targets biological pathway, improving various outcomes such as asthma control and quality of life, exacerbation rate and hospitalizations. If as researchers we want to set ourselves the goal of achieving complete remission of asthma, without the need for ongoing maintenance treatment, we need to change the approach to finding new asthma treatment strategies. The One Health approach, an interdisciplinary strategy with focal point on human, animal, and environmental health interconnections, appears to be the right tool for researching asthma prevention and treatment.

Associations of complete blood cell count-derived inflammatory biomarkers with asthma and mortality in adults: a population-based study

Objective

This study aims to assess the associations of complete blood cell count (CBC)-derived inflammatory biomarkers with the prevalence of asthma and mortality.

Methods

Data was collected from the 1999-2018 National Health and Nutrition Examination Survey (NHANES). Mortality was identified using the National Death Index until December 31, 2019. The study analyzed the relationship between CBC-derived inflammatory biomarkers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic inflammatory response index (SIRI), and systemic immune-inflammation index (SII), and the prevalence of asthma using multiple logistic regressions. To assess the significance of CBC-derived inflammatory biomarkers in predicting all-cause and respiratory disease mortality in asthma patients, Cox proportional regressions and the random survival forest (RSF) analysis were utilized.

Results

A total of 48,305 participants were included, with a mean age of 47.27 ± 0.18 years and 49.44% male. Among them, 6,403 participants had asthma, with a prevalence of 13.28%. The all-cause and respiratory disease deaths at a median follow-up of 8.2 (4.5, 12.8) years were 929 and 137 respectively. After adjusting for confounders, the prevalence of asthma was found to be positively associated with NLR, PLR, MLR, SIRI and SII. Compared to the lowest quartile, the highest quartile of NLR (HR=1.765 [1.378-2.262]), MLR (HR=1.717 [1.316-2.241]), SIRI (HR=1.796 [1.353-2.383]) and SII (HR=1.432 [1.141-1.797]) were associated with an increased risk of all-cause mortality. These associations were more pronounced in respiratory disease mortality of asthma patients. RSF analysis showed that MLR had the highest predictive value for all-cause and respiratory disease mortality in adults with asthma. The sensitivity analysis demonstrated the stability of our results.

Conclusion

The findings suggest that CBC-derived inflammatory biomarkers are associated with a higher risk of all-cause and respiratory disease mortality in adults with asthma.

Comorbid asthma in patients with chronic rhinosinusitis with nasal polyps: did dupilumab make a difference?

BACKGROUND

The clinical heterogeneity of chronic rhinosinusitis (CRS) and bronchial asthma is attributable to different underlying inflammatory profiles. However, the similarity between CRS with nasal polyps (CRSwNP) and type-2 asthma pathophysiology speculates that one biological therapy could affect both comorbidities. Despite dupilumab, a monoclonal antibody that targets IL-4α and IL-13 receptors, being used in patients with nasal polyps and severe asthma, real-life data about its efficacy in improving the quality of life and patient symptoms is still lacking. This study's primary objective was to evaluate dupilumab treatment's effect on the frequency of olfactory symptoms and health-related quality of life tests as measured by the Sino-nasal outcome test (SNOT-22) in patients with NP. The secondary objective was the effect of dupilumab on asthma symptom control as measured by the asthma control test (ACT).

METHODS

A prospective study was conducted of 166 patients with CRSwNP, with or without asthma. The following variables were collected at baseline and after at least six months of continuous dupilumab therapy; SNOT-22, olfactory symptoms frequency, and ACT score.

RESULTS

Asthma prevalence in patients with CRSwNP was high (59.63%), and being female with a history of frequent use of oral corticosteroid (OCS) courses and repeated unsuccessful nasal and para-nasal surgeries for polyposis increased the likelihood of having underlying asthma by 2, 1 and 4 times more, respectively. Additionally, being asthmatic required a longer duration of dupilumab treatment. However, both the health-related quality of life and olfactory symptoms improved equally in both groups.

CONCLUSION

Even with associated comorbid asthma in patients with CRSwNP, treatment with dupilumab could improve the quality of life, olfactory symptoms, and asthma symptom control.

Mild asthma: Lessons learned and remaining questions

Patients living with mild disease represent the largest proportion of asthma patients. There are significant challenges in proposing a definition that would best describe these patients, while also accurately identifying at-risk individuals. Current literature suggests considerable inflammatory and clinical heterogeneity within this group. Research has shown that these patients are at risk of poor control, exacerbations, lung function decline, and death. Despite conflicting data on its prevalence, eosinophilic inflammation appears to be a predictor of poorer outcomes in mild asthma. There is an immediate need to better understand phenotypic clusters in mild asthma. It is also important to understand factors that influence disease progression and remission, as it is evident that both vary in mild asthma. Guided by robust literature that supports inhaled corticosteroid-based strategies over short-acting beta-agonist (SABA) reliant regimens, the management of these patients has evolved considerably. Unfortunately, SABA use remains high in clinical practice despite strong advocacy from the Global Initiative for Asthma. Future mild asthma research should explore the role of biomarkers, develop prediction tools based on composite risk scores, and explore targeted therapies at least for at-risk individuals.

[A Study of the Prevalence of Asthma in the General Population in Spain]

Introduction

Asthma is a disease with high prevalence, which affects all age groups and generates high health and social care costs. Studies carried out in a number of populations show great variability in its prevalence, even in geographically close populations, with data suggesting a relevant influence of socio-economic factors. At present, we do not have reliable data on the prevalence of this disease in the adult population of Spain. The objectives of this study are to estimate the prevalence of asthma in the Spanish population for those aged 18-79, to describe the variability between autonomous communities, to estimate the prevalence of under and overdiagnosis, to analyse the prevalence of uncontrolled asthma and steroid-dependent asthma, to evaluate the health care cost, to identify the most frequent phenotypes and to establish a starting point to evaluate the temporal trend with subsequent studies.

Methods

A cross-sectional, two-stage study will be carried out, including patients from 50 catchment areas. The study will be carried out in 3 phases: 1) screening and confirmation in the clinical history, in which patients with a previously correctly established diagnosis of asthma will be identified; 2) diagnosis of asthma to evaluate patients without a confirmed or excluded diagnosis; 3) characterization of asthma, where the characteristics of the asthmatic patients will be analysed, identifying the most frequent phenotypes.

Discussion

It seems necessary and feasible to carry out an epidemiological study of asthma in Spain to identify the prevalence of asthma, to optimize healthcare planning, to characterize the most frequent phenotypes of the disease, and to evaluate inaccurate diagnoses.

Clinical Remission of Asthma and Allergic Rhinitis - in a Longitudinal Population Study

BACKGROUND

Although asthma and allergic rhinitis are chronic diseases, some patients experience periods of remission. Information on prognostic factors associated with the remission of asthma and allergic rhinitis is valuable in resource prioritization. This study investigated factors associated with the clinical remission of asthma and allergic rhinitis.

METHODS

In the Respiratory Health In Northern Europe (RHINE) study, data was collected with questionnaires in stage one (RHINE I, 1989-1992) and two follow-ups (RHINE II, 1999-2001 and RHINE III, 2010-2012) from Sweden, Norway, Denmark, Iceland and Estonia. Clinical remission was defined as having reported asthma or allergic rhinitis in RHINE I or RHINE II but not in RHINE III.

RESULTS

Of 13,052 participants, 975 (7.5%) reported asthma in RHINE I or RHINE II, and 3379 (25.9%) allergic rhinitis. Clinical remission of asthma and allergic rhinitis was found in 46.4% and 31.8%, respectively. Living in Estonia (OR (95% CI) 2.44 (1.22-4.85)) and living in an apartment (1.45 (1.06-1.98)) were related to remission of asthma, while subjects reporting allergic rhinitis (0.68 (0.51-0.90)), asthma onset ≤ 12 years of age (0.49 (0.35-0.68)), receiving treatment with antibiotics for respiratory illness (0.64 (0.47-0.87)) were less likely to have asthma remission. Factors related to a higher likelihood of remission of allergic rhinitis were no asthma at baseline, age ≥ 58 years in RHINE III, allergic rhinitis onset after 12 years of age, living in rural areas as a child, having only a primary school education and not being pregnant.

CONCLUSION

Clinical remission was found in almost one-half of those with asthma and one-third of persons with allergic rhinitis. Coexisting allergic symptoms were associated with less clinical asthma remission. Age, asthma symptoms and environmental factors in childhood, such as living in a rural area, were found to influence the clinical remission of allergic rhinitis.

Risk factors associated with comorbid asthma in patients with chronic rhinosinusitis with nasal polyps: a cross-sectional study

Background

Although 20–60% of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have asthma, the risk factors associated with comorbid asthma are not clear. The aim of the study was to investigate the factors associated with asthma, and develop a practical scoring system to screen asthma comorbidity in CRSwNP patients.

Methods

This report describes a cross-sectional study with consecutive CRSwNP patients. Two cohorts of CRSwNP patients named “modelling” group and “validation” group were investigated respectively. Logistic regression analysis was performed based on demographic and clinical data collected from patients in the modelling group to determine the risk factors associated with asthma, and establish a scoring system for screening comorbid asthma. Receiver operating characteristic curve was constructed to evaluate the screening system; the optimal cut-off point was established by means of the Yoden Index. The consistency between the diagnosis of asthma by the Global Initiative for Asthma (GINA) criteria and by the screening system was assessed by Kappa value in the validation group.

Results

Totally 150 patients in modelling group and 78 patients in validation group were enrolled. Female gender (odds ratio [OR] = 6.4; P < 0.001), allergic rhinitis (OR = 2.9; P = 0.021), serum total (T)-immunoglobulin (Ig) E ≥ 69.0kU/L (OR = 12.0; P < 0.001), and blood eosinophil count  ≥ 0.35 × 10⁹/L (OR = 4.0; P = 0.001) were shown to be independent risk factors for asthma in patients with CRSwNP. Based on these variables, a scoring system (FAIE) ranging from 0(no risk) to 6(high risk); was developed. The area under the receiver operating characteristic curve of the system was 0.823, and the optimal cut-off value was 3 points, with sensitivity 83.8% and specificity 68.6% for screening asthma. The asthma comorbidity determined with FAIE score ≥ 3 points in the validation group, was moderately consistent with that defined by GINA (Kappa = 0.513, P < 0.001), with sensitivity 76.9% and specificity 74.4%.

Conclusions

Female gender, allergic rhinitis, serum T-IgE level, and blood eosinophil count are independent risk factors for asthma comorbidity in patients with CRSwNP, and the FAIE system may be practical for screening comorbid asthma in these patients.

Age at asthma diagnosis is related to prevalence and characteristics of asthma symptoms

Background

Although asthma may begin at any age, knowledge about relationship between asthma age of onset and the prevalence and character of different symptoms is scarce.

Objectives

The aim of this study was to investigate if adult-diagnosed asthma is associated with more symptoms and different symptom profiles than child-diagnosed asthma.

Methods

A FinEsS postal survey was conducted in a random sample of 16 000 20-69-year-old Finnish adults in 2016. Those reporting physician-diagnosed asthma and age at asthma diagnosis were included. Age 18 years was chosen to delineate child- and adult-diagnosed asthma.

Results

Of responders (N = 8199, 51.5%), 842 (10.3%) reported asthma diagnosis. Adult-diagnosed asthma was reported by 499 (59.3%) and child-diagnosed by 343 (40.7%). Of responders with adult-diagnosed and child-diagnosed asthma, 81.8% versus 60.6% used asthma medication (p < 0.001), respectively. Current asthma was also more prevalent in adult-diagnosed asthma (89.2% versus 72.0%, p < 0.001). Risk factors of attacks of breathlessness during the last 12 months were adult-diagnosis (OR = 2.41, 95% CI 1.64–3.54, p < 0.001), female gender (OR = 1.49, 1.07–2.08, p = 0.018), family history of asthma (OR = 1.48, 1.07–2.04, p = 0.018) and allergic rhinitis (OR = 1.49, 1.07–2.09, p = 0.019). All the analysed asthma symptoms, except dyspnea in exercise, were more prevalent in adult-diagnosed asthma in age- and gender-adjusted analyses (p = 0.032-<0.001) which was also more often associated with 5 or more asthma symptoms (p < 0.001) and less often with non-symptomatic appearance (p < 0.001) than child-diagnosed asthma.

Conclusion

Responders with adult-diagnosed asthma had more often current asthma and a higher and multiform asthma symptom burden, although they used asthma medication more often compared to responders with child-diagnosed asthma.

Identification of key genes and pathways in chronic rhinosinusitis with nasal polyps and asthma comorbidity using bioinformatics approaches

Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma comorbidity (ACRSwNP) present severe symptoms and are more likely to relapse. However, the pathogenesis of ACRSwNP is not fully understood. The aim of this study was to explore the underlying pathogenesis of ACRSwNP using bioinformatics approaches. ACRSwNP-related differentially expressed genes (DEGs) were identified by the analysis of the GSE23552 dataset. The clusterProfiler R package was used to carry out functional and pathway enrichment analysis. A protein–protein interaction (PPI) network was built using the STRING database to explore key genes in the pathogenesis of ACRSwNP. The bioinformatics analysis results were verified through qRT-PCR. The Connectivity Map (CMap) database was used to predict potential drugs for the treatment of ACRSwNP. A total of 36 DEGs were identified, which were mainly enriched in terms of regulation of immune response and detection sensory perception of taste. Thirteen hub genes including AZGP1, AQP9, GAPT, PIP, and PRR4 were identified as potential hub genes in ACRSwNP from the PPI network. Analysis of the GSE41861 dataset showed that upregulation of CST1 in nasal mucosa was associated with asthma. qRT-PCR detection confirmed the bioinformatics analysis results. Tacrolimus and spaglumic acid were identified as potential drugs for the treatment of ACRSwNP from the CMap database. The findings of this study provide insights into the pathogenesis of ACRSwNP and may provide a basis for the discovery of effective therapeutic modalities for ACRSwNP.

Expert consensus recommendations for the management of asthma in older adults

Asthma is a public health problem in patients of any age, although there is still a tendency to erroneously assume that it is almost always confined to children and young people. Epidemiological studies indicate that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6-10%, with a higher prevalence among women aged 64 to 75 years. In addition, two-thirds of asthma deaths occur at this stage of life, resulting in a substantial number of hospital admissions, longer hospital stays and, from a finance point of view, significant direct economic costs. Asthma in older adults (65 years or older) is now a matter of great concern, the reality of which is underestimated and undertreated. It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population. This consensus, which brings together the latest evidence available, was conceived with this objective. The proposed recommendations/conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting.

Long-Term Natural History of Severe Asthma Exacerbations and Their Impact on the Disease Course

Rationale: The long-term natural history of asthma in terms of successive severe exacerbations and the influence of each exacerbation on the course of the disease is not well studied. Objectives: To investigate the long-term natural history of asthma among patients who are hospitalized for asthma for the first time in terms of the risk of future severe exacerbations and heterogeneity in this risk across patients. Methods: Using the administrative health databases of British Columbia, Canada (January 1, 1997 to March 31, 2016), we created an incident cohort of patients with at least one asthma exacerbation that required inpatient care. We estimated the 5-year cumulative incidence of severe exacerbations after successive numbers of previous events. We used a joint frailty model to investigate the extent of between-individual variability in exacerbation risk and the associations of each exacerbation with the rate of subsequent events. Analyses were conducted separately for pediatric (<14 years old) and adult (⩾14 years old) patients. Results: Analyses were based on 3,039 pediatric (mean age at baseline, 6.4; 35% female) and 5,442 (mean age at baseline, 50.8; 68% female) adult patients. The 5-year rates of severe exacerbations after the first three events were 0.16, 0.29, and 0.35 for the pediatric group, and 0.14, 0.33, and 0.49 for the adult group. Both groups exhibited substantial variability in patient-specific risks of exacerbation: the mid-95% interval of 5-year risk of experiencing a severe exacerbation ranged from 11% to 24% in pediatric patients and from 8% to 40% in adult patients. After controlling for potential confounders, the first follow-up exacerbation was associated with an increase of 79% (95% confidence interval [CI], 11-189%) in the rate of subsequent events in the pediatric group, whereas this increase was 188% (95% CI, 35-515%) for the adult group. The effects of subsequent exacerbations were not statistically significant. Conclusions: After the first severe exacerbation, the risk of subsequent events is substantially different among patients. The number of previous severe exacerbations carries nuanced prognostic information about future risk. Our results suggest that severe exacerbations in the early course of asthma detrimentally affect the course of the disease and risk of subsequent exacerbations.

Discovery of a Highly Selective β2-Adrenoceptor Agonist with a 2-Amino-2-phenylethanol Scaffold as an Oral Antiasthmatic Agent

Asthma patients in resource-poor countries cannot obtain adequate basic asthma medications because most asthma medications are supplied as inhalants. An alternative approach is to create oral antiasthmatic drugs with high β₂/β₁-selectivity, which should reduce treatment costs. In this study, we designed a cohort of compounds 1 using 2-(4-amino-3-chloro-5-(trifluoromethyl)phenyl)-2-(tert-butylamino)ethan-1-ol hydrogen chloride (1a) as the lead compound with an aim to expand the library of compounds possessing the 2-amino-2-phenylethanol scaffold. Structure-activity relationship studies on these compounds revealed that compounds created showed remarkable β₂ selectivity compared to isoproterenol and gave additional insights on the rational design of β₂-adrenoceptor agonists. Moreover, 1a was found as the best candidate compound showing the greatest potential for drug development. Cell-based assays showed that 1a was about 10 times more selective than salbutamol toward the β₂-adrenoceptor. Moreover, 1a exhibited good oral bioavailability and low acute oral toxicity. These data reveal 1a as an oral antiasthmatic agent.

Sex Disparities in Asthma Development and Clinical Outcomes: Implications for Treatment Strategies

A gender-related disparity exists in asthma morbidity and mortality, which shifts at around puberty from a male predominance to a female predominance. This is clinically reflected in the fact that asthma that occurs in childhood (childhood-onset asthma) mainly affects boys, and that asthma that occurs in adulthood (adult-onset asthma) mainly affects women. Adult-onset asthma is often non-atopic, more severe, and associated with a poorer prognosis, thus posing a marked burden to women’s health and healthcare system. Many factors have been indicated to explain this gender-related disparity, including sociocultural and environmental factors as well as biological sex differences (genetic, pulmonary and immunological factors). It has long been suggested that sex hormones may be implicated in at least these biological sex differences. Overall, the evidence remains equivocal for the role of most sex hormones in asthma pathogenesis and clinical outcomes. Well-designed randomized clinical trials are required assessing the potential preventive or therapeutic effects of hormonal contraceptives on asthma in women, thereby helping to advance the evidence to inform future practice guidelines. The mechanisms underlying the role of sex hormones in asthma are complex, and our understanding is not yet complete. Additional mechanistic studies elucidating sex hormone signaling pathways and their interactions involved in the pathogenesis and clinical manifestations of asthma will help to identify potential sex hormone-driven asthma endotypes and novel therapeutic targets, providing the basis for a more personalized asthma management strategy.

An Elevated METS-IR Index Is Associated With Higher Asthma Morbidity and Earlier Age of First Asthma in US Adults: Results Based on a Cross-Sectional Study

OBJECTIVE

The purpose of this study was to evaluate whether there is a correlation between the METS-IR index and asthma among Americans.

METHODS

In an attempt to establish the relationship between the METS-IR index and asthma prevalence and age at first onset of asthma, we conducted a logistic regression analysis, subgroup analysis, and dose-response curve analysis using the National Health and Nutrition Examination Survey (NHANES) database.

RESULTS

In model 3, each unit increase in METS-IR index led to 1.5% increase in asthma prevalence (OR= 1.015, 95% CI: 1.012, 1.018) and an earlier age of onset of asthma by 0.057years (β= -0.057, 95% CI: -0.112, -0.002).Stratified analysis determined that an increase in METS-IR index was associated with asthma prevalence in almost all subgroups, except in the group where it was not known whether a blood relative had asthma, and a positive linear relationship was found between METS-IR index and asthma prevalence, as well as a linear negative relationship with age at asthma onset.

CONCLUSION

Despite the fact that a direct causal relationship cannot be demonstrated, a higher METS-IR index is positively related to asthma prevalence and correspondingly may result in asthma onset at younger ages.

Proximity to Heavy Traffic Roads and Patient Characteristics of Late of Onset Asthma in an Urban Asthma Center

Background: Traffic-related pollution is associated with the onset of asthma and the development of different phenotypes of asthma. Few studies have investigated the association between traffic proximity and late-onset of asthma (LOA) and early-onset asthma (EOA). This study was conducted to investigate the associations of LOA phenotypes with a function of the distance between residence and heavy traffic roads (HTRs).

Methods: The study group consisted of 280 patients who were (LOA: 78.4%) recruited consecutively from a pay-for-performance asthma program to clarify the patient characteristics and proximity to HTRs within 1,000 m from their residences between EOA and LOA in three urban centers in Taiwan. The subsequent analysis focused on patients with LOA (n = 210) linking phenotypes and distance to HTRs.

Results: Subjects with LOA tended to be older than those with EOA and had shorter asthma duration, poorer lung function, lower atopy, and less exposure to fumes or dust at home. Patients with LOA were more likely than those with EOA to live within 900 m of two or more HTRs (14.3 vs. 3.4%, p = 0.02). Among patients with LOA, minimum distance to an HTR was negatively associated with numbers of specific IgE as well as positively associated with the age of onset and body weight significantly. A higher proportion of patients with atopy (26.3 vs. 20.6%, p = 0.001. odds ratio [OR]: 2.82) and anxiety/depression (21.0 vs. 18.1%, p = 0.047. OR: 1.81) and a trend of lower proportion of patients with obese (5.7 vs. 12.4%, p = 0.075) were found to be living within 900 m from HTRs.

Conclusions: Late-onset of asthma (LOA) tended to live in areas of higher HTR density compared to EOAs. Among patients with LOA living close to HTRs, the interaction between traffic-related pollution, allergy sensitization, and mood status were the factors associated with asthma onset early. Obesity may be the factor for later onset who live far from HTRs.

Natural history and associated early life factors of childhood asthma: a population registry-based cohort study in Denmark

OBJECTIVE

Asthma is a common chronic disease that imposes a substantial burden on individuals and society. However, the natural history of childhood asthma in a large population remained to be studied. This study aimed to describe the natural course of childhood asthma and examine the association between early life factors and childhood asthma.

DESIGN

A population-based cohort study.

SETTING

This study was based on the national registry data in Denmark.

PARTICIPANTS

All liveborn singletons in Denmark during 1995-1997 were identified and followed them till the end of 2009. Finally, 193 673 children were eligible for our study.

EXPOSURES

The following characteristics were examined as potential early life factors associated with childhood asthma, including parity, maternal asthma history, maternal smoking during pregnancy, maternal social status, delivery method and gender.

MAIN OUTCOMES AND MEASURES

Asthma cases were identified on the basis of hospitalisation for asthma and prescriptions for antiasthmatic medications. Asthma remission was defined as no hospitalisation or prescription recorded for 2 years. Cox proportional hazards' regression and logistic regression were used to evaluate the association between early life factors and the occurrence and remission of childhood asthma.

RESULTS

The cumulative occurrence rate of asthma in children aged 3-14 years was 13.3% and the remission rate was 44.1%. The occurrence rate decreased with age. Being female had a lower risk of asthma (HR: 0.72, 95% CI 0.70 to 0.74) and higher remission rate of asthma (HR: 1.18, 1.13 to 1.22), while maternal asthma was associated with a higher risk of asthma (HR: 2.15, 2.04 to 2.26) and decreased remission rate of asthma (HR: 0.79, 0.73 to 0.85). These patterns remained the same for early onset asthma.

CONCLUSIONS

Female gender had a lower risk of asthma and a better chance of remission, while maternal asthma history had an opposite effect. The early life factors may influence the natural course of childhood asthma.

Asthma diagnosis: into the fourth dimension

Asthma is the most common chronic respiratory disease in the UK; however, the misdiagnosis rate is substantial. The lack of consistency in national guidelines and the paucity of data on the performance of diagnostic algorithms compound the challenges in asthma diagnosis. Asthma is a highly rhythmic disease, characterised by diurnal variability in clinical symptoms and pathogenesis. Asthma also varies day to day, seasonally and from year to year. As much as it is a hallmark for asthma, this variability also poses significant challenges to asthma diagnosis. Almost all established asthma diagnostic tools demonstrate diurnal variation, yet few are performed with standardised timing of measurements. The dichotomous interpretation of diagnostic outcomes using fixed cut-off values may further limit the accuracy of the tests, particularly when diurnal variability straddles cut-off values within a day, and careful interpretation beyond the 'positive' and 'negative' outcome is needed. The day-to-day and more long-term variations are less predictable and it is unclear whether performing asthma diagnostic tests during asymptomatic periods may influence diagnostic sensitivities. With the evolution of asthma diagnostic tools, home monitoring and digital apps, novel strategies are needed to bridge these gaps in knowledge, and circadian variability should be considered during the standardisation process. This review summarises the biological mechanisms of circadian rhythms in asthma and highlights novel data on the significance of time (the fourth dimension) in asthma diagnosis.

Systemic and breath biomarkers for asthma: an update

PURPOSE OF REVIEW

Finding suitable biomarkers to phenotype asthma, identify individuals at risk of worsening and guide treatment is highly prioritized in asthma research. We aimed to provide an analysis of currently used and upcoming biomarkers, focusing on developments published in the past 2 years.

RECENT FINDINGS

Type 2 inflammation is the most studied asthma mechanism with the most biomarkers in the pipeline. Blood eosinophils and fractional exhaled nitric oxide (FeNO) are those most used clinically. Recent developments include their ability to identify individuals at higher risk of exacerbations, faster decline in lung function and more likely to benefit from anti-IL-5 and anti-IL-4/-13 treatment. Certain patterns of urinary eicosanoid excretion also relate to type 2 inflammation. Results of recent trials investigating the use of serum periostin or dipeptidyl peptidase-4 to guide anti-IL-13 therapy were somewhat disappointing. Less is known about non-type 2 inflammation but blood neutrophils and YKL-40 may be higher in patients with evidence of non-type 2 asthma. Volatile organic compounds show promise in their ability to distinguish both eosinophilic and neutrophilic asthma.

SUMMARY

The ultimate panel of biomarkers for identification of activated inflammatory pathways and treatment strategies in asthma patients still lies in the future, particularly for non-type 2 asthma, but potential candidates are available.

Asthma Across the Ages: Adults

Asthma is a common disease affecting approximately 300 million people worldwide, across all age ranges. Despite advances in asthma outcomes of the last few decades, there remains room for improvement in asthma management and for patient outcomes, particularly in older patients. The heterogeneity of asthma is now well recognized, and is known to complicate response to treatment and patient behavior and impact health outcomes. Asthma and its heterogeneity change according to age. Asthma affects people differently across the life span. In adults, prevalence is highest among those in middle age; however, mortality is greater in the older age group. In this clinical commentary, we describe how age impacts asthma prevalence and incidence, outcomes, disease expression, and approach to management in adulthood and in older patients.

Asthma phenotypes and endotypes: a systematic review

INTRODUCTION

Asthma is a complex disorder characterized by expiratory airflow limitation, wheeze, shortness of breath, chest tightness and cough, which can vary over time and in intensity. Being highly heterogeneous, asthma was characterized and classified in several asthma phenotypes and endotypes from 1947 until today. The present systematic review aims to summarize and describe evidence that was published in the last ten years in the field of asthma phenotyping and endotyping.

EVIDENCE ACQUISITION

The systematic review resumed high-quality evidence (clinical trials and randomized control trials) retrieved on MEDLINE and EMBASE databanks and involving adult asthmatic populations. Analyses of literature were conducted according to PRISMA and CASP guidelines.

EVIDENCE SYNTHESIS

Querying MEDLINE and EMBASE databanks, 5019 and 12261 entries were retrieved, respectively. Applying limitations for year of publication, age of participants, and type of publication, the search results were reduced to 98 and 132 articles, respectively. After data abstraction and resolution of duplications, only 50 articles were further evaluated. The research products were then classified first in macro-areas of interest (phenotypes or endotypes) and then in detailed micro-areas.

CONCLUSIONS

This systematic review overviews the principal findings available from high-quality literature in the last decade concerning asthma phenotypes and endotypes. Asthma has been described from different points of view, characterizing symptoms, microbiota composition, comorbidities, viral infections, and airway and/or systemic inflammatory status. The comprehension of precise mechanisms underlying asthma pathogenesis is thereby the basis for the development of novel therapeutic strategies, likely essential to the development of precision medicine.

Asthma Remission by Age at Diagnosis and Gender in a Population-Based Study

BACKGROUND

Child-onset asthma is known to remit with high probability, but remission in adult-onset asthma is seemingly less frequent. Reports of the association between remission and asthma age of onset up to late adulthood are scarce.

OBJECTIVE

To evaluate the association between asthma remission, age at diagnosis and gender, and assess risk factors of nonremission.

METHODS

In 2016, a random sample of 16,000 subjects aged 20 to 69 years from Helsinki and Western Finland were sent a FinEsS questionnaire. Physician-diagnosed asthma was categorized by age at diagnosis to early- (0-11 years), intermediate- (12-39 years), and late-diagnosed (40-69 years) asthma. Asthma remission was defined by not having had asthma symptoms and not having used asthma medication in the past 12 months.

RESULTS

Totally, 8199 (51.5%) responded, and 879 reported physician-diagnosed asthma. Remission was most common in early-diagnosed (30.2%), followed by intermediate-diagnosed (17.9%), and least common in late-diagnosed asthma (5.0%) (P < .001), and the median times from diagnosis were 27, 18.5, and 10 years, respectively. In males, the corresponding remission rates were 36.7%, 20.0%, and 3.4%, and in females, 20.4%, 16.6%, and 5.9% (gender difference P < .001). In multivariable binary logistic regression analysis, significant risk factors of asthma nonremission were intermediate (odds ratio [OR] = 2.15, 95% confidence interval: 1.37-3.36) and late diagnosis (OR = 11.06, 4.82-25.37) compared with early diagnosis, chronic obstructive pulmonary disease (COPD) (OR = 5.56, 1.26-24.49), allergic rhinitis (OR = 2.28, 1.50-3.46), and family history of asthma (OR = 1.86, 1.22-2.85). Results were similar after excluding COPD.

CONCLUSION

Remission was rare in adults diagnosed with asthma after age 40 years in both genders. Late-diagnosed asthma was the most significant independent risk factor for nonremission.

Remission of adult-onset asthma is rare: a 15-year follow-up study

Background

There are few long-term clinical follow-up studies of adult-onset asthma. The aim of this article was to study clinical characteristics of adult-onset asthma in relation to remission and persistence of the disease in a 15-year follow-up.

Methods

A cohort of 309 adults aged 20–60 years with asthma onset during the last 12 months verified by bronchial variability, was recruited between 1995 and 1999 from the general population in northern Sweden. The cohort was followed-up in 2003 (n=250) and between 2012 and 2014 (n=205). Structured interviews and spirometry were performed at recruitment and the follow-ups. Bronchial hyperreactivity (BHR) and skin-prick tests were performed at recruitment and blood samples were collected at the last follow-up. Remission of asthma was defined as no asthma symptoms and no use of asthma medication during the last 12 months.

Results

Of eight individuals in remission in 2003, five had relapsed between 2012 and 2014 and in total, 23 (11%) were in remission, while 182 had persistent asthma. Those in remission had higher mean forced expiratory volume in 1 s % predicted at recruitment than those with persistent asthma (94.6 versus 88.3, p=0.034), fewer had severe BHR (27.3% versus 50.9%, p=0.037) and they had less body mass index increase (+1.6 versus +3.0, p=0.054). Of those with persistent asthma, 13% had uncontrolled asthma and they had higher levels of blood neutrophils than those with partly controlled or controlled asthma.

Conclusion

Higher forced expiratory volume in 1 s % predicted and less-severe BHR was associated with remission of adult-onset asthma, but still, the proportion in remission in this 15-year follow-up was low.

In this 15-year follow-up of a cohort with adult-onset asthma, the remission rate was low, and predictors of remission were higher FEV₁ % predicted and less-severe bronchial hyperreactivity at asthma onsethttps://bit.ly/2FEgoFa

Remission and Changes in Severity Over 30 Years in an Adult Asthma Cohort

BACKGROUND

Long-term follow-up studies of adults with well-characterized asthma are sparse.

OBJECTIVE

We aimed to examine long-term remission and change in disease severity over 30 years in adults with asthma.

METHODS

A total of 125 individuals diagnosed with asthma between 1974 and 1990 at a Danish respiratory and allergy clinic, based on history and objective assessments, were included. At follow-up (2017-2019), participants completed questionnaires and had spirometry, bronchodilator reversibility, airway responsiveness, and blood biomarkers measured. Based on these assessments, participants were classified as having either active asthma, clinical remission (no symptoms or prescribed asthma medication within the last year), or complete remission (fractional exhaled nitric oxide <50 parts per billion, no bronchodilator reversibility, no airway hyperresponsiveness, and no airflow limitation). Changes in severity were determined according to Global Initiative for Asthma guidelines based on symptom control and currently prescribed medication.

RESULTS

At follow-up, 25% (n = 31) and 15% (n = 19), respectively, had clinical and complete remission. Our analyses showed that a longer duration of symptoms before the initial assessment (odds ratio, 0.86; 95% confidence interval, 0.75-0.98) was associated with a lower chance of asthma remission. At follow-up, 30% had well-controlled asthma compared with none at baseline. Female sex, previous severe exacerbation(s), and older age at baseline were associated with uncontrolled asthma at follow-up. Blood-eosinophil count (≥0.3 × 10⁹/L) and prescribed inhaled corticosteroid (ICS) at baseline were associated with being prescribed medium/high-dose ICS at follow-up.

CONCLUSION

Despite 30 years of follow-up, asthma rarely remits in adults, especially in individuals with longer duration and presumably more severe disease. Initial signs of pronounced disease activity were associated with uncontrolled asthma at follow-up.

The Relationship of Asthma Biologics to Remission for Asthma

Asthma treatments have evolved from bronchodilators to interventions directed toward the regulation of airway inflammation. From these advances has come greater disease control and reduced morbidity. The addition of biologics directed toward specific pathways of inflammation has advanced the efficacy of asthma control. With these treatment advances, a renewed interest in achieving a remission in asthma has arisen. Although asthma remission has been considered to reflect a "cure," new evaluations of this concept have proposed criteria for remission while on treatment. These criteria reflect a high level of disease control including absence of symptoms, optimization and stabilization of lung function, and absence of the use of systemic corticosteroids and have been proposed to indicate a remission of disease activity. Given the added efficacy found with biologics in asthma treatment for patients with moderate to severe disease, the question has arisen as to whether the use of biologics meets criteria for remission and may this change a component of underlying disease and risks. Biologics are highly effective in reducing exacerbations, diminishing symptoms, and improving lung function in well-defined asthma populations. At present, however, biologics achieve some, but in most cases not all criteria for a remission on treatment. However, the concept of promoting treatment efforts to achieve disease remission in asthma is important, potentially achievable, and merits consideration for future guideline-directed care approaches.

Rapid effect of benralizumab for severe asthma with chronic rhinosinusitis with nasal polyps

BACKGROUND

The anti-interleukin (IL)-5 agent benralizumab has recently become available for treatment of severe asthma with promising results; however, it appears effective only in specific subgroups of asthma patients. Severe asthma with chronic rhinosinusitis/nasal polyps (CRSwNP or eosinophilic chronic rhinosinusitis, ECRS) is a severe eosinophilic asthma phenotype that necessitates individualized treatment.

OBJECTIVE

To assess differences in response to benralizumab between severely eosinophilic asthma patients with and without CRSwNP.

METHODS

Seventeen outpatients with severe eosinophilic asthma treated with benralizumab for 1 year were evaluated at the Osaka Habikino Medical Center. Blood eosinophil count, Asthma Control Questionnaire 5 (ACQ5), Asthma Quality of Life Questionnaire (AQLQ), fractional exhaled nitric oxide (FeNO), and spirometry were recorded at weeks 0, 4, 16, 24, and 50.

RESULTS

ACQ5 and AQLQ in CRSwNP(+) groups improved significantly after 4, 16, 24, and 50 weeks (p = 0.0195, 0.0156, 0.0117, and 0.0078 and p = 0.0098, 0.0098, 0.0029, and 0.0098, respectively) of benralizumab treatment. ACQ5 in CRSwNP(-) groups did not improve significantly after benralizumab treatment, but AQLQ improved significantly after 24 (p = 0.0313) and 50 weeks (p = 0.0313). Forced expiratory volume in 1s (FEV1) predicted in CRSwNP(+) groups were improved significantly after 4 weeks (p = 0.0137), 16 weeks (p = 0.0127), 24 weeks (p = 0.0098) and 50 weeks (p = 0.0420) of benralizumab treatment. %FEV1 in CRSwNP(-) groups were improved significantly after 24 weeks (p = 0.0313) and 50 weeks (p = 0.0313) of benralizumab treatment (Fig. 3). Forced vital capacity (FVC) predicted in CRSwNP(+) groups were improved significantly after 24 weeks (p = 0.0195) and %FVC in CRSwNP(-) groups improved significantly after 50 weeks (p = 0.0313) of benralizumab treatment. Maximum mid-expiratory flow rate predicted in CRSwNP(+) groups were improved significantly after 16 (p = 0.0137 and 50 weeks (p = 0.0371) of benralizumab treatment.

CONCLUSIONS

Benralizumab can exert a very rapid therapeutic action, detectable 4 weeks after treatment initiation in patients with severe eosinophilic asthma with CRSwNP. However, severe eosinophilic asthma without CRSwNP takes longer to respond to benralizumab treatment.

Outcome measures to be considered on asthma in elderly

PURPOSE OF REVIEW

Asthma is a chronic heterogeneous respiratory disease which is characterized by airflow limitation and variable respiratory symptoms. Asthma in patients more than 65 years of age has an important negative impact on quality of life. The pathophysiology and treatment of asthma in older patients are not as well identified as in younger groups of ages. In this review we intend to outline characteristics found in elderly adults which distinguish them from other age groups of patients with asthma.

RECENT FINDINGS

With increasing age, there are alterations in the innate and adaptive immune responses, known as 'immunosenescence.' These age-associated modifications include an altered response after a pathogenic exposure or tissue injury, moderately mediated through an irreversible loss of cellular replication and defective tissue repair.

SUMMARY

Asthma is a consequence of complex gene-environment interactions, with diversity in clinical presentation and the type and intensity of airway inflammation and remodeling. Age-associated changes in lung physiology and morphology may occur and contribute to asthma. Aging is correlated with a notable decrease in elastic recoil, greater chest wall rigidity, and poor respiratory muscle strength. Underreporting of symptoms by elderly patients is common because of multiple underlying causes. VIDEO ABSTRACT: http://links.lww.com/COAI/A17.

Effectiveness of omalizumab in patients with severe allergic asthma with and without chronic rhinosinusitis with nasal polyps: a PROXIMA study post hoc analysis

Background

A significant proportion of patients with severe asthma may also suffer from nasal polyposis, which is commonly defined as chronic rhinosinusitis with nasal polyps (CRSwNP), the presence of which may adversely affect asthma treatment outcomes. The biologic agent omalizumab is effective as add-on therapy in patients with severe allergic asthma. The aim of this post hoc analysis of the PROXIMA study was to compare the efficacy of omalizumab between patients with severe allergic asthma, with and without comorbid CRSwNP.

Methods

PROXIMA was a prospective observational 2-part study conducted in Italy in adult patients with severe allergic asthma, where, in the second part, patients eligible for add-on omalizumab initiated treatment for 12 months. Patient baseline data such as comorbidities and history of exacerbations were collected. Outcomes were asthma control (Asthma Control Questionnaire [ACQ]), lung function (forced expiratory volume in 1 s [FEV₁]) and exacerbation rate. The post hoc analysis compared these outcomes between the cohort with comorbid CRSwNP and the cohort without CRSwNP.

Results

Of 123 patients included in this analysis, 17 (13.8%) were in the CRSwNP cohort. There was no significant difference between cohorts in baseline clinical characteristics or in change from baseline at 12 months in ACQ values,  % of predicted FEV₁ or annual asthma exacerbation rate, although results were numerically in favor of the CRSwNP cohort versus the non-CRSwNP cohort. The proportion of patients who achieved an improvement in all three outcomes was numerically greater in the CRSwNP cohort (35.7% vs 23.0%).

Conclusions

In an observational real-world setting, add-on omalizumab for severe allergic asthma was effective in improving asthma control, lung function and in reducing exacerbations, including in those patients with CRSwNP.

The first year of treatment predicts the prognosis of asthma over 25 y-A prospective study

BACKGROUND

An investigator-driven, real-life follow-up study of adult-onset steroid-naïve, newly diagnosed asthma (162 patients) to investigate the treatment results over the 25-year course of the disease and whether the first treatment year's forced expiratory volume in one second (FEV₁ ) predicts the long-term prognosis.

METHODS

Eighty-three per cent of the 133 living patients participated in the 25-year examinations. At this visit, basic asthma examinations including lung function, as well as questionnaires for health-related quality of life (HRQoL), GINA and the Asthma Control Test, were used for evaluation. The use of medication and remission was verified.

RESULTS

There was no statistically significant change in mean FEV₁ % predicted (FEV₁ %) from baseline to the 25-year control. The changes in FEV₁ % during the first year predicted the results at the end of follow-up. Normal FEV₁ % at the end of the first year predicted normal FEV₁ , and below-normal FEV₁ % at 1 year predicted below-normal FEV₁ % at 25 years. Twenty-nine patients (26.4%) had discontinued their medication, and six (5.5%) used ICS periodically. Clinical remission was reached by 16.4% of the patients, and 7.6% reached functional remission. The general HRQoL remained unchanged.

CONCLUSION

In adult-onset asthma, the level of FEV₁ reached during the first treatment year seems to predict the later lung function level. One quarter of the patients discontinued the asthma treatment, but their HRQoL was better than that of those continuing to use ICS. Clinical remission was reached by 16% of the patients, which is in concordance with other studies.

An expert consensus framework for asthma remission as a treatment goal

With novel therapies in development, there is an opportunity to consider asthma remission as a treatment goal. In this Rostrum, we present a generalized framework for clinical and complete remission in asthma, on and off treatment, developed on the basis of medical literature and expert consensus. A modified Delphi survey approach was used to ascertain expert consensus on core components of asthma remission as a treatment target. Phase 1 identified other chronic inflammatory diseases with remission definitions. Phase 2 evaluated components of those definitions as well as published definitions of spontaneous asthma remission. Phase 3 evaluated a remission framework created using consensus findings. Clinical remission comprised 12 or more months with (1) absence of significant symptoms by validated instrument, (2) lung function optimization/stabilization, (3) patient/provider agreement regarding remission, and (4) no use of systemic corticosteroids. Complete remission was defined as clinical remission plus objective resolution of asthma-related inflammation and, if appropriate, negative bronchial hyperresponsiveness. Remission off treatment required no asthma treatment for 12 or more months. The proposed framework is a first step toward developing asthma remission as a treatment target and should be refined through future research, patient input, and clinical study.

Advances in asthma, asthma-COPD overlap, and related biologics in 2018

Over the past year, numerous important advances in our understanding of multiple aspects of asthma, ranging from disease pathogenesis to epidemiology to therapeutics, have been reported. This review is a compilation of highlights from articles published largely in the Journal of Allergy and Clinical Immunology and supplemented by articles published elsewhere that have substantially advanced the fields of asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlap and biologic therapies for these disorders. The intention of this article is not to provide a comprehensive review but rather to focus on several areas that have developed quickly and/or received extensive attention from our readers.

Asthma from immune pathogenesis to precision medicine

Asthma is characterized by multiple immunological mechanisms (endotypes) determining variable clinical presentations (phenotypes). The identification of endotypic mechanisms is crucial to better characterize patients and to identify tailored therapeutic approaches with novel biological agents targeting specific immunological pathways. This review focused on summarizing the major immunological mechanisms involved in the pathogenesis of asthma, as well as on discussing the emergence of phenotypic features of the disease. Novel biological agents and other drugs targeting specific endotypes are discussed, as their use represent a precision medicine approach to the disease that is nowadays mandatory particularly for treating more severe patients.

Prevalence of Asthma and COPD and Blood Eosinophil Count in a Middle-Aged Belgian Population

Various phenotypes exist in asthma and Chronic Obstructive Pulmonary Disease (COPD). These are important to identify in order to guide treatment decisions. We aim to investigate the prevalence and clinical characteristics of obstructive airway diseases in the middle-aged population. We estimated the prevalence of COPD and/or asthma in the Asklepios cohort study (Belgium), using information from the third European Community Respiratory Health Survey (ECRHS3), medical records, and spirometry. Respiratory symptoms, respiratory medication, and current disease status distinguished clinical from sub-clinical cases. In addition, we compared the blood eosinophil count/µL (median [IQR]) between cases and controls. Of the 2221 participants (mean age 56.1 ± 5.9 years; 48.7% males), 138 (6.2%) participants had clinical current asthma, 22 (1.0%) participants had sub-clinical ever asthma, 102 (4.6%) had sub-clinical spirometry-defined COPD, 104 (4.6%) participants had clinical spirometry-confirmed COPD, and 11 (0.5%) had asthma and COPD overlap (ACO). Clinical current asthma (160.0 [110.0–250.0]), sub-clinical ever asthma (170.0 [110.0–230.0]), and clinical COPD (160.0 [110.0–220.0])—but less sub-clinical COPD (140.0 [90.0–210.0])—had higher eosinophil counts, compared to controls (130.0 [80.0–200.0]). We conclude that obstructive airway diseases are prevalent in the middle-aged Asklepios cohort. Moreover, the systemic eosinophil count is increased in clinical COPD cases, and in asthma cases regardless of clinical remission.

Dupilumab Efficacy in Uncontrolled, Moderate-to-Severe Asthma with Self-Reported Chronic Rhinosinusitis

BACKGROUND

Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for IL-4 and IL-13 signaling, key drivers of type 2 inflammation. In the phase 3 study (NCT02414854), add-on dupilumab 200 mg/300 mg every 2 weeks, versus placebo, significantly reduced severe asthma exacerbations and improved pre-bronchodilator forced expiratory volume in 1 second (FEV₁) and quality-of-life measures in patients with uncontrolled, moderate-to-severe asthma, with greater efficacy observed in those with a high baseline type 2 phenotype.

OBJECTIVE

To assess the efficacy and safety of dupilumab in patients with uncontrolled, moderate-to-severe asthma with or without self-reported comorbid chronic rhinosinusitis (CRS or non-CRS).

METHODS

Comorbid CRS was self-reported by patients using an e-diary. Annualized severe exacerbation rates, changes from baseline in pre- and post-bronchodilator FEV₁, patient-reported outcomes, type 2 biomarkers, and safety were assessed.

RESULTS

CRS was self-reported by 382 of 1902 (20.1%) patients. Dupilumab 200 mg/300 mg reduced annualized severe exacerbation rates by 63%/61%, respectively, in patients with CRS, and by 42%/40% in patients without CRS (all P < .001 vs placebo). Dupilumab also improved lung function and patient-reported asthma control and quality of life, and suppressed type 2 biomarkers versus placebo in both subgroups. Clinical responses were rapid, with near-maximal responses observed at the earliest measured time points and sustained at week 52. Improvements observed in the CRS subgroup were similar to or numerically greater than those in the non-CRS subgroup.

CONCLUSION

Dupilumab showed efficacy and was generally well tolerated in patients with uncontrolled, moderate-to-severe asthma with or without CRS.

A review on the pathophysiology of asthma remission

Asthma is a chronic respiratory condition, which is highly prevalent worldwide. Although no cure is currently available, it is well recognized that some asthma patients can spontaneously enter remission of the disease later in life. Asthma remission is characterized by absence of symptoms and lack of asthma-medication use. Subjects in asthma remission can be divided into two groups: those in clinical remission and those in complete remission. In clinical asthma remission, subjects still have a degree of lung functional impairment or bronchial hyperresponsiveness, while in complete asthma remission, these features are no longer present. Over longer periods, the latter group is less likely to relapse. This remission group is of great scientific interest due to the higher potential to find biomarkers or biological pathways that elicit or are associated with asthma remission. Despite the fact that the definition of asthma remission varies between studies, some factors are reproducibly observed to be associated with remitted asthma. Among these are lower levels of inflammatory markers, which are lowest in complete remission. Additionally, in both groups some degree of airway remodeling is present. Still, the pathological disease state of asthma remission has been poorly investigated. Future research should focus on at least two aspects: further characterisation of the small airways and airway walls in order to determine histologically true remission, and more thorough biological pathway analyses to explore triggers that elicit this phenomenon. Ultimately, this will result in pharmacological targets that provide the potential to steer the course of asthma towards remission.

A high blood eosinophil count may be a risk factor for incident asthma in population at risk

BACKGROUND

Eosinophilia is considered to be associated with allergic disease and may predict asthma exacerbation. Eosinophils contribute to the pathophysiology and pathogenesis of asthma. However, studies on high blood eosinophil counts (BECs) and incident asthma remain scarce.

OBJECTIVE

To examine whether high BECs are positively associated with incident asthma in adults.

METHODS

Our study included 57975 participants aged from 20 to 79 years from the Shandong multi-center health check-up longitudinal study for Health Management. All patients with determined baseline BECs were ≥20 years old and free from asthma. We defined incident asthma as self-reported new-onset asthma occurring during the 10-year follow-up period. Multivariate modeling employed Poisson regression and Cox proportional hazards models to verify the association between BEC and incident asthma by adjusting demographics and some relevant comorbidities (rhinitis, nasal polyps, pneumonia, bronchitis, and chronic obstructive pulmonary disease).

RESULTS

A BEC ≥110 cells/μL was a risk factor for incident asthma (adjusted IRR = 1.62, 95% CI: 1.05-2.50, P = .028) in the Poisson regression. In the Cox proportional hazards model, the BEC cutoff point for incident asthma was also determined to be 110 cells/μL (HR = 1.59, 95% CI: 1.01-2.51, P = .045).

CONCLUSION

A high BEC is a risk factor for incident asthma, especially when the BEC exceeds 110 cells/μL. This suggests that adults with high BECs are more likely to develop asthma.

Bronchoprovocation Testing in Asthma: An Update

Bronchial hyperresponsiveness (BHR) is defined as a heightened bronchoconstrictive response to airway stimuli. It complements the cardinal features in asthma, such as variable or reversible airflow limitation and airway inflammation. Although BHR is considered a pathophysiologic hallmark of asthma, it should be acknowledged that this property of the airway is dynamic, because its severity and even presence can vary over time with disease activity, triggers or specific exposure, and with treatment. In addition, it is important to recognize that there is a component that is not reflective of a specific disease entity.

Severe Occupational Asthma: Insights From a Multicenter European Cohort

BACKGROUND

Although sensitizer-induced occupational asthma (OA) accounts for an appreciable fraction of adult asthma, the severity of OA has received little attention.

OBJECTIVE

The aim of this study was to characterize the burden and determinants of severe OA in a large multicenter cohort of subjects with OA.

METHODS

This retrospective study included 997 subjects with OA ascertained by a positive specific inhalation challenge completed in 20 tertiary centers in 11 European countries during the period 2006 to 2015. Severe asthma was defined by a high level of treatment and any 1 of the following criteria: (1) daily need for a reliever medication, (2) 2 or more severe exacerbations in the previous year, or (3) airflow obstruction.

RESULTS

Overall, 162 (16.2%; 95% CI, 14.0%-18.7%) subjects were classified as having severe OA. Multivariable logistic regression analysis revealed that severe OA was associated with persistent (vs reduced) exposure to the causal agent at work (odds ratio [OR], 2.78; 95% CI, 1.50-5.60); a longer duration of the disease (OR, 1.04; 95% CI, 1.00-1.07); a low level of education (OR, 2.69; 95% CI, 1.73-4.18); childhood asthma (OR, 2.92; 95% CI, 1.13-7.36); and sputum production (OR, 2.86; 95% CI, 1.87-4.38). In subjects removed from exposure, severe OA was associated only with sputum production (OR, 3.68; 95% CI, 1.87-7.40); a low education level (OR, 3.41; 95% CI, 1.72-6.80); and obesity (OR, 1.98; 95% CI, 0.97-3.97).

CONCLUSIONS

This study indicates that a substantial proportion of subjects with OA experience severe asthma and identifies potentially modifiable risk factors for severe OA that should be targeted to reduce the adverse impacts of the disease.