GEMA 5.3. Spanish Guideline on the Management of Asthma

Drug survival of omalizumab in atopic asthma: Impact of clinical and genetic variables

It is estimated that 40-50% of severe asthma has an atopic basis, representing a clinical challenge and a significant economic burden for healthcare systems. The most effective treatment has emerged with the use of biologic therapies such as omalizumab; however, the rate of therapy switching due to loss of efficacy is high, which has a negative impact on the healthcare system. The aim was to evaluate the influence of genetic polymorphisms as predictors of omalizumab survival. We conducted a retrospective observational cohort study of 110 patients with uncontrolled severe allergic asthma treated with omalizumab in a tertiary hospital. We analyzed FCER1A (rs2251746, rs2427837), FCER1B (rs1441586, rs573790, rs1054485, rs569108), C3 (rs2230199), FCGR2A (rs1801274), FCGR2B (rs3219018, rs1050501), FCGR3A (rs10127939, rs396991), IL1RL1 (rs1420101, rs17026974, rs1921622) and GATA2 (rs4857855) by real-time PCR using Taqman probes. Drug survival was defined as the time from initiation to discontinuation of omalizumab. Cox regression analysis adjusted for the presence of respiratory disease, GERD, SAHS and years with asthma showed that the SNPs FCER1B rs573790 - CT (p < .001; HR = 3.38; CI95% = 1.66-6.87), FCGR3A rs10127939-AC (p = .018; HR = 3.85; CI95% = 1.25-11.81) and FCGR3A rs396991-CC (p = .020; HR = 2.23; CI95% = 1.14-4.38) were the independent variables associated with worse survival in patients diagnosed with asthma. A trend toward statistical significance was also found between and FCGR3A rs10127939-CC (p = .080; HR = 0.13; CI95% = 0.01-1.28) and longer drug survival. The results of this study demonstrate the potential influence of the polymorphisms studied on omalizumab survival and the clinical benefit that could be achieved by defining predictive biomarkers of drug survival.

Psychological intervention in severe asthma: from theory to practice

Background

Severe asthma is frequently associated with psychological comorbidities that negatively affect disease control and quality of life. Despite clinical guideline recommendations, psychological care remains limited in multidisciplinary asthma units.

Objective

To evaluate the effectiveness of an online group psychological intervention in improving emotional well-being and disease control in patients with severe asthma.

Methods

A longitudinal study was conducted between 2021 and 2024 in a specialized severe asthma unit. The intervention consisted of eight weekly online sessions combining cognitive-behavioral techniques and emotional regulation strategies. Psychological and quality-of-life variables were assessed at baseline, post-intervention, and at 6 and 12 months of follow-up.

Results

A total of 41 patients completed the program. Significant and sustained improvements were observed in anxiety, depression, hyperventilation, and asthma-related quality of life up to 12 months after the intervention. No changes were found in alexithymia, perceived social support, or family functioning.

Conclusion

An online group psychological intervention is a feasible and effective approach to improving emotional health and quality of life in patients with severe asthma. Its integration into asthma care units may contribute to a more comprehensive and patient-centered management strategy.

Personal exposure to particulate matter oxidative potential and airway inflammation: differences between asthmatic and non-asthmatic adults

We aimed to determine whether exposure to particulate matter PM, measured as the oxidative potential (OP) of filters collected from 24 h personal samplers, is associated with increased airway inflammation in asthmatic and non-asthmatic volunteers. Forty-two adult asthmatic patients (25 women and 17 men) and 37 matched controls wore a personal sampler for a day collecting fine (PM2.5) and coarse (PM10-2.5) particles, and determining 24 h afterwards their fractional exhaled nitric oxide (FeNO). The PM-OP was determined by two methods: dithiothreitol (DTT) and ascorbic acid (AA) being OP levels dichotomized based on the median, to calculate adjusted mean differences (aMDs) and odds ratios (aORs) with sex, age, study level, body mass index and interleukin-6 (IL-6) levels as confounders. Statistically significant associations between PM-OP and FeNO levels in non-asthmatic volunteers were observed: aMD for OP-DTT PM2.5 = 11.64 ppbs; 95 %CI (0.13-22.79); aMD for OP-AA PM10-2.5 = 15.67; 95 %CI (2.91-28.43) with aORs = 4.87 and 18.18 respectively. In asthmatic patients an association was also observed in the form of aORs, but of lower magnitude (1.91 and 1.94 respectively). Non-significant higher FeNO levels (aMD = 5.22) and an aOR = 3.92 were also observed in non-asthmatic volunteers for OP-AA in the fine fraction. As a conclusion, the effect of personal PM-OP on airway inflammation appears to be differential between asthmatic and non-asthmatic volunteers suggesting a potential implication of inhaled corticosteroids diminishing the reactivity of airway epithelium since adjusted associations were higher in volunteers without asthma.

Utility of the Basophil Reactivity Test in the Clinical Management of People with Severe Uncontrolled Asthma

Introduction

The prognosis of asthma has improved significantly since the availability of monoclonal antibodies (mAbs). However, there are no robust predictive markers of response to help clinicians select one of the multiple biologicals recommended in clinical practice guidelines. The aim of this study was to evaluate the utility of basophil reactivity, measured through the basophil activation test (BAT), as a marker of response to mAbs.

Methods

We measured basophil reactivity, using anti-immunoglobulin E (anti-IgE) antibodies as a stimulus, in 72 consecutive patients with severe uncontrolled asthma before initiation of treatment with mAbs. Forty-nine patients received omalizumab, 28 received mepolizumab, and 23 received benralizumab at some point. The Spanish Asthma Management Guidelines (GEMA) informed clinical management throughout the study. We studied clinical characteristics, laboratory values, and measures of respiratory function and asthma control.

Results

Basophil reactivity (at the highest anti-IgE dilution at which basophil activation was positive) was inversely associated with asthma control and response to any mAb. The patients with higher basophil reactivity (≥ 29% versus < 29%) had lower mAb complete response, more frequent mAb switches, and worse baseline lung function and Asthma Control Test (ACT) scores. The BAT was associated with poor response above the cut-off values of 10.5% for mepolizumab, 15.5% for omalizumab, and 28% for benralizumab.

Conclusion

Patients with basophil reactivity greater than or equal to 29% were less likely to achieve full control of asthma when treated with omalizumab, mepolizumab, or benralizumab, independently of classic clinical or biological markers of type 2 asthma.

The Role of Bronchial Biopsy in the Prediction of Response to Biologic Therapy in Severe Uncontrolled Asthma: A Prospective Study

BACKGROUND

Up to two-thirds of patients with severe uncontrolled asthma (SUA) who received biologic therapy do not have a complete response.

RESEARCH QUESTION

Can bronchial biopsy (BB) play a role in the identification of patients with SUA who have a better response to biologic therapy?

STUDY DESIGN AND METHODS

This prospective multicenter study included consecutive patients with SUA who were candidates for biologic therapy. They underwent bronchoscopy and BB prior to biologic therapy, and clinical response was evaluated 6 months later. BB was evaluated according to a previously validated pathological score (PS) and was compared with a score of type 2 (T2) inflammation (T2 score) that includes blood eosinophil count and fractional exhaled nitric oxide in predicting response to biologic therapy. Response was graded as super-response, good response, and partial/no response according to a composite score that includes exacerbations, oral corticosteroid steroid (OCS) use, asthma control test, and improvement in FEV1.

RESULTS

A total of 92 patients were recruited. Of the 92 patients recruited, 78 completed the study. Among them, 63 received an anti-IL-5 or IL-5 receptor (anti-IL5/5R) (mepolizumab, reslizumab, and benralizumab) while 15 received dupilumab. The proportion of super-responders was 36.5% in the anti-IL5/5R group and 26.6% in the dupilumab group (P = .126). The PS was the only variable independently associated with response; the T2 score was not. Super-responders had a statistically significantly higher PS. Response was better predicted by the PS compared with the T2 score in those receiving OCSs and especially in those taking anti-IL5/5Rs. Reduced eosinophil levels (< 10 eosinophils/field) were associated with poor response to biologic therapy.

INTERPRETATION

Our findings indicate that BB is more precise in the prediction of response to biologic therapy than the T2 score, especially in those requiring OCSs or receiving anti-IL5/5Rs. Tissue eosinophilia is the main driver of this predictive capacity. However, other items in the PS related to bronchial remodeling might contribute to the identification of response to biologic therapy.

The impact of blood eosinophil count and FeNO on benralizumab effectiveness in clinical practice: An ORBE II subanalysis

BACKGROUND

The ORBE II study showed the real-world effectiveness of benralizumab in severe eosinophilic asthma (SEA). This subgroup analysis aimed to characterize patients and outcomes based on baseline blood eosinophil count (BEC) and/or fractional exhaled nitric oxide (FeNO) levels.

METHODS

In this analysis of the ORBE II retrospective study, SEA patients receiving benralizumab were categorized into subgroups based on individual or combined BEC/FeNO levels, according to the following thresholds: high BEC (hiBEC): ≥300 cells/μL; low BEC (loBEC): <300 cells/μL; high FeNO (hiFeNO): ≥50 ppb; low FeNO (loFeNO): <50 ppb. Baseline and up to 1 year of follow-up data are described.

RESULTS

Most patients with available data were classified as hiBEC (72.6 %) and 38.3 % as hiFeNO. The distribution according to combined baseline BEC and FeNO levels revealed a heterogeneous patient population. Although common SEA features were shared among subgroups, some distinct characteristics were observed, including elevated allergic asthma prevalence in hiBEC/loFeNO patients, high obesity prevalence and fewer non-smokers in loBEC/loFeNO patients, remarkable severe exacerbation rates in loBEC/hiFeNO patients [5.5 SD (6.0)], and more severe symptoms in the hiBEC/loBEC subgroup. All subgroups showed benefits following benralizumab treatment, with super-responder rates ranging from 68.2 % to 83.3 % and clinical remission rates reaching 70.0 %. Particularly good responses were noted in hiBEC/hiFeNO patients.

CONCLUSIONS

This study shows the variability of T2 biomarkers in ORBE II SEA patients, emphasizing the prevalence of high BEC values. While benralizumab benefits were important regardless of BEC, high BEC predicted good outcomes and FeNO had less influence on treatment effectiveness.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Protocol for the enhanced management of multimorbid patients with COPD and severe asthma: role of indoor air quality

INTRODUCTION

Reducing unplanned hospital admissions in chronic patients at risk is a key area for action due to the high healthcare and societal burden of the phenomenon. The inconclusive results of preventive strategies in patients with chronic obstructive respiratory disorders and comorbidities are explainable by multifactorial but actionable factors.The current protocol (January 2024-December 2025) relies on the hypothesis that intertwined actions in four dimensions: (1) management change, (2) personalisation of the interventions based on early detection/treatment of acute episodes and enhanced management of comorbidities, (3) mature digital support and (4) comprehensive assessment, can effectively overcome most of the limitations shown by previous preventive strategies. Accordingly, the main objective is to implement a novel integrated care preventive service for enhanced management of these patients, as well as to evaluate its potential for value generation.

METHODS AND ANALYSIS

At the end of 2024, the specifics of the novel service will be defined through the articulation of its four main components: (1) enhanced lung function testing through oscillometry, (2) continuous monitoring of indoor air quality as a potential triggering factor, (3) digital support with an adaptive case management (ACM) approach and (4) predictive modelling for early identification and management of exacerbations. During 2025, the novel service will be assessed using a Quintuple Aim approach. Moreover, the Consolidated Framework for Implementation Research will be applied to assess the implementation. The service components will be articulated through four sequential 6-month plan-do-study-act cycles. Each cycle involves a targeted cocreation process following a mixed-methods approach with the active participation of patients, health professionals, managers and digital experts.

ETHICS AND DISSEMINATION

The Ethics Committee for Human Research at Hospital Clinic de Barcelona approved the protocol on 29 June 2023 (HCB/2023/0126). Before any procedure, all patients in the study must sign an informed consent form.

TRIAL REGISTRATION NUMBER

NCT06421402.

Real-world outcomes on quality-of-life improvement in patients with nasal polyposis treated with mepolizumab. RINOSUR study

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by nasal obstruction, reduced sense of smell, rhinorrhea, and facial pain for more than 12 weeks, significantly affecting quality of life (QoL), especially in patients with NSAID-exacerbated respiratory disease (NERD). Initial treatment includes intranasal corticosteroids and nasal irrigations, followed by systemic corticosteroids (SC) in severe cases, as well as endoscopic sinus surgery (ESS) and biological agents. Mepolizumab, a monoclonal antibody against IL-5, has been shown to reduce eosinophilic inflammation in CRSwNP. This study evaluates the improvement in quality of life of patients with CRSwNP treated with mepolizumab before December 2023, recorded by the RINOSUR group. A retrospective observational multicenter cohort study is presented in adult patients with severe asthma and concomitant CRSwNP, treated with mepolizumab 100 mg. Variables such as sex, asthma, allergies, NERD, corticosteroid dependence, and serum eosinophil count were recorded. All patients underwent nasal endoscopy and completed the SNOT22 questionnaire. Therapeutic response was evaluated at 12 months. Out of 143 patients recruited, only 28.6% had the necessary data. 61% were women with a mean age of 55 years. All were corticosteroid-dependent and had required at least one ESS. A 22% reduction in SC cycles was observed, and no patient required revision surgery in the 12 months following treatment. The SNOT22 score was reduced by 53 points, and serum eosinophilia also showed a significant decrease. Mepolizumab is effective in treating severe uncontrolled CRSwNP, improving QoL and reducing dependence on systemic corticosteroids. Its activity is monitored by peripheral blood eosinophilia. Consistency in data collection is crucial to evaluate efficacy and manage the disease.

Identification of regional and sex differences in asthma mortality trends in Spanish Autonomous Communities (1980-2022)

OBJECTIVE

Despite global declines in asthma mortality, regional variations and sex disparities persist. This study investigates asthma mortality trends in Spanish Autonomous Communities (ACs) from 1980 to 2022, analyzing data by sex.

METHODS

Data on asthma deaths and population were obtained from the National Institute of Statistics for the study period. Age-standardized mortality rates (ASMRs) were calculated, and joinpoint regression models were applied to identify trends.

RESULTS

Overall, 44,728 asthma deaths occurred, with a steeper decline observed in men (-3.5% per year) compared to women (-0.7% per year). The female-to-male mortality ratio climbed from 0.7 in 1980 to 5.4 in 2016. Both sexes exhibited a significant decrease in ASMRs, with a more substantial decline in males (-6.3%).While all ACs showed a significant decrease in male ASMRs, female trends varied, with significant decreases in 13 ACs and stable trends elsewhere. Joinpoint analysis revealed diverse regional patterns for both sexes, with some ACs experiencing steady declines and others exhibiting periods of slower decline or even stabilization.

CONCLUSION

This study identified concerning regional and sex disparities in Spanish ACs' asthma mortality (1980-2022). While male rates declined significantly across all regions, female rates showed variation, with even increases in some ACs. Targeted interventions addressing these disparities and their underlying causes (healthcare access, management practices, etc.) are crucial.

Time is lung: higher preservation of lung function in severe asthma patients after earlier mepolizumab treatment

Introduction

Severe asthma involves a persistent inflammation of the airways that is associated with a greater risk of exacerbations. Exacerbations are associated with a higher lung function decline over time. The prevention of lung function decline could become a strategy for disease modification, and this could be more likely to happen in patients with an earlier therapeutic approach. Thus, this study means to analyse the effect of asthma duration in clinical outcomes such as lung function in patients from the REDES study. REDES was an observational real-world study that assessed the effectiveness and safety of mepolizumab 100 mg s.c. every 4 weeks for 12 months in 318 patients with severe asthma in Spain.

Methods

This post hoc analysis evaluated how disease duration affected the study results through a stratification according to quartiles on their disease progression. Continuous analyses were also performed to assess the impact of confounder variables on forced expiratory volume in 1 s (FEV1) (%).

Results

At baseline, patients with shorter time of disease had a significantly higher lung function than patients with longer asthma duration. At 12 months, pre-bronchodilator (BD) FEV1 values and the proportion of patients with ≥80% pre-BD FEV1 were higher according to a shorter disease persistence (Q1>Q2>Q3>Q4).

Conclusion

These results support that time of disease persistence contributes to the lung function decline of patients with severe asthma, uncontrolled while on previous treatment, and that an earlier approach with mepolizumab may imply a higher preservation of their lung function.

SANI clinical remission definition: a useful tool in severe asthma management

In the field of severe asthma, the concept of disease control has recently been integrated by the one of clinical remission. With this new concept, we move on to analyze the efficacy of therapy on multiple parameters simultaneously, starting with the mandatory discontinuation of the systemic glucocorticoids, to which is added the effect on exacerbations, respiratory function, and symptoms control. The Italian severe asthma registry SANI (Severe Asthma Network Italy) drafted criteria for the definition of disease remission, allowing patients to be classified into two groups, partial and complete remission. The greater dynamism of the definition, provided by SANI, allows us to hypothesize its practical use, concerning therapy management of severe asthma patients, starting from the level of remission, with the aim to facilitate the clinical decision on replacement, continuation or modulation of patients' therapy.

Clinical characteristics of complete responders versus non-complete responders to omalizumab, benralizumab and mepolizumab in patients with severe asthma: a long-term retrospective analysis

BACKGROUND

Some patients with severe asthma may benefit from treatment with biologics, but evidence has been mostly collected from randomized controlled trials (RCTs), in which patients' characteristics are different from those encountered in asthma patients in the real-world setting. The aim of this study was to describe the clinical features of complete responders versus non-complete responders to long-term treatment with biologics in patients with severe asthma attended in routine daily practice.

METHODS

Data of a cohort of 90 patients with severe asthma who were treated with biologics (omalizumab, benralizumab, and mepolizumab) for at least 12 months and were followed up to March 2022. Data recorded included clinical characteristics and effectiveness of treatment (exacerbation, Asthma Control Test [ACT] score, lung function, use of maintenance oral corticosteroids [mOCS]), FeNO, and blood eosinophils at baseline, at 12 months, and at the end of follow-up. Complete response is considered if, in addition to not presenting exacerbations or the use of mOCS, the ACT score was >20 and, the FEV1 >80% predicted.

RESULTS

An improvement in all asthma control parameters was observed after 12 months of treatment and a mean follow-up of 55 months. After 12 months of treatment 27.2% of patients met the criteria of complete response and this percentage even increased to 35.3% at the end of follow-up. Long-term complete response was associated to better lung function with mepolizumab and omalizumab treatment and to less previous exacerbations in the benralizumab group. The main cause of not achieving a complete response was the persistence of an airflow obstructive pattern.

CONCLUSIONS

This study shows that omalizumab, benralizumab, and mepolizumab improved the clinical outcomes of patients with severe asthma in a clinic environment with similar effect sizes to RCTs in the long term follow-up. Airflow obstruction, however, was a predictor of a non-complete response to biologics.

Clinical response and on-treatment clinical remission with tezepelumab in a broad population of patients with severe, uncontrolled asthma: results over 2 years from the NAVIGATOR and DESTINATION studies

BACKGROUND

In asthma, clinical response is characterised by disease improvement with treatment, whereas clinical remission is characterised by long-term disease stabilisation with or without ongoing treatment. The proportions of patients receiving tezepelumab who responded to treatment and who achieved on-treatment clinical remission were assessed in the NAVIGATOR (ClinicalTrials.gov identifier NCT03347279) and DESTINATION (ClinicalTrials.gov identifier NCT03706079) studies of severe, uncontrolled asthma.

METHODS

NAVIGATOR and DESTINATION were phase 3, randomised, double-blind, placebo-controlled studies; DESTINATION was an extension of NAVIGATOR. Complete clinical response was defined as achieving all of the following: ≥50% reduction in exacerbations versus the previous year, improvements in pre-bronchodilator (BD) forced expiratory volume in 1 s (FEV1) of ≥100 mL or ≥5%, improvements in Asthma Control Questionnaire (ACQ)-6 score of ≥0.5 and physician's assessment of asthma improvement. On-treatment clinical remission was defined as an ACQ-6 total score ≤1.5, stable lung function (pre-BD FEV1 >95% of baseline) and no exacerbations or use of oral corticosteroids during the time periods assessed.

RESULTS

Higher proportions of tezepelumab than placebo recipients achieved complete clinical response over weeks 0-52 (46% versus 24%; OR 2.83, 95% CI 2.10-3.82) and on-treatment clinical remission over weeks 0-52 (28.5% versus 21.9%; OR 1.44, 95% CI 0.95-2.19) and weeks >52-104 (33.5% versus 26.7%; OR 1.44, 95% CI 0.97-2.14). Tezepelumab recipients who achieved on-treatment clinical remission versus complete clinical response at week 52 had better preserved lung function and lower inflammatory biomarker levels at baseline, and fewer exacerbations in the 12 months before the study.

CONCLUSIONS

Among patients with severe, uncontrolled asthma, tezepelumab treatment was associated with an increased likelihood of achieving complete clinical response and on-treatment clinical remission compared with placebo. Both are clinically important outcomes, but may be driven by different patient characteristics.

Prognostic Factors in Severe Eosinophilic Asthma in a Pediatric Population: A Prospective Cohort Study in Spain

Background/Objectives: The objective of this study was to provide real-world data on prognostic factors in children with severe eosinophilic asthma and to assess biomarkers of outcome. Methods: Fifty-nine children (aged 6-17 years) were included in a prospective cohort attended in a Severe Asthma Unit of a tertiary care teaching hospital in Badalona (Barcelona, Spain) and visited at baseline and at 1-year follow-up. Study variables included asthma control using the Asthma Control Test (ACT), forced expiratory volume in one second (FEV1), exacerbation episodes, fractional exhaled nitric oxide (FeNO), and inflammatory biomarkers (blood tests, sputum cells, immunoallergic tests, and levels of cytokines and effector cells in blood and sputum). Results: There were 36 boys and 23 girls, with a mean (SD) age of 11.9 (2.8) years. Uncontrolled severe asthma was diagnosed in 83.1% of cases, with poor symptom control (ACT score < 20) in 52.5%, obstructive pattern (FEV1 < 80% predicted) in 35.6%, and more than one exacerbation in the previous year in 30.5%. The mean duration of asthma was 9.2 (3.6) years. Positive prick tests were recorded in 55 patients, with polysensitization in 6. The mean percentage of sputum eosinophils was 2.5% (3.1%), and the mean eosinophil blood count 543.4 (427.7) cells/µL. Ten patients (32%) showed sputum eosinophilia (>3% eosinophils). Sputum eosinophils did not correlate with blood eosinophils, FeNO, and serum periostin. At 12 months, 13 (22%) children had uncontrolled asthma and 46 (78%) had controlled asthma. Variables significantly associated with uncontrolled asthma were duration of asthma (OR = 1.23, 95% CI 1.01-1.49, p = 0.04) and an ACT score < 20 (OR = 0.80, 95% CI 0.69-0.93, p = 0.004). Lower serum levels of IL-9 appeared to be related with uncontrolled asthma, but statistical significance was not reached. Conclusions: Pediatric severe eosinophilic asthma showed a predominant allergic phenotype with symptomatic disease as a main contributor of uncontrolled asthma at 1 year. Predictive biomarkers of outcome were not identified. Further studies are needed to confirm the present findings especially considering additional variables for a better phenotypic characterization of severe eosinophilic asthma in children and to study in-depth the role of inflammatory biomarkers.

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

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

Biologics in Asthma: Potential to Achieve Clinical Remission

Establishing a universal definition for asthma remission has the potential to improve asthma outcomes and advance research. However, there is still no consensus definition despite broad multidisciplinary efforts to achieve this goal. This study explores the evolving concept of asthma remission, emphasizing the potential of biologics to achieve this state. We will discuss various proposed definitions of asthma remission, international guidelines, and studies evaluating the effectiveness of biologics at achieving clinical remission. We highlight the need for a consensus definition of asthma remission to standardize treatment goals and improve patient outcomes.

Integrating asthma care guidelines into primary care electronic medical records: a review focused on Canadian knowledge translation tools

INTRODUCTION

Asthma is one of the most common chronic respiratory diseases globally. Despite national and international asthma care guidelines, gaps persist in primary care. Knowledge translation (KT) electronic tools (eTools) exist aiming to address these gaps, but their impact on practice patterns and patient outcomes is variable. We aimed to conduct a nonsystematic review of the literature for key asthma care gaps and identify limitations and future directions of KT eTools optimised for use in electronic medical records (EMRs).

METHODS

The database OVID Medline was searched (1999-2024) using keywords such as asthma, KT, primary healthcare and EMRs. Primary research articles, systematic reviews and published international/national guidelines were included. Findings were interpreted within the knowledge-to-action framework.

RESULTS

Key asthma care gaps in primary care include under-recognition of suboptimal control, underutilisation of pulmonary function tests, barriers to care delivery, provider attitudes/beliefs, limited access to asthma education and referral to asthma specialists. Various KT eTools have been validated, many with optimisation for use in EMRs. KT eTools within EMRs have been a recent focus, including asthma management systems, decision support algorithms, data standards initiatives and asthma case definition validation for EMRs.

CONCLUSIONS

The knowledge-to-action cycle is a valuable framework for developing and implementing novel KT tools. Future research should integrate end-users into the process of KT tool development to improve the perceived utility of these tools. Additionally, the priorities of primary care physicians should be considered in future KT tool research to improve end-user uptake and overall asthma management practices.

[Highlights 57th SEPAR Congress]

The Spanish Society of Pneumology and Thoracic Surgery (SEPAR) has held its 57th Congress in Valencia from 6 to 8 of June 2024. The SEPAR Congress is the leading meeting for the entire respiratory scientific community, which allows learning about the main scientific advances in this area and provides the ideal situation to create and strengthen ties. This year, under the title "Respiratory Health for everybody", the SEPAR Congress stressed the importance of raising awareness about the importance of caring for and protecting our respiratory system. In this review, we offer a summary of some notable issues addressed in six selected areas of interest: chronic obstructive pulmonary disease (COPD), asthma, interstitial lung diseases (ILDs), pulmonary vascular diseases, sleep and breathing disorders and respiratory physiotherapy.

Clinical remission and control in severe asthma: agreements and disagreements

Over the last two decades, we have witnessed great advancements in our understanding of the immunological pathways of asthma, leading to the development of targeted therapies, such as biologic drugs, that have radically and definitively changed the clinical outcomes of severe asthma. Despite the numerous therapeutic options available, ~4-10% of all people with asthma have severe or uncontrolled asthma, associated with an increased risk of developing chronic oral corticosteroid use, fixed airflow limitation, exacerbations, hospitalization and, finally, increased healthcare costs. The new concept of disease modification in asthma comes from the evolution of asthma management, which encompasses phenotyping patients with different inflammatory endotypes characterizing the disease, followed by the advent of more effective therapies capable of targeting the proximal factors of airway inflammation. This treat-to-target approach aims to achieve remission of the disease. Because the novel treatment paradigm for severe asthma with the advent of biologic therapies is no longer clinical control but rather clinical remission - a step closer to the concept of cure - a deeper and more accurate understanding of the critical causal mechanisms and endotypes of asthma is necessary to achieve the goal of clinical remission, which has the potential to generate real life-changing benefits for patients. This review aims to frame the evolution of the debated concept of clinical remission and provide clinicians with insights that may be helpful in achieving remission in the greatest number of patients.

New Vaccines for Chronic Respiratory Patients

Chronic respiratory diseases (CRD) are responsible for more than four million deaths worldwide and have become especially prevalent in developed countries. Although the current therapies help manage daily symptoms and improve patients' quality of life, there is a major need to prevent exacerbations triggered mainly by respiratory infections. Therefore, CRD patients are a prime target for vaccination against infectious agents. In the present manuscript we review the state of the art of available vaccines specifically indicated in patients with CRDs. In addition to pneumococcus, influenza, pertussis, and SARS-CoV-2 vaccines, recently added immunization options like vaccines and monoclonal antibodies against respiratory syncytial virus, are particularly interesting in CRD patients. As new products reach the market, health authorities must be agile in updating immunization recommendations and in the programming of the vaccination of vulnerable populations such as patients with CRDs. Organizational and educational strategies might prove useful to increase vaccine uptake by CRD patients.

Clinical remission in severe asthma: lights and shadows on an ambitious goal

PURPOSE OF REVIEW

The aim of this study was Describe the latest evidence related to the concept of clinical remission in patients with severe asthma, focusing on the lights and shadows of this concept.

RECENT FINDINGS

The idea of clinical remission in severe asthma patients brings about a significant shift in the way asthma is treated and managed. Although there has yet to be unanimous agreement among various scientific societies on the precise definition, this concept can be extremely useful in advancing the treatment of the disease.

SUMMARY

Asthma is a common respiratory condition that affects more than 300 million people globally. It has variable symptoms and severity levels, with about 10% of patients experiencing severe asthma. While there have been advancements in treatment, severe asthma poses significant challenges. Recent approaches have focused on achieving clinical remission, which goes beyond symptom control to address underlying inflammation and biological processes. Clinical remission criteria include the absence of symptoms, reduced medication usage, and normalized inflammatory markers. Various biologic therapies show promise, with some patients achieving remission. However, remission's definition varies globally, hindering standardization and a valid comparison. Standardizing remission criteria and refining predictive factors are crucial for effective asthma management. Overall, achieving clinical remission offers hope for improved long-term outcomes in severe asthma patients.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Real-Life Clinical Outcomes of Benralizumab Treatment in Patients with Uncontrolled Severe Asthma and Coexisting Chronic Rhinosinusitis with Nasal Polyposis

Background: The objective of this study was to evaluate, the clinical benefit of benralizumab in patients with uncontrolled severe asthma associated with chronic rhinosinusitis with nasal polyposis (CRSwNP). Methods: The study included patients with uncontrolled severe asthma associated with CRSwNP who started therapy with benralizumab. Pulmonary function, eosinophilia, IgE, comorbidity, changes in the Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ), Visual Analogue Scale (VAS), Quality of Life (AQLQ), VAS (obstruction, drip, anosmia, facial pressure), SNOT-22, decrease or withdrawal of steroids and other medication, hospital admissions and emergency visits were analysed. The FEOS scale and EXACTO were employed in the assessment of response. Results: We analyzed 58 patients who completed minimal treatment at 12 months. After treatment with benralizumab, exacerbations were reduced by 82% (p < 0.001), steroid cycles by 84% (p < 0.001), emergencies visit by 83% p < 0.001) and admissions by 76% (p < 0.001), improving all the scales for asthma control, (p < 0.001). In terms of lung function, differences were observed in FVC% (p < 0.001), FEV1% (p < 0.001), and FEV1/FVC% (69.5 ± 10 vs. 74 ± 10, p < 0.001). In relation to CRSwNP, differences were observed in SNOT-22 (54.66 ± 17 vs. 20.24 ± 9, p < 0.001), VAS obstruction (7.91 ± 1 vs. 1.36 ± 1, p < 0. 001), VAS drip (7.76 ± 1 vs. 1.38 ± 1, p < 0.001), VAS anosmia (7.66 ± 1 vs. 1.38 ± 1, p < 0.001) and VAS facial pressure (7.91 ± 1 vs. 1.22 ± 1, p < 0.001). The mean FEOS score after treatment was 73 ± 14. A complete response/super response was achieved in 33 patients (57%), good response in 16 (28%) and partial response in 9 (15%). Conclusions: The administration of benralizumab to patients with uncontrolled severe asthma associated with CRSwNP has been demonstrated to improve nasal symptoms, asthma control and lung function. This resulted in a reduction in the need for oral steroids, maintenance and rescue medication, emergency room visits, and hospital admissions, with 57% of patients achieving the clinical remission criteria.

Analysis of Patients Admitted for Asthma Exacerbation in a Tertiary Hospital in Spain

OBJECTIVES

To analyze the characteristics of adult patients admitted for asthma exacerbation and determine optimization, treatment adherence, and follow-up in clinics.

METHODS

Patients ≥ 18 years old admitted from May 2021 to June 2023 with a primary diagnosis of asthma exacerbation were included. Patients with a secondary diagnosis of asthma exacerbation and those without a confirmed diagnosis were excluded.

RESULTS

A total of 186 patients were analyzed, 63% were female, with a mean age of 49 ± 34 years, mean body mass index (BMI) of 26.4 ± 5 kg/m2, mean immunoglobulin E level of 132 ± 235 IU/mL (range: 25-2041), mean eosinophils count of 180 ± 443, and length of stay of 8.6 ± 5 days. Comparing patients with one admission to those with multiple admissions, differences were observed in age (39 ± 15 vs. 58 ± 20, p < 0.0001), BMI (25.2 ± 3 vs. 27.4 ± 4, p < 0.0003), comorbidity (15% vs. 60%, p < 0.0001), and length of stay (4.5 ± 2 vs. 11 ± 3, p < 0.0001). Of the patients, 15% had undiagnosed asthma, 28% had known asthma without maintenance therapy, 23% were managed by primary care, and 34% were followed by pneumology. The mean Test of Adherence to Inhalers (TAI) score was 42.5 ± 8 points, with 70% showing erratic non-adherence, 46% showing deliberate non-adherence, and 21% showing unconscious non-adherence.

CONCLUSIONS

The young population represents a significant percentage of admissions for asthma exacerbation due to poor follow-up in pulmonology clinics, inadequate treatment optimization, and low adherence. This study adds that it is necessary to improve the approach to asthma in primary care to optimize treatment, reduce under-diagnosis, and avoid hospital admissions.

The impact of smoking on bronchiectasis and its comorbidities

INTRODUCTION

Bronchiectasis, characterized by irreversible bronchial dilatation, is a growing global health concern with significant morbidity. This review delves into the intricate relationship between smoking and bronchiectasis, examining its epidemiology, pathophysiology, clinical manifestations, and therapeutic approaches. Our comprehensive literature search on PubMed utilized MESH terms including 'smoking,' 'smoking cessation,' 'bronchiectasis,' and 'comorbidities' to gather relevant studies.

AREAS COVERED

This review emphasizes the role of smoking in bronchiectasis development and exacerbation by compromising airways and immune function. Interconnected comorbidities, including chronic obstructive pulmonary disease, asthma, and gastroesophageal reflux disease, create a detrimental cycle affecting patient outcomes. Despite limited studies on smoking cessation in bronchiectasis, the review stresses its importance. Advocating for tailored cessation programs, interventions like drainage, bronchodilators, and targeted antibiotics are crucial to disrupting the inflammatory-infection-widening cycle.

EXPERT OPINION

The importance of smoking cessation in bronchiectasis management is paramount due to its extensive negative impact on related conditions. Proactive cessation programs utilizing technology and targeted education for high-risk groups aim to reduce smoking's impact on disease progression and related comorbidities. In conclusion, a personalized approach centered on smoking cessation is deemed vital for bronchiectasis, aiming to improve outcomes and enhance patients' quality of life in the face of this complex respiratory condition.

[Asthma]

Asthma is a chronic inflammatory disease that affects about 5% of the world's population and generates high health and social costs. Proper management of the disease requires a correct diagnosis, based on objective measures of functional impairment, as well as symptom control and assessment of the future risk of exacerbations.It has been estimated that 18% of asthma patients in Western Europe have severe asthma and approximately 50% of them have poor control. The severity of asthma is established based on the minimum maintenance treatment needs to achieve control. Asthma clinical practice guidelines recommend classifying severe patients into allergic asthma (T2); eosinophilic asthma (T2) and non-T2 asthma in order to establish the most appropriate treatment.In recent decades, new biological therapies have been developed that can be applied according to the phenotype and endotype of asthma, allowing for selective and personalized treatment. These phenotypes and endotypes can change over time and therefore, the identification of biomarkers capable of predicting the severity, the course of the disease and the response to a given treatment seems essential. A large number of biomarkers have been studied in asthma, but so far only a few can be readily used in routine clinical practice. The application of omics technologies (epigenomics, genomics, transcriptomics, proteomics, metabolomics, lipidomics, etc.) for this purpose is still in the research phase.

The pharmacological management of asthma in adults: 2023 update

INTRODUCTION

The pharmacotherapy of asthma is a dynamic process that changes as our knowledge of the underlying pathophysiology and treatment of this disease continues to evolve. This implies the need for continuous revision of the recommendations of asthma guidelines and strategies.

AREAS COVERED

This review summarizes the latest key practical information on the pharmacological management of asthma in adults. We provide the background to the 2023 update of the GINA strategy report, focusing on changes and discussing areas of uncertainty. We review current and emerging pharmacotherapy for uncontrolled asthma, including synthetic agents and new biologics, and provide expert perspectives and opinions on the treatment of uncontrolled asthma.

EXPERT OPINION

The current pharmacological treatment of asthma, based on a step-by-step, control-based approach, with ICSs, LABAs and LAMAs being the mainstay generally provides good symptom control. Biologic therapies are often effective in treating T2high severe asthma. However, there is still room for improvement, such as the discovery of new molecules that specifically target chronic inflammation and, most importantly, the ability to provide solutions to the various areas of uncertainty that still exist. Also finding solutions to improve the accessibility and affordability of rescue ICS in resource-constrained settings is critical.