Determinants of Incomplete Asthma Control in Patients with Allergic Rhinitis and Asthma

Update on the Role of FeNO in Asthma Management

Asthma is a heterogenous disorder characterized by presence of different phenotypes and endotypes. Up to 10% of the individuals suffer from severe asthma and are at increased risk of morbidity and mortality. Fractional exhaled nitric oxide (FeNO) is a cost-effective, point of care biomarker that is used to detect type 2 airway inflammation. Guidelines have proposed to measure FeNO as an adjunct to diagnostic evaluation in individuals with suspected asthma and to monitor airway inflammation. FeNO has lower sensitivity, suggesting that it may not be a good biomarker to rule out asthma. FeNO may also be used to predict response to inhaled corticosteroids, predict adherence and deciding on biologic therapy. Higher levels of FeNO have been associated with lower lung function and increased risk for future asthma exacerbations and its predictive value increases when combined with other standard measurements of asthma assessment.

Effectiveness of mobile health interventions to improve nasal corticosteroid adherence in allergic rhinitis: A systematic review

BACKGROUND

Mobile health interventions (MHI) offer the potential to help improve nasal corticosteroid (NCS) adherence in allergic rhinitis (AR). The aim of this systematic review was to summarise the current evidence on the effectiveness of MHI for improving NCS adherence in AR.

METHODS

We systematically searched MEDLINE, Embase and the Cochrane Central register of Controlled Trials (CENTRAL) for randomised controlled trials filtered for publication dates between 2010 and 2021. We evaluated the effects of MHI aiming to improve NCS adherence on self-management outcomes in AR and comorbid conditions. Two reviewers independently screened potential studies, extracted study characteristics and outcomes from eligible papers and assessed risk of bias using the Cochrane Risk of Bias tool 2.0. High heterogeneity precluded meta-analysis. Data were descriptively and narratively synthesised.

RESULTS

Our searches identified 776 individual studies of which 4 met the inclusion criteria. These studies were heterogeneous with respect to participant, intervention and outcome characteristics. We considered all outcome-specific overall risk of bias assessments to be of high risk of bias except for two studies examining NCS adherence which received 'some concern' grades. The three studies which reported on NCS adherence found that MHI were associated with improvement in NCS adherence. Significant MHI-associated improvement in symptoms or disease-specific quality of life was found in one study each, whilst no study reported significant differences in nasal patency.

CONCLUSIONS

Whilst MHI showed potential to improve NCS adherence, their effect on clinical outcomes varied. Furthermore, robust studies with longer intervention durations are needed to adequately assess effects of MHI and their individual features on NCS adherence and clinical outcomes.

Rhinitis and Asthma Patient Perspective (RAPP): Clinical Utility and Predictive Value

BACKGROUND

RhinAsthma Patient Perspective (RAPP) is the only validated tool for assessing of health-related quality of life (HRQoL) related to asthma and rhinitis in individual patients.

OBJECTIVE

To compare the HRQoL burden among countries and explore the usefulness of RAPP as a complementary measure in disease management.

METHODS

In this post hoc analysis of the RAPP International Study, the enrolled population was clustered into patients with controlled rhinitis and controlled asthma (CA/CR), uncontrolled rhinitis and controlled asthma (CA/UR), controlled rhinitis and uncontrolled asthma (UA/CR), and uncontrolled rhinitis and uncontrolled asthma (UA/UR).

RESULTS

We recruited 575 adult patients. Significant differences among countries were observed in the mean RAPP score (from 15.7 in Spain to 18.7 in the Philippines) although the percentage of subjects with an optimal HRQoL (RAPP <15) was not significantly different. Compared with patients with AR and asthma disease control, those with UR/CA, CR/UA, and UR/UA had significantly higher RAPP scores (4.7, 5, and 9.8, respectively). The best cutoffs for detecting uncontrolled diseases were RAPP of 15 or greater (SE = 75%; specificity = 69%; and area under the receiver operating characteristic curve [AUC] = 0.78) for AR; RAPP of 16 or greater (SE = 78%; specificity = 76%; and AUC = 0.83) for asthma; and RAPP of 18 or greater (SE = 86%; specificity = 87%; and AUC = 0.92) for both AR and asthma.

CONCLUSIONS

These findings provide a better understanding of the individual burden of HRQoL related to asthma and rhinitis in daily practice. In addition, the RAPP estimates how much of the risk for uncontrolled disease depends on uncontrolled AR and asthma, allowing its use as a clinical support tool in clinical management.

Association Between a Type 2 Inflammatory Disease Burden Score and Outcomes Among Patients with Asthma

Background

Although prevalence of co-existing type 2 inflammatory diseases (cT2) in asthma patients has been reported, limited data exist regarding their impact on asthma outcomes.

Objective

To assess the impact of cT2 burden on asthma outcomes and to evaluate patterns of clustering of cT2 in a real-world setting.

Methods

From medical records of 4.5 million enrollees in 650 primary care practices in the UK (January 2010–December 2017), patients with ≥1 diagnosis code for asthma at any time pre-index date (date of most recent asthma-related medical encounter) and ≥2 asthma-related prescriptions during the year before index date were categorized into the Global Initiative of Asthma (GINA) guideline severity steps. A cT2 burden score (range 0–9) was assigned based on the total number of co-existing conditions (allergic conjunctivitis, allergic rhinitis, anaphylaxis, eczema/atopic dermatitis, chronic rhinosinusitis, eosinophilic esophagitis, food allergy, nasal polyps, or urticaria) for which patients received a medical diagnosis. Multivariate regression models evaluated associations between cT2 burden score and asthma exacerbations and asthma control. Factor analysis was performed to assess which cT2 comorbidities were correlated and exhibited patterns of clustering.

Results

Overall, 245,893 patients with asthma were included (mean [SD] age 44.8 [22.1] years; 43.8% male). Between 55% (GINA step 1) and 60% (GINA step 5) of asthma patients had a medical diagnosis for ≥1 other type2dx. Patients with increased cT2 burden were significantly more likely to experience asthma exacerbations and less likely to achieve asthma control.

Conclusion

Asthma patients with a higher cumulative cT2 burden score were more likely to experience worse asthma outcomes than those without any cT2 (burden score of 0).

Management of adult asthma and chronic rhinitis as one airway disease

Introduction: Chronic rhinitis is defined as nasal inflammation with the presence of minimum two symptoms such as nasal obstruction, rhinorrhea, sneezing and/or itching one hour daily for a minimum of 12 weeks/year. According their etiology, four groups of rhinitis are described: allergic, infectious, non-allergic non-infectious and mixed.Chronic rhinitis is frequently associated with asthma, shares similar mechanisms of the pathogenesis and has a negative impact of its outcomes sustaining the concept of unified airways disease.Areas covered: The present review summarizes the complex relationship between chronic rhinitis and asthma on the basis of recent epidemiological data, clinical characteristics, diagnosis and therapeutic management. All four groups are discussed with the impact of their specific treatment on asthma outcomes. Some medications are common for chronic rhinitis and asthma while others are more specific but able to treat the associated comorbidity.Expert opinion: The systematic assessment of chronic rhinitis in patients with asthma and its specific treatment improves both disease outcomes. Conversely, several therapies of asthma demonstrated beneficial effects on chronic rhinitis. Treating both diseases at the same time by only one medication is an interesting option to explore in the future in order to limit drugs administration, related costs and side effects.

The relationship between asthma control and health-related quality of life in asthma and the role of atopy: a cross-sectional study of Nigerian adult asthmatics

Introduction

the relationship between asthma control and health-related quality of life (HRQoL) in adult asthmatics is fairly established, but the unique contribution of atopy to this relationship has received less attention. The aim of this study was to quantify the contribution of atopy to this relationship.

Methods

in a cross-sectional study, we assessed HRQoL using mini-Asthma Quality of Life Questionnaire (AQLQ). Asthma control, atopy and lung function were assessed using the Asthma Control Test (ACT), skin prick test and spirometry respectively. Hierarchical multiple regression was used to examine the association between of HRQol and asthma control, atopy and other clinical and demographical factors.

Results

eighty-two adult asthmatics (59 females), with median age of 44 years and median duration of asthma of 15 years were recruited from a tertiary hospital. Fifty-two (63%) were classified as atopic based on sensitization to at least one aeroallergen. The atopic individuals were younger and had better quality of life in activity domain; however, there was no significant difference between the atopic and non-atopic asthmatics in ACT score (19.0 vs 18.0) p=0.91, total AQLQ score (4.9 vs 4.6) p=0.22. The ACT scores correlated positively with total AQLQ scores [rho= 0.53, 95% Confidence Interval (CI) 0.35, 0.67; p< 0.001]. However, atopy contributed significantly to the emotional domain of HRQoL score, p=0.028.

Conclusion

we concluded that better asthma control is associated with better quality of life and atopy contributed uniquely to emotional domain in health-related quality of life.

Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document

OBJECTIVE

The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD).

METHODS

Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members.

RESULTS

The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life.

CONCLUSIONS

Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.

Multimorbidity in asthma, association with allergy, inflammatory markers and symptom burden, results from the Swedish GA2 LEN study

Background

Asthma is common worldwide and a large part of subjects with asthma have concomitant allergic multimorbidity in the form of rhinitis and/or eczema.

Objective

The aim of this study is to investigate whether the presence of allergic multimorbidity in asthma relates to allergic sensitization, allergic and respiratory symptoms, quality of life, inflammatory markers, lung function, use of medication and background factors.

Methods

A total of 437 asthmatics from the (GA²LEN) cross‐sectional survey in Sweden were grouped depending on the presence of rhinitis and/or eczema. The impact of allergic multimorbidity was assessed in terms of allergic sensitization, allergic and respiratory symptoms, quality of life, type‐2 inflammatory markers (exhaled nitric oxide, eosinophil activation markers, periostin), lung function, use of medication and background factors.

Results

Subjects with asthma, rhinitis and eczema were more likely to be sensitized to seasonal allergens (67% vs 32%, P < .001), food allergens (54% vs 18%, P < .001) and to have a higher degree of sensitization than subjects with only asthma (23% vs 10%, P < .001). Subjects with allergic multimorbidity more often had allergic reactions to food (28% vs 10%, P = .002), more respiratory symptoms and anxiety/depression (40% vs, 14%, P < .001) than subjects with only asthma, despite having similar levels of type 2 inflammatory markers. Individuals with allergic multimorbidity were more likely to be diagnosed with asthma before the age of 12 (48% vs 27%, P = .016) and to have maternal heredity for allergy (53% vs 33%, P = .011) than subjects with only asthma.

Conclusion and clinical relevance

Asthmatics with allergic multimorbidity are more likely to be sensitized to seasonal aeroallergens, food allergens and they have a higher degree of sensitization compared with those with only asthma. Allergic multimorbidity is associated with respiratory and allergy symptoms, anxiety and/or depression.

Nasal nitric oxide in relation to asthma characteristics in a longitudinal asthma cohort study

OBJECTIVE

Cross-sectional studies report relations between low nasal nitric oxide (nNO) and poor asthma control and between low nNO and chronic rhinosinusitis (CRS). In our cohort study, we studied if changes in nNO related to changes in asthma control, symptoms of CRS, or asthma or rhinitis medication.

METHODS

A total of 196 subjects with predominantly mild to moderate asthma, aged 10-35 years, performed nNO measurements at both baseline and follow-up after a median of 43 (range 23-65) months. Asthma control, CRS symptoms, and medication, were questionnaire-assessed at both timepoints. IgE sensitisation against aeroallergens was quantified at baseline.

RESULTS

There was an increase in nNO between baseline and follow-up (764 ± 269 ppb vs. 855 ± 288 ppb, p < 0.001). When adjusted for covariates, a larger increase in nNO was found in subjects sensitised to perennial aeroallergens than those not sensitised (92 (16-167) ppb), as well as in subjects with daily use of inhaled corticosteroids (ICS) at baseline but not at follow-up than those on ICS daily at both timepoints (146 (51-242) ppb). In the same model, subjects using nasal steroids daily at both timepoints had decreased nNO compared with those without such treatment at both timepoints (-185 (-321-(-48)) ppb). No relations between changes in nNO levels and changes in asthma control or symptoms of CRS were found.

CONCLUSION

Longitudinal changes in nNO were not related to changes in asthma control, but were related to changes in asthma or rhinitis medication.

Eicosanoids seasonally impact pulmonary function in asthmatic patients with Japanese cedar pollinosis

BACKGROUND

Condition of asthma in patients with asthma and concomitant seasonal allergic rhinitis (SAR) deteriorates during the Japanese cedar pollen (JCP) season. However, the underlying mechanisms remain unclear.

METHODS

We analyzed seasonal variations in eicosanoid levels in the airways of patients with asthma and concomitant SAR sensitized to JCP (N = 29, BA-SAR-JCP group) and those not sensitized (N = 13, BA-AR-non-JCP group) during the JCP season. The association between changes in eicosanoid concentrations and pulmonary function was assessed. Exhaled breath condensate (EBC) was collected, and pulmonary function tests were performed during the JCP and non-JCP seasons. The cysteinyl leukotriene (CysLT), thromboxane B₂ (TXB₂), prostaglandin D₂-methoxime (PGD₂-MOX), and leukotriene B₄ (LTB₄) levels in the collected EBC were measured via enzyme-linked immunosorbent immunoassays.

RESULTS

The log CysLT levels significantly increased in the BA-SAR-JCP group during the JCP season compared with the non-JCP season (1.78 ± 0.55, 1.39 ± 0.63 pg/mL, mean ± standard deviation, respectively, p = 0.01) and those in the BA-AR-non-JCP group during the JCP season (1.39 ± 0.38 pg/mL, p = 0.04). Moreover, the log TXB₂ levels seemed to increase. However, the log LTB₄ and log PGD₂-MOX levels did not increase. The changes in the log CysLT levels during the two seasons were negatively correlated to forced expiratory volume in one second (FEV₁) in the BA-SAR-JCP group (r = -0.52, p < 0.01).

CONCLUSIONS

In the BA-SAR-JCP group, seasonal increases in eicosanoid levels in the airway likely promoted deterioration in pulmonary function despite optimal maintenance treatment.

Real-life safety and efficacy of omalizumab in Japanese patients with severe allergic asthma who were subjected to dosing table revision or expansion: A post-marketing surveillance

BACKGROUND

Omalizumab is an anti-immunoglobulin E monoclonal antibody approved for patients with severe allergic asthma in Japan. With regard to omalizumab dosage in Japanese adults with severe allergic asthma in clinical practice settings, this post-marketing surveillance evaluated safety and efficacy of the dosing table revision (DTR) based on a dosing regimen of omalizumab administration every 4 weeks dosing regimen and dosing table expansion (DTE) for patients with baseline IgE levels >700 IU/mL.

METHODS

This 52-week, multicenter study, conducted from September 2013 to November 2018, evaluated omalizumab safety outcomes including adverse events (AEs), serious AEs (SAEs), adverse drug reactions (ADRs), efficacy outcomes including Global Evaluation of Treatment Effectiveness (GETE), change in oral corticosteroid dose, and asthma exacerbation-related events such as hospitalization, emergency room visits, and worsening of symptoms.

RESULTS

Of the 405 patients registered in the study, safety was evaluated in 392 and efficacy in 390. The mean age of patients was 58.5 years and 58.7% were women. In total, 41.3% of the patients were subjected to DTE and 58.7% to DTR. In the safety dataset, 6.6% experienced an ADR, 32.9% experienced an AE, and 16.1% experienced an SAE. In the efficacy dataset, 63.3% of patients at Week 16 and 63.5% at Week 52 had an 'effective' or 'good' GETE score. Omalizumab was associated with a reduction in worsening of asthma symptoms requiring systemic corticosteroids and frequency of hospitalization. All outcomes were comparable among the DTE and DTR subgroups.

CONCLUSION

The findings from this study support the safety and efficacy of omalizumab administered based on the revised and expanded dosing table in Japanese patients with severe allergic asthma.

Janus looks both ways: How do the upper and lower airways interact?

Our understanding of the relationship between the upper and lower airways has greatly increased as a consequence of epidemiologic and pharmacologic studies. A consistent body of scientific evidence supports the concept that rhinitis, rhinosinusitis and asthma may be the expression of a common inflammatory process, which manifests at different sites of the respiratory tract, at different times. This paradigm states that allergic reactions may begin at the local mucosa, but tend to propagate along the airway. Central to the allergic diathesis is the eosinophil and its interaction with the airway epithelium. The implications of the interplay between upper and lower airway are not only academic, but also important for diagnostic and therapeutic reasons. Furthermore, there is significant overlap in symptomatology and pathophysiology for childhood sleep disordered breathing (SDB) and asthma. Recent evidence supports an association between these two conditions, but causality has not been demonstrated. Regardless, it is important to recognize the overlap and evaluate for the other condition when one is present. In children with poorly controlled asthma, the presence of SDB may significantly contribute to asthma morbidity and, as such, should be actively excluded. On the other hand, clinical evaluation for asthma should be considered in children with SDB. Future robust longitudinal research is needed to explore the association between upper and lower airway diseases using objective measures in children.

Fractional Exhaled Nitric Oxide (FENO) in the management of asthma: a position paper of the Italian Respiratory Society (SIP/IRS) and Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC)

Asthma prevalence in Italy is on the rise and is estimated to be over 6% of the general population. The diagnosis of asthma can be challenging and elusive, especially in children and the last two decades has brought evidences that asthma is not a single disease but consists of various phenotypes. Symptoms can be underestimated by the patient or underreported to the clinician and physical signs can be scanty. Usual objective measures, like spirometry, are necessary but sometimes not significant. Despite proper treatment, asthma can be a very severe condition (even leading to death), however new drugs have recently become available which can be very effective in its control. Since asthma is currently thought to be caused by inflammation, a direct measure of the latter can be of paramount importance. For this purpose, the measurement of Fractional Exhaled Nitric Oxide (FE_NO) has been used since the early years of the current century as a non-invasive, easy-to-assess tool useful for diagnosing and managing asthma. This SIP-IRS/SIAAIC Position Paper is a narrative review which summarizes the evidence behind the usefulness of FE_NO in the diagnosis, management and phenotypization of asthma.

Impact of sinus surgery on type 2 airway and systemic inflammation in asthma

Objective: Asthma is frequently associated with chronic rhinosinusitis with nasal polyps (CRSwNP). Although endoscopic sinus surgery (ESS) improves asthma control in CRSwNP patients with asthma, the mechanism that underlies the response to surgical treatment is still unclear. We evaluated the relevance of changes in asthma control and changes in airway/systemic inflammation in eosinophilic CRSwNP patients with not well controlled asthma who underwent ESS.Methods: We prospectively assessed changes in the asthma control questionnaire (ACQ) score, blood eosinophil counts (B-Eos), forced expiratory volume in 1 s (FEV₁), and fraction of exhaled nitric oxide (FeNO) levels at 1-week before and 8 and 52 weeks after ESS.Results: Twenty-five subjects were analyzed. The ACQ score, B-Eos, and FeNO decreased, and FEV₁ increased significantly after ESS. In the period from baseline to 52 weeks after ESS, changes in ACQ were significantly correlated with the changes in blood eosinophil counts (r = 0.58, p<.01) and FeNO (r = 0.45, p<.05). Ten subjects (40%) showed consistently improved asthma control at 52-weeks after ESS. In the remaining subjects, although the ACQ score temporarily improved at 8-weeks after ESS, but eventually deteriorated at 52-weeks. Higher levels of total immunoglobulin E were associated with long-term improved asthma control after ESS.Conclusions: In eosinophilic CRSwNP patients with asthma, sinus surgery impacts asthma control through the suppression of airway/systemic type 2 inflammation. The present study reinforced the common pathophysiology of type 2 inflammation between the upper and lower airways.

Prevalence and Predictors of Uncontrolled Asthma in Children Referred for Asthma and Other Atopic Diseases

Background

Uncontrolled asthma in children is still highly prevalent despite the availability of effective asthma treatment. We investigated 1) the prevalence of uncontrolled asthma among children referred for asthma and referred for atopic diseases other than asthma (ie food allergy, allergic rhinitis or atopic dermatitis) to secondary care; and 2) the predictors associated with uncontrolled asthma.

Methods

All children (4 to 18 years) referred for asthma or atopic diseases other than asthma to 8 secondary care centers in The Netherlands were invited to an electronic portal (EP). The EP is a web-based application with several validated questionnaires including the ISAAC questionnaires and the Asthma Control Test (ACT). Children were eligible for inclusion in this study when their parents reported in the EP that their child had asthma diagnosed by a physician. The ACT was used to assess asthma control. Multiple predictors of asthma control (patient, asthma and atopic characteristics) were evaluated by univariable and multivariable logistic regression analyses.

Results

We included 408 children: 259 children (63%) with asthma referred for asthma and 149 children (37%) with asthma referred for atopic diseases other than asthma. Thirty-nine percent of all children had uncontrolled asthma: 47% of the children referred for asthma and 26% of the children referred for atopic diseases other than asthma. Predictors associated with uncontrolled asthma were a family history of asthma (odds ratio [OR] 2.08; 95% confidence interval [95% CI] 1.34 to 3.24), and recurrent upper and lower respiratory tract infections in the past year (OR 2.40; 95% CI 1.52 to 3.81 and OR 2.00; 95% CI 1.25 to 3.23, respectively).

Conclusion

Uncontrolled asthma is highly prevalent in children with asthma referred to secondary care, even if children are primarily referred for atopic diseases other than asthma. Thus, attention should be paid to asthma control in this population.

Effect of omalizumab on lung function and eosinophil levels in adolescents with moderate-to-severe allergic asthma

BACKGROUND

Omalizumab improves clinical outcomes in patients with asthma. Several studies have shown lung function improvements with omalizumab; however, this has not been examined exclusively in adolescents.

OBJECTIVE

To assess the effect of omalizumab on lung function and eosinophil counts in adolescents with uncontrolled moderate-to-severe allergic asthma.

METHODS

In this post hoc analysis, data from adolescents aged 12 to 17 years from 8 randomized trials of omalizumab were pooled (studies 008, 009, and 011, and SOLAR, INNOVATE, ALTO, ETOPA, and EXTRA). Changes from baseline to end of study in forced expiratory volume in 1 second (FEV₁), percent predicted FEV₁ (ppFEV₁), forced vital capacity (FVC), and blood eosinophil counts were assessed by fitting an analysis of covariance model and calculating least squares mean (LSM) difference for omalizumab vs placebo.

RESULTS

A total of 340 adolescents were identified (omalizumab, n = 203 [59.7%]; placebo, n = 137 [40.3%]). Omalizumab increased all baseline lung function variables more than placebo by end of study: LSM treatment differences (95% confidence interval) were 3.0% (0.2%-5.7%; P = .035), 120.9 mL (30.6-211.2 mL; P = .009), and 101.5 mL (8.3-194.6 mL; P = .033) for ppFEV₁, absolute FEV₁, and FVC, respectively. The LSM difference demonstrated a greater reduction in eosinophil counts for omalizumab vs placebo: -85.9 cells/μL (-137.1 to -34.6 cells/μL; P = .001).

CONCLUSION

Omalizumab was associated with lung function improvements and circulating eosinophil counts reductions in adolescents with moderate-to-severe uncontrolled asthma. Findings emphasize the effect of omalizumab in young patients and the need to optimize treatment early in the disease course. https://clinicaltrials.gov/: NCT00314574, NCT00046748, NCT00401596.

Understanding allergic multimorbidity within the non-eosinophilic interactome

BACKGROUND

The mechanisms explaining multimorbidity between asthma, dermatitis and rhinitis (allergic multimorbidity) are not well known. We investigated these mechanisms and their specificity in distinct cell types by means of an interactome-based analysis of expression data.

METHODS

Genes associated to the diseases were identified using data mining approaches, and their multimorbidity mechanisms in distinct cell types were characterized by means of an in silico analysis of the topology of the human interactome.

RESULTS

We characterized specific pathomechanisms for multimorbidities between asthma, dermatitis and rhinitis for distinct emergent non-eosinophilic cell types. We observed differential roles for cytokine signaling, TLR-mediated signaling and metabolic pathways for multimorbidities across distinct cell types. Furthermore, we also identified individual genes potentially associated to multimorbidity mechanisms.

CONCLUSIONS

Our results support the existence of differentiated multimorbidity mechanisms between asthma, dermatitis and rhinitis at cell type level, as well as mechanisms common to distinct cell types. These results will help understanding the biology underlying allergic multimorbidity, assisting in the design of new clinical studies.

[Correlation of fractional exhaled nitric oxide in the upper and lower airways with the level of asthma control]

OBJECTIVE

To study the clinical value of combined measurement of fractional exhaled nitric oxide (FeNO) and nasal fractional exhaled nitric oxide (FnNO) and its correlation with the level of asthma control.

METHODS

A total of 120 children who were diagnosed with asthma from January to June, 2018 and were in the chronic persistent stage were enrolled as subjects. The childhood asthma control test (C-ACT) was performed for all the 120 children. According to the C-ACT score, these children were divided into 4 groups: complete control group with a C-ACT score of >23, partial control group with a C-ACT score of 20-23, and uncontrolled group with a C-ACT score of ≤19 (n=40 each). According to the presence or absence of allergic rhinitis, they were divided into 2 groups: non-rhinitis group with 55 children and rhinitis group with 65 children. A total of 40 children who underwent physical examination during the same period of time were enrolled as the control group. FeNO and FnNO levels were measured for all the 120 children.

RESULTS

The uncontrolled group had the highest level of FeNO, followed by the partial control group and the complete control group (P<0.05). The uncontrolled and partial control groups had a significantly higher level of FeNO than the control group (P<0.05). The uncontrolled and partial control groups had a significantly higher level of FnNO than the complete control and control groups (P<0.05). The rhinitis group had significantly higher FeNO and FnNO levels than the non-rhinitis group (P<0.05).

CONCLUSIONS

FeNO can be used to assess the level of asthma control in children, and its combination with FnNO may be useful for the evaluation of the degree of inflammation in the upper and lower airways and provide a basis for the combined treatment of the upper and lower airways.

Rhinitis in children and adolescents with asthma: Ubiquitous, difficult to control, and associated with asthma outcomes

BACKGROUND

Rhinitis and asthma are linked, but substantial knowledge gaps in this relationship exist.

OBJECTIVE

We sought to determine the prevalence of rhinitis and its phenotypes in children and adolescents with asthma, assess symptom severity and medication requirements for rhinitis control, and investigate associations between rhinitis and asthma.

METHODS

Seven hundred forty-nine children with asthma participating in the Asthma Phenotypes in the Inner-City study received baseline evaluations and were managed for 1 year with algorithm-based treatments for rhinitis and asthma. Rhinitis was diagnosed by using a questionnaire focusing on individual symptoms, and predefined phenotypes were determined by combining symptom patterns with skin tests and measurement of serum specific IgE levels.

RESULTS

Analyses were done on 619 children with asthma who completed at least 4 of 6 visits. Rhinitis was present in 93.5%, and phenotypes identified at baseline were confirmed during the observation/management year. Perennial allergic rhinitis with seasonal exacerbations was most common (34.2%) and severe. Nonallergic rhinitis was least common (11.3%) and least severe. The majority of children remained symptomatic despite use of nasal corticosteroids with or without oral antihistamines. Rhinitis was worse in patients with difficult-to-control versus easy-to-control asthma, and its seasonal patterns partially corresponded to those of difficult-to-control asthma.

CONCLUSION

Rhinitis is almost ubiquitous in urban children with asthma, and its activity tracks that of lower airway disease. Perennial allergic rhinitis with seasonal exacerbations is the most severe phenotype and most likely to be associated with difficult-to-control asthma. This study offers strong support to the concept that rhinitis and asthma represent the manifestations of 1 disease in 2 parts of the airways.

Adherence to treatment in allergic respiratory diseases

Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice. Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence. Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.

Asthma Over the Age of 65: All's Well That Ends Well

Asthma in older adults (often classified as those 65 years or older) is relatively common, underdiagnosed, and suboptimally treated. It is an important health problem, as the population of the United States continues to age. Unfortunately, asthma morbidity and mortality rates are highest in this age group. Alterations in the innate and adaptive immune responses occur with aging, and contribute to pathophysiologic differences and subsequent treatment challenges. The symptoms of asthma may differ from those in younger populations, and often include fatigue. There are unique factors that can complicate asthma management among older adults, including comorbidities, menopause, caregiver roles, and depression. Pharmacologic therapies are often not as effective as in younger populations, and may have greater side effects. Spirometry, peak flow measurements, and asthma education are typically underused, and may contribute to delays in diagnosis as well as worse outcomes. There are specific strategies that health care providers can take to improve the care of older adults with asthma.

The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review

An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.

The role of upper airway pathology as a co-morbidity in severe asthma

INTRODUCTION

Severe asthma is a complex heterogeneous disease that is refractory to standard treatment and is complicated by multiple co-morbidities and risk factors. Several co-morbidities may contribute to worsen asthma control and complicate diagnostic and therapeutic management of severe asthmatic patients. Areas covered: A prevalent cluster of chronic upper airway co-morbid diseases is recognized in severe asthma. Evaluation for these disorders should always be considered in clinical practice. The aim of this review is to provide an updated overview of the prevalence, the pathogenetic mechanisms, the clinical impact and the therapeutic options for upper airway pathology in severe asthma, focusing on chronic rhinosinusitis and allergic rhinitis. Expert commentary: In the context of severe asthma, the clinical significance of upper airway co-morbidities is based on mutual interactions complicating diagnosis and management. A better analysis and understanding of phenotypes and endotypes of both upper and lower airway diseases are crucial to further develop targeted treatment.

Study of nasal exhaled nitric oxide levels in diagnosis of allergic rhinitis in subjects with and without asthma

Background

The measure of fractional exhaled nitric oxide (FENO) in the airways is a useful tool to guide the diagnosis and titration of inhaled corticosteroids in patients with asthma. However, its role in diagnosis of allergic rhinitis (AR), especially in subjects with asthma, is not well established.

Objective

To study the cutoff of nasal FENO in the diagnosis of subjects with AR and AR-asthma compared to age-matched subjects without AR or asthma and its correlations with the clinical and functional characteristics.

Methods

The study was cross sectional and descriptive. Subjects were grouped into control subjects, AR, and AR-asthma, based on the inclusion criteria. Exhaled NO (nasal FENO, bronchial FENO, and alveolar concentration of NO) was measured by multiple flow electro-luminescence device.

Results

Six hundred twenty-eight subjects were included: 217 control subjects (children: n=98, 10±4 years; adults: n=119, 50±16 years), 168 subjects with AR (children: n=54, 10±3 years; adults: n=114, 49±15 years), and 243 subjects with AR-asthma (children: n=115, 10±3 years; adults: n=128, 51±14 years). Nasal peak inspiratory flow and peak expiratory flow were lower in subjects with AR and AR-asthma than in control subjects (P<0.01 and P<0.01; and P<0.05 and P<0.01, respectively). Nasal FENO levels were significantly higher in subjects with AR and AR-asthma than in control subjects (1614±629 and 1686±614 ppb vs 582±161 ppb; P<0.001 and P<0.001, respectively). In subjects with AR non-asthma, the cutoffs of nasal FENO for those diagnosed with AR were 775 ppb in children, 799 ppb in adults, and 799 in the general population (sensitivity: 92.68%, 92.63%, and 92.65%, respectively; specificity: 91.67%, 95.00%, and 96.87%, respectively). In subjects with AR-asthma, the cutoffs of nasal FENO were higher, especially in asthma children (1458 ppb; sensitivity: 72.97% and specificity: 95.83%).

Conclusion

Nasal FENO measurement is a useful technique for the diagnosis of AR in subjects with and without asthma.