A systematic literature review of burden of illness in adults with uncontrolled moderate/severe asthma

Uncovering the spectrum of healthcare resource utilization and costs across moderate to severe asthma: high-cost subgroups and impact of biologics

OBJECTIVES

The healthcare burden of moderate asthma is not as well studied as severe asthma. This study used 2019 US claims data to characterize patients in Global Initiative for Asthma (GINA) steps 3 to 5 (moderate to severe) during the first 90 days of 2019.

METHODS

Patient characteristics, healthcare resource utilization and costs were described for all patients and GINA groups. Patients in GINA 3 accounting for the top 10% and 20% of asthma-related total costs were also analyzed.

RESULTS

In the overall asthma population (N = 337 015), mean asthma-related healthcare cost per patient was $12 560; for GINA 3, 4 and 5, costs were $10 265, $12 923, and $22 601, respectively. For the GINA 3 top 10% and 20% cost subgroups, these expenditures were higher than for GINA 5 ($54 549 and $94 386, respectively), driven by outpatient and inpatient costs. The high-cost GINA 3 subgroups were older, more often female and had a higher comorbidity burden versus GINA 4 or 5. An exploratory analysis suggested that biologic initiation significantly increased costs in patients initially in GINA 3 (p < 0.0001), but significantly reduced costs in GINA 3 top 10% and 20% cost subgroups (both p < 0.01).

CONCLUSION

Results indicate patients receiving GINA 3 treatment can have a high disease burden and may benefit from treatment with a biologic.

Fueling the fire in the lung-brain axis: The salience network connects allergen-provoked TH17 responses to psychological stress in asthma

BACKGROUND

Asthma, a highly prevalent chronic inflammatory disease of the airways, results in an average of 10 deaths per day in the U.S., and psychological stress hinders its effective management. Threat-sensitive neurocircuitry, active during psychological stress, may intensify airway inflammatory responses and contribute to poor clinical outcomes. However, the neural mechanisms and descending pathways connecting acute stress and inflammatory responses to allergen exposure remain poorly understood. We hypothesized that stress-induced engagement of the salience network would prime Th17 immune pathways and potentiate airway inflammation.

METHODS

We measured brain glucose metabolism during the Trier Social Stress Test (TSST) and a non-stressful control task using [18F]fluorodeoxyglucose positron emission tomography (PET) in 28 adults (18F) with asthma. Salivary cortisol was collected to quantify physiological stress responses. Before and after airway provocation with a whole-lung allergen challenge (WL-AG), airway inflammation was assessed using fraction of exhaled nitric oxide (FeNO), sputum % eosinophils, and expression of Th17-related cytokine mRNA in the airway.

RESULTS

As expected, the WL-AG increased all inflammatory biomarkers. Acute stress significantly increased salivary cortisol (t(27.3) = -27.3, p < 0.01), but did not significantly affect airway inflammation overall. Instead, more robust cortisol responses to stress predicted increased glucose metabolism in the amygdala, insula, and dorsal anterior cingulate cortex, key nodes in the salience network, as well as increased IL-23A mRNA expression (t(22.1) = 2.38, p = 0.026) and FeNO (t(21.5) = 2.17, p = 0.041). Moreover, differential increases in amygdala and dACC glucose metabolism predicted differential increases IL-23A mRNA expression following WL-AG. In addition, compared to low chronic stress, high chronic stress was associated with enhanced IL-17A mRNA expression in response to acute stress and WL-AG.

CONCLUSIONS

Individual differences in salience network and cortisol responses to acute stress predict enhanced allergen challenge-provoked Th17-related responses, advancing our understanding of the efferent arm of the lung-brain axis in asthma. This work underscores the importance of translational research for the development of novel interventions that target stress-sensitive brain and immune pathways.

Describing the burden of moderate exacerbations in patients with asthma from the Extended Salford Lung Study (Ext-SLS): a retrospective cohort study

BACKGROUND

There is a need for real-world data describing the frequency and impact of moderate asthma exacerbations in patients receiving inhaled corticosteroids/long-acting β2-agonists (ICS/LABA). The Salford Lung Study (SLS) and associated extension study (Ext-SLS) evaluated ICS/LABA versus existing maintenance therapy in adults with asthma. This analysis assessed the impact of moderate exacerbations in patients from the Ext-SLS.

METHODS

This retrospective cohort study analysed linked primary and secondary care and patient questionnaire data from patients enrolled in the Ext-SLS (indexed April 2018-May 2019). Primary outcome was number of self-reported moderate asthma exacerbations 12 months pre-index, overall, by maintenance treatment class and asthma control status at index, using the Asthma Control Test (ACT; poor [< 16], somewhat controlled [16-18], and controlled [> 19]) and 6-item Asthma Control Questionnaire (ACQ-6; uncontrolled [≥ 1.50], partially controlled [> 0.75-<1.50], and controlled [≤ 0.75]). Secondary outcomes included index ACT and ACQ-6 score, healthcare resource utilisation (HCRU) and direct costs 12 months pre- and post-index, stratified by self-reported moderate exacerbation frequency pre-index.

RESULTS

Of 485 patients with ≥ 12 months' pre-index data, 86.6% (n = 420) self-reported moderate exacerbations, with similar frequency irrespective of maintenance treatment class (66.7-100.0%; ICS/LABA: 85.4%). Numerically greater proportions of patients self-reported a moderate exacerbation in the 12 months pre-index in ACT poor-control (n = 110/115 [95.7%]) and ACQ-6-uncontrolled (n = 200/210 [95.3%]) versus ACT- and ACQ-6-controlled (n = 205/260 [78.8%], n = 105/145 [72.4%]) groups. Symptom control worsened with increasing exacerbation frequency: mean (SD) ACT scores were 21.8 (3.3) and 15.7 (4.4) for patients with 0 or ≥ 7 events, respectively; mean (SD) ACQ-6 scores followed the same trend. Direct costs and HCRU increased with pre-index exacerbation frequency; mean (SD) all-cause and asthma-related total costs were £1509 (£2384) and £717 (£1459) for patients with no moderate exacerbations 12 months pre-index and £2002 (£2058) and £1086 (£1538) for patients with ≥ 7 exacerbations; similar trends occurred over 12 months post-index.

CONCLUSIONS

Patients with asthma experience frequent moderate exacerbations, which are associated with poor asthma control, increased HCRU and costs, emphasising the poor quality of life patients experience. Tackling poor adherence, risk behaviour, and comorbidities as well as holistic management and medication review are needed.

CLINICAL TRIAL DETAILS

Registered on clinicaltrials.gov: NCT03152669, 12 May 2017.

Burden of illness among patients with asthma prescribed inhaled corticosteroids/long-acting β2-agonists

Inhaled corticosteroids (ICS) plus long-acting β2-agonists (LABA) are recommended for maintenance-only or maintenance and reliever therapy (MART) in patients with asthma. However, real-world data on ICS/LABA as maintenance-only or MART are limited. This study characterized clinical, economic, and humanistic burdens of asthma in Canada, China, Europe, Japan, and the US, using data collected from patients and physicians via a cross-sectional survey (Asthma Disease Specific Programme). Patients were ≥18 years of age with physician-confirmed asthma and receiving fixed-dose ICS/LABA for ≥3 months. Mean physician-reported symptom-free days over the past 30 days ranged from 10.1-20.6 days, and 31.5-34.6% of ICS/LABA users self-reported not well-controlled asthma. SABA co-prescription was reported in 8.8-67.8% of patients. These findings highlight the continued disease burden among ICS/LABA users, with the high level of SABA co-prescription indicating potentially inappropriate prescribing of ICS/LABA as MART or detrimental reliance on SABA medication in addition to MART.

Understanding Caregiver Burden in Severe Pediatric Asthma - A Qualitative Study

Objective

This study aimed to clarify the emotional and practical burden on primary caregivers of children with severe asthma and identify the support needs of those caring for individuals with severe asthma.

Methods

A phenomenological research approach in qualitative research was used. Semi-structured interviews with caregivers of children with asthma waiting in the outpatient clinic of Shanghai Children's Hospital were conducted from January to August 2024 through purposive sampling. The researcher transcribed audio-recorded interview data verbatim into text and thematically analyzed the data using the Colaizzi 7-step analysis method and then obtained the final results.

Results

There were a total of 12 participants. Through these 12 in-depth one-on-one interviews, all necessary study data were obtained. The study identified the following four main burdens for caregivers of children with severe asthma: 1) Multiple barriers to the care-giving process. (Incomplete knowledge of disease management; lack of competence in care as well as poor child compliance making care more difficult; lack of support for asthma in schools). 2) Excessive consumption of time and energy. (Disturbed sleep rhythms and lack of physical energy). 3) Family dysfunction. (Conflicts among family members; disruption of normal life; increased financial burden). 4) Negative emotions. (fear; nervousness, worry).

Conclusion

This study focuses on caregivers of children with severe asthma who face multiple stressors. Caregivers are critical to disease management: healthcare professionals and the community should provide support; family members should share tasks; and children's poor self-management skills place a burden on caregivers, and professionals should teach children to better care for themselves. These findings have important implications for healthcare providers to develop targeted support programs and improve overall care for children with severe asthma.

Poor Agreement Among Asthma Specialists on the Choice and Timing of Initiation of a Biologic Treatment for Severe Asthma Patients

BACKGROUND

Because the number of monoclonal antibodies available for severe asthma is growing, specialists currently choose without clear guidelines. Despite increasing knowledge on treatment response to these monoclonal antibodies, making the optimal choice for each individual patient remains a challenge. However, evidence of this daily challenge is lacking.

OBJECTIVE

To evaluate interobserver agreement on the choice of biologic therapy in severe asthma patients among severe asthma specialists, based on clinical cases.

METHODS

This 2-phase study included a pilot local study and an international validation study. Asthma specialists were presented 7 real-life asthma cases managed with a monoclonal antibody. Based on the clinical information provided in the cases, they were asked whether they would have initiated a monoclonal antibody and, if so, their treatment of choice between (1) omalizumab, (2) mepolizumab, (3) reslizumab, (4) benralizumab, and (5) dupilumab. Interobserver agreement for each question was assessed using Gwet agreement coefficient (AC1).

RESULTS

Sixteen physicians from the Province of Quebec (Canada) completed the pilot survey, and 70 physicians from 26 countries completed the international survey. The Gwet AC1 for the decision to initiate a biological therapy was 0.48 in the pilot survey and 0.33 in the international survey. For the choice of therapy, agreement was 0.33 and 0.26, respectively.

CONCLUSIONS

The interobserver agreement among asthma specialists in both the decision to initiate a biological treatment in patients with severe asthma and the selection of treatment is weak. These results highlight the need for studies seeking reliable predictors for optimal response to biological therapies.

Development of an asthma health-care burden score as a measure of severity and predictor of remission in SARP III and U-BIOPRED: results from two major longitudinal asthma cohorts

BACKGROUND

Current asthma guidelines, including those of the European Respiratory Society (ERS) and American Thoracic Society (ATS), suboptimally predict asthma remission, disease severity, and health-care utilisation. We aimed to establish a novel approach to assess asthma severity based on asthma health-care burden data.

METHODS

We analysed prospectively collected data from the Severe Asthma Research Program III (SARP III; USA) and the European Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes (U-BIOPRED; 11 European countries) to calculate a composite burden score based on asthma exacerbations and health-care utilisation, which was modified to include the use of short-acting beta agonists (SABAs) to reflect asthma symptom burden.

FINDINGS

In SARP III, 528 adult participants with asthma were followed up for a mean of 4·4 (SD 1·6) years, and 312 (59%) had severe asthma according to the ERS-ATS definition. Among the 205 participants with asthma who used rescue SABAs daily, 90 used these two or more times a day. In U-BIOPRED, 509 adult participants with asthma were followed up for 1 year, and 421 (83%) had severe asthma. The burden score was less than 1·29 per patient-year in 106 (34%) of 312 SARP III participants and in 80 (19%) of 421 U-BIOPRED participants with severe asthma. By contrast, the burden score was above the median value in 58 (28%) SARP III and 24 (27%) U-BIOPRED participants with non-severe asthma. In both cohorts, the burden score negatively correlated with lung function, asthma control, and quality of life. A burden score of 0·15 or lower predicted asthma remission with a sensitivity greater than 91% and a specificity of 99%.

INTERPRETATION

Our findings highlight considerable discrepancies between the current definition of asthma severity and our burden score. Although the definition of severe asthma proposed by the ERS-ATS and the and Global Initiative for Asthma (GINA) is based on prescribed asthma medications, our personalised health-care burden score includes patient-centred data that reflect disease severity and accurately predicts asthma remission. Subject to prospective validation, the burden score could help to optimise the management of high-risk individuals with asthma.

FUNDING

SARP III: US National Heart, Lung, and Blood Institute; AstraZeneca; Boehringer Ingelheim; Genentech; GlaxoSmithKline; Sanofi Genzyme/Regeneron; and Teva Pharmaceuticals.

U-BIOPRED

Innovative Medicines Initiative Joint Undertaking (EU's Seventh Framework Programme and European Federation of Pharmaceutical Industries and Associations) and eTRIKS project.

Disease Burden and Access to Biologic Therapy in Patients with Severe Asthma, 2017-2022: An Analysis of the International Severe Asthma Registry

Introduction

Patients with severe asthma may be prescribed biologic therapies to improve disease control. The EVEREST study aimed to characterize the global disease burden of patients with severe asthma without access to biologics and those who have access but do not receive biologics, as well as the remaining unmet need despite use of these therapies.

Methods

This was a historical cohort study of patients with severe asthma (aged ≥18 years) in the International Severe Asthma Registry receiving Global Initiative for Asthma (GINA) 2018 step 5 treatment, or with uncontrolled disease at GINA step 4. Prospective data on patient clinical characteristics, healthcare resource utilization, and medication use over a 12-month period between December 2017 and May 2022 were assessed for the following five groups: biologics accessible (omalizumab, mepolizumab, reslizumab, benralizumab, or dupilumab); biologics inaccessible; biologics accessible but not received; biologics accessible and received; and biologic recipients whose asthma remained suboptimally controlled.

Results

Overall, 9587 patients from 21 countries were included. Among patients in the biologics accessible (n=5073), biologics inaccessible (n=3041), and biologics accessible but not received (n=382) groups, 41.4%, 18.7%, and 49.6% experienced at least two exacerbations, 11.5%, 10.5%, and 6.2% required at least one hospitalization, 47.9%, 54.6%, and 71.2% had uncontrolled asthma, and 23.9%, 8.6%, and 11.0% received long-term oral corticosteroids (LTOCS), respectively. Following biologic therapy, among patients who received biologics overall (n=2666) and among those whose asthma remained suboptimally controlled (n=1780), 19.1% and 23.0% experienced at least two exacerbations, 2.7% and 2.9% required at least one hospitalization, and 16.7% and 22.0% received LTOCS, respectively.

Conclusion

There is a substantial disease burden in both patients without access to biologics and those with access who do not receive these therapies, although specific outcomes may vary between these groups. There also remains a high unmet need among biologic recipients, many of whom have a suboptimal response to treatment.

Real-world clinical remission of severe asthma with benralizumab in Spanish adults with severe asthma

OBJECTIVE

Patients with severe eosinophilic asthma experience high risk of exacerbations and reduced quality of life. Benralizumab, a monoclonal antibody binding to IL-5 receptor α subunit, is an approved drug for its treatment. The objective was to describe clinical remission after benralizumab prescription in routine clinical practice.

METHODS

Retrospective multicenter study with data from four hospitals in Valencian Community (Spain) with asthma units between 2019 and 2020. Data was gathered at baseline and after 12 months. We considered clinical remission after 1 year if the patient remained without exacerbations and use of systemic corticosteroids and with good clinical control and normal lung function.

RESULTS

Data from 139 patients was gathered. At the 12-month follow-up, 44.1% were in clinical remission, since 84.0%, 77.5%, 51.0% and 95.5% of patients did not experience exacerbations, had total asthma control test score of ≥20, prebronchodilator FEV1 of ≥80% and did not use systemic corticosteroids. A significant reduction of long-acting muscarinic antagonists (p = 0.0001), leukotriene receptor antagonists (p = 0.0326), oral corticosteroids (p < 0.0001) and short-acting beta agonists (p = 0.0499) was observed. Baseline factors with greatest individual influence on clinical remission were employment situation, tobacco use, comorbidity number, eosinophil value, number of exacerbations, FEV1, emergency visit number, and ACT, MiniAQLQ and TAI scores. Final analysis of multiple logistic regression indicated that having baseline FEV1 value below 80% increases remission chance 9.7 times a year compared to FEV1 >80%.

CONCLUSION

Clinical remission after treatment with benralizumab is achievable in a high percentage of patients with severe asthma eosinophilia not controlled in real life.

Efficacy of bronchial thermoplasty in a patient panel with uncontrolled severe persistent asthma

BACKGROUND

Bronchial thermoplasty (BT) is an approved procedure to manage uncontrolled severe persistent asthma. Many insurance providers are reluctant to pay for BT without proven benefit among their specific patient panel.

OBJECTIVE

Determine if BT is effective in a panel patient panel with uncontrolled severe persistent asthma.

STUDY DESIGN AND METHODS

This was an unblinded prospective study of adult subjects with uncontrolled severe persistent asthma who underwent BT. Outcomes were assessed at baseline and then 3-, 6-, 12-, 18- and 24-months post-BT. The primary metric was an improved Asthma Quality of Life Questionnaire (AQLQ) score. Other metrics included improved Asthma Control Test (ACT), peak expiratory flow rates (PEFR), spirometry, fractional excretion of nitric oxide (FeNO), number of unscheduled medical visits, and lost days of work/activity. Respiratory adverse events were assessed during the BT treatment period and at each post-BT visit.

RESULTS

Twenty-nine subjects completed the study; the median interquartile range (IQR) age was 47 (42-61), and the majority were female (69%), white (93%), and non-Hispanic (90%). After BT, mean (±std) AQLQ scores improved by 1.6(±1.1) at 3 months (p < 0.0001), 1.6(±1.2) at 6 months (p < 0.0001), 1.4(±1.0) at 12 months (p < 0.0001), 1.8(±1.1) at 18 months (p < 0.0001), and 1.6 (±1.5) at 24 months (p < 0.0001). There were significant improvements in ACT, PEFR, unscheduled medical visits and lost days of work and activity. Spirometry and FeNO metrics were unchanged. The average cost for subjects completing all 3 BT procedures was approximately $15,000.

CONCLUSION

BT is an effective adjunctive therapeutic modality in subjects with uncontrolled severe persistent asthma.

Botanical formulation HX110B ameliorates PPE-induced emphysema in mice via regulation of PPAR/RXR signaling pathway

Chronic obstructive pulmonary disease (COPD), an inflammatory lung disease, causes approximately 3 million deaths each year; however, its pathological mechanisms are not fully understood. In this study, we examined whether HX110B, a mixture of Taraxacum officinale, Dioscorea batatas, and Schizonepeta tenuifolia extracts, could suppress porcine pancreatic elastase (PPE)-induced emphysema in mice and its mechanism of action. The therapeutic efficacy of HX110B was tested using a PPE-induced emphysema mouse model and human bronchial epithelial cell line BEAS-2B. In vivo data showed that the alveolar wall and air space expansion damaged by PPE were improved by HX110B administration. HX110B also effectively suppresses the expression levels of pro-inflammatory mediators including IL-6, IL-1β, MIP-2, and iNOS, while stimulating the expression of lung protective factors such as IL-10, CC16, SP-D, and sRAGE. Moreover, HX110B improved the impaired OXPHOS subunit gene expression. In vitro analysis revealed that HX110B exerted its effects by activating the PPAR-RXR signaling pathways. Overall, our data demonstrated that HX110B could be a promising therapeutic option for COPD treatment.

Quality of Life Improvements with Biologic Initiation Among Subspecialist-Treated US Patients with Severe Asthma

Purpose

Patients living with severe asthma (SA) experience multiple health-related quality of life (HRQoL) impairments. This study examined HRQoL changes after biologic treatment initiation among a large, real-world cohort of patients with SA.

Patients and methods

CHRONICLE is an ongoing observational study of subspecialist-treated adults with SA who receive biologics or maintenance systemic corticosteroids or are uncontrolled on high-dosage inhaled corticosteroids with additional controllers. Patients enrolled February 2018-February 2023 were asked to complete the St. George's Respiratory Questionnaire (SGRQ) every 6 months (total score range of 0-100 [0=best possible health], meaningful change threshold is a 4-unit reduction in the total score). Changes in SGRQ responses from 6 months before initiation to 12 to 18 months after initiation were summarized.

Results

A total of 76 patients completed the SGRQ 0 to 6 months before and 12 to 18 months after biologic initiation. The mean (SD) SGRQ total score decreased from 52.2 (20.6) to 41.9 (23.8), with improvement across the symptoms (-14.5), activity (-11.0), and impacts (-8.3) components. For specific impairments reported by ≥50% of patients before biologic initiation, fewer reported each impairment after biologic initiation; the largest reductions were for "Questions about what activities usually make you feel short of breath these days [Walking outside on level ground]" (67% to 43%), "Questions about other effects that your respiratory problems may have on you these days [I feel that I am not in control of my respiratory problems]" (55% to 34%), and "Questions about your cough and shortness of breath these days [My coughing or breathing disturbs my sleep]" (63% to 45%).

Conclusion

In this real-world cohort of adults with SA, biologic initiation was associated with meaningful improvements in asthma-related HRQoL. These data provide further insight into the burden SA places on patients and the benefits of biologic treatment.

Burden of Uncontrolled Severe Asthma With and Without Elevated Type-2 Inflammatory Biomarkers

BACKGROUND

Many patients with asthma have type-2 airway inflammation, identified by the presence of biomarkers, including history of allergy, high blood eosinophil (EOS) count, and high fractional exhaled nitric oxide levels.

OBJECTIVE

To assess disease burden in relation to type-2 inflammatory biomarker status (history of allergy, blood EOS count, and fractional exhaled nitric oxide level) in patients with uncontrolled and controlled severe asthma in the NOVEL observational longiTudinal studY (NOVELTY) (NCT02760329).

METHODS

Asthma diagnosis and severity were physician-reported. Control was defined using Asthma Control Test score (uncontrolled <20, controlled ≥20) and/or 1 or more severe physician-reported exacerbation in the previous year. Biomarker distribution (history of allergy, blood EOS count, and fractional exhaled nitric oxide level), symptom burden (Asthma Control Test score, modified Medical Research Council dyspnea scale), health status (St George's Respiratory Questionnaire score), exacerbations, and health care resource utilization were assessed.

RESULTS

Of 647 patients with severe asthma, 446 had uncontrolled and 123 had controlled asthma. Among those with uncontrolled asthma, 196 (44%) had 2 or more positive biomarkers, 187 (42%) had 1 positive biomarker, 325 (73%) had low blood EOS, and 63 (14%) were triple-negative. Disease burden was similarly high across uncontrolled subgroups, irrespective of biomarker status, with poor symptom control (Asthma Control Test score 14.9-16.6), impaired health status (St George's Respiratory Questionnaire total score 46.7-49.4), clinically important breathlessness (modified Medical Research Council grade ≥2 in 47.3%-57.1%), and 1 or more severe exacerbation (70.6%-76.2%).

CONCLUSIONS

Type-2 inflammatory biomarkers did not differentiate disease burden in patients with severe asthma. Patients with low type-2 inflammatory biomarker levels have few biologic therapy options; their needs should be addressed.

Moderate asthma: burden, mechanisms and therapeutic perspectives

PURPOSE OF REVIEW

Global Initiative for Asthma (GINA) document provides a classification of asthma severity according with the current level of treatment required to achieve diseases control and underlines the limitations of this approach. In this review, we will provide an overview of recent investigations that have analyzed clinical and molecular features of moderate asthma.

RECENT FINDINGS

Moderate asthma is heterogeneous in terms of response to inhaled treatment and pathogenetic mechanisms underlying the clinical features. Analysis of inflammatory pathways in patients who do not achieve disease remission allows identification of patient subgroups that may benefit from specific biological treatments.

SUMMARY

Scientific progress makes increasingly clear that there are biological mechanisms capable of identifying and justifying the degree of severity of asthma. The identification of these, combined with the development of new pharmacological treatments, will be the cornerstones of improving the management of asthma in its degrees of severity.

Resting state functional connectivity changes following mindfulness-based stress reduction predict improvements in disease control for patients with asthma

BACKGROUND

The staggering morbidity associated with chronic inflammatory diseases can be reduced by psychological interventions, including Mindfulness-Based Stress Reduction (MBSR). Proposed mechanisms for MBSR's beneficial effects include changes in salience network function. Salience network perturbations are also associated with chronic inflammation, including airway inflammation in asthma, a chronic inflammatory disease affecting approximately 10% of the population. However, no studies have examined whether MBSR-related improvements in disease control are related to changes in salience network function.

METHODS

Adults with asthma were randomized to 8 weeks of MBSR or a waitlist control group. Resting state functional connectivity was measured using fMRI before randomization, immediately post-intervention, and 4 months post-intervention. Using key salience network regions as seeds, we calculated group differences in change in functional connectivity over time and examined whether functional connectivity changes were associated with increased mindfulness, improved asthma control, and decreased inflammatory biomarkers.

RESULTS

The MBSR group showed greater increases in functional connectivity between salience network regions relative to the waitlist group. Improvements in asthma control correlated with increased functional connectivity between the salience network and regions important for attention control and emotion regulation. Improvements in inflammatory biomarkers were related to decreased functional connectivity between the salience network and other networks.

CONCLUSIONS

Increased resting salience network coherence and connectivity with networks that subserve attention and emotion regulation may contribute to the benefits of MBSR for patients with asthma. Understanding the neural underpinnings of MBSR-related benefits in patients is a critical step towards optimizing brain-targeted interventions for chronic inflammatory disease management.

Potential of MAIT cells to modulate asthma

Despite recent advances in asthma treatments, the search for novel therapies remains necessary because there are still patients with recurrent asthma exacerbations and poor responses to the existing treatments. Since group 2 innate lymphoid cells (ILC2) play a pivotal role in asthma by triggering and exacerbating type 2 inflammation, controlling ILC2s function is key to combating severe asthma. Mucosal-associated invariant T (MAIT) cells are innate-like T cells abundant in humans and are activated both in a T cell receptor-dependent and -independent manner. MAIT cells are composed of MAIT1 and MAIT17 based on the expression of transcription factors T-bet and RORγt, respectively. MAIT cells play pivotal roles in host defense against pathogens and in tissue repair and are essential for the maintenance of immunity and hemostasis. Our recent studies revealed that MAIT cells inhibit both ILC2 proliferation and functions in a mouse model of airway inflammation. MAIT cells may alleviate airway inflammation in two ways, by promoting airway epithelial cell barrier repair and by repressing ILC2s. Therefore, reagents that promote MAIT cell-mediated suppression of ILC2 proliferation and function, or designer MAIT cells (genetically engineered to suppress ILC2s or promote repair of airway damage), may be effective therapeutic agents for severe asthma.

Interleukin 31 receptor α promotes smooth muscle cell contraction and airway hyperresponsiveness in asthma

Asthma is a chronic inflammatory airway disease characterized by airway hyperresponsiveness (AHR), inflammation, and goblet cell hyperplasia. Multiple cytokines, including IFNγ, IL-4, and IL-13 are associated with asthma; however, the mechanisms underlying the effects of these cytokines remain unclear. Here, we report a significant increase in the expression of IL-31RA, but not its cognate ligand IL-31, in mouse models of allergic asthma. In support of this, IFNγ, IL-4, and IL-13 upregulated IL-31RA but not IL-31 in both human and mice primary airway smooth muscle cells (ASMC) isolated from the airways of murine and human lungs. Importantly, the loss of IL-31RA attenuated AHR but had no effect on inflammation and goblet cell hyperplasia in mice challenged with allergens or treated with IL-13 or IFNγ. We show that IL-31RA functions as a positive regulator of muscarinic acetylcholine receptor 3 expression, augmenting calcium levels and myosin light chain phosphorylation in human and murine ASMC. These findings identify a role for IL-31RA in AHR that is distinct from airway inflammation and goblet cell hyperplasia in asthma.

Picturing asthma in Turkey: results from the Turkish adult asthma registry

INTRODUCTION

National data on asthma characteristics and the factors associated with uncontrolled asthma seem to be necessary for every country. For this purpose, we developed the Turkish Adult Asthma Registry for patients with asthma aiming to take a snapshot of our patients, thereby assigning the unmet needs and niche areas of intervention.

METHODS

Case entries were performed between March 2018 and March 2022. A web-based application was used to record data. Study outcomes were demographic features, disease characteristics, asthma control levels, and phenotypes.

RESULTS

The registry included 2053 patients from 36 study centers in Turkey. Female subjects dominated the group (n = 1535, 74.8%). The majority of the patients had allergic (n = 1158, 65.3%) and eosinophilic (n = 1174, 57.2%) asthma. Six hundred nineteen (32.2%) of the patients had obese asthma. Severe asthma existed in 670 (32.6%) patients. Majority of cases were on step 3-5 treatment (n: 1525; 88.1%). Uncontrolled asthma was associated with low educational level, severe asthma attacks in the last year, low FEV1, existence of chronic rhinosinusitis and living in particular regions.

CONCLUSION

The picture of this registry showed a dominancy of middle-aged obese women with moderate-to-severe asthma. We also determined particular strategic targets such as low educational level, severe asthma attacks, low FEV1, and chronic rhinosinusitis to decrease uncontrolled asthma in our country. Moreover, some regional strategies may also be needed as uncontrolled asthma is higher in certain regions. We believe that these data will guide authorities to reestablish national asthma programs to improve asthma service delivery.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dupilumab sustains efficacy in patients with moderate-to-severe type 2 asthma regardless of inhaled corticosteroids dose

BACKGROUND

Dupilumab, a human monoclonal antibody, blocks the shared receptor component for interleukins-4/13, key and central drivers of type 2 inflammation. The TRAVERSE (NCT02134028) open-label extension study demonstrated the long-term safety and efficacy of dupilumab in patients ≥12 years who completed a previous dupilumab asthma study. The safety profile was consistent with that observed in the parent studies. Here, we assess whether dupilumab sustains long-term efficacy in patients regardless of inhaled corticosteroid (ICS) dose at parent study baseline (PSBL).

METHODS

Patients from phase 2b (NCT01854047) or phase 3 (QUEST; NCT02414854) studies receiving high- or medium-dose ICS at PSBL and enrolled in TRAVERSE were included. We analyzed unadjusted annualized severe exacerbation rates, change from PSBL in pre-bronchodilator (BD) forced expiratory volume in 1 second (FEV1 ), 5-item asthma control questionnaire, and type 2 biomarkers in patients with type 2 asthma at baseline (blood eosinophils ≥150 cells/μL or fractional exhaled nitric oxide [FeNO] ≥25 ppb), and subgroups defined by baseline blood eosinophils or FeNO.

RESULTS

Of patients with type 2 asthma (n = 1666), 891 (53.5%) were receiving high-dose ICS at PSBL. In this subgroup, unadjusted exacerbation rates for dupilumab versus placebo were 0.517 versus 1.883 (phase 2b) and 0.571 versus 1.300 (QUEST) over the parent study (52 weeks) and remained low throughout TRAVERSE (0.313-0.494). Improvements in pre-BD FEV1 were sustained throughout TRAVERSE. Similar clinical efficacy was observed among patients receiving medium-dose ICS at PSBL and biomarker subgroups.

CONCLUSIONS

Dupilumab showed sustained efficacy for up to 3 years in patients with uncontrolled, moderate-to-severe type 2 asthma on high- or medium-dose ICS.

Setting up and assessing a therapeutic education program for asthmatic patients

BACKGROUND

Asthma is a major public health issue. It remains uncontrolled, despite the availability of effective treatments. Appropriate education programs are required to improve the situation. The study aims to design and assess an educational program based on asthma patients' perceived needs.

MATERIALS AND METHODS

A cross-sectional prospective study was conducted in the pulmonology department of the Hassan II University Hospital in Fez. A convenience sample of asthma patients, whether hospitalized or not, was recruited. Two hundred and twenty adult asthma patients completed an educational needs survey (ENS). An asthma knowledge questionnaire for adult patients was used to assess the program on the criterion of improving asthma knowledge. Data collected by ENS was analyzed by standard descriptive statistics. The Student's T test for paired samples was used to compare the means of the Asthma Knowledge Questionnaire scores before and after therapeutic education.

RESULTS

Most patients were married and residing in urban areas. The illiteracy rate was 50%. One patient was a regular smoker. 125 patients (56.82%) reported non-compliance to treatment. The pathophysiology of asthma (chronic airway inflammation, bronchial hyperreactivity, and bronchial obstruction), causes and complications, treatment (inhalation technique), asthma attacks and environmental management, lifestyle, and psychological support were the patients' main perceived educational needs. Based on these findings, an instructional program was created and evaluated with 30 patients. After the program, asthma knowledge increased significantly.

CONCLUSION

Our results suggest that an educational intervention can improve asthma knowledge.

Global Burden of Asthma, and Its Impact on Specific Subgroups: Nasal Polyps, Allergic Rhinitis, Severe Asthma, Eosinophilic Asthma

Background

The complex nature of asthma has resulted in a poor understanding of its epidemiology, particularly in low-and middle-income countries (LMIC). Clinical subgroups, such as patients with severe asthma, eosinophilic asthma, allergic rhinitis, or nasal polyps, experience additional barriers to care.

Methods

Prevalence estimates for asthma and key clinical subgroups were extracted from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 and from a targeted literature review conducted through PubMed in October of 2021. National estimates were calculated and the roles of potential explanatory factors were explored through qualitative analysis.

Results

In total, 162 publications from 69 countries were included. Across continents, asthma prevalence values ranged from 3.44% (Asia), 3.67% (Africa), 4.90% (South America), 5.69% (Europe), 8.29% (North America), to 8.33% (Oceania). Globally, of those with asthma, 26.70% had severe asthma, 30.99% had eosinophilic asthma, 48.95% had allergic rhinitis, and 7.0% to 25.40% had nasal polyps. Countries with higher air quality, income status, and healthcare access and quality reported a higher asthma prevalence.

Conclusion

Asthma prevalence values were low in LMICs, potentially indicating health system deficiencies resulting in low diagnosis and reporting. The prevalence of eosinophilic asthma and severe asthma phenotypes was high in many countries, although the prevalence estimates of all asthma subgroups were quite variable.

A multicomponent nutraceutical (<i>Perilla frutescens</i>, quercetin, and vitamin D3) as add-on therapy in patients with grass pollen-induced mild persistent asthma and rhinitis

Background Allergic asthma is an inflammatory disease characterized by a type 2 immune response. Pollens are a common cause of seasonal asthma. Allergic rhinitis (AR) frequently associates with asthma. The treatment usually aims at controlling inflammation and relieving symptoms. Inhaled corticosteroids are the most effective controller and short-acting b2-agonists (SABA) as a reliever for asthma. Oral antihistamines and nasal corticosteroids (NC) are the mainstays for AR. A multicomponent nutraceutical containing perilla, quercetin, and vitamin D3 significantly prevented AR exacerbations in children. Thus, the current study explored the add-on use in adult patients with mild persistent asthma and AR due to grass pollen allergy. Methods The treatment lasted three months. Asthma and AR symptoms, asthma control test, spirometry, nasal eosinophils, and use of rescue medications (SABA and NC) were evaluated in the previous grass season and throughout the treatment. All patients were treated with ciclesonide (320 mcg/day) and cetirizine (10 mg/day). Patients were randomly stratified into Group A, taking the nutraceutical, and Group B using the predetermined therapy. Results 90 patients (13-59 years old) were enrolled, and 84 completed the trial. Group A significantly improved all outcomes (p<0.001). Group B did not achieve an improvement in AR symptoms, nasal eosinophils, and nasal steroid use. The intergroup analysis showed that Group A patients experienced less severe bronchial symptoms (- 32 %), AR symptoms (- 39 %), better asthma control (+ 38 %), higher FEV1 (+ 10 %), lower SABA (- 30 %) and NC use (- 41 %), and nasal eosinophils count (- 35 %) than Group B (p<0.0001 for all). No clinically relevant adverse events occurred. Conclusion A multicomponent nutraceutical containing perilla, quercetin, and vitamin D3, as an add-on treatment to inhaled ciclesonide and cetirizine, provided a clinically relevant benefit in patients with mild persistent asthma and AR due to grass pollen uncontrolled by standard therapy.

Interleukin 31 receptor alpha augments muscarinic acetylcholine receptor 3-driven calcium signaling and airway hyperresponsiveness in asthma

Asthma is a chronic inflammatory airway disease characterized by airway hyperresponsiveness (AHR), inflammation, and goblet cell hyperplasia. Both Th1 and Th2 cytokines, including IFN-γ, IL-4, and IL-13 have been shown to induce asthma; however, the underlying mechanisms remain unclear. We observed a significant increase in the expression of IL-31RA, but not its cognate ligand IL-31 during allergic asthma. In support of this, IFN-γ and Th2 cytokines, IL-4 and IL-13, upregulated IL-31RA but not IL-31 in airway smooth muscle cells (ASMC). Importantly, the loss of IL-31RA attenuated AHR but had no effects on inflammation and goblet cell hyperplasia in allergic asthma or mice treated with IL-13 or IFN-γ. Mechanistically, we demonstrate that IL-31RA functions as a positive regulator of muscarinic acetylcholine receptor 3 expression and calcium signaling in ASMC. Together, these results identified a novel role for IL-31RA in AHR distinct from airway inflammation and goblet cell hyperplasia in asthma.

Mometasone/Indacaterol/Glycopyrronium (MF/IND/GLY) and MF/IND at Different MF Strengths versus Fluticasone Propionate/Salmeterol Xinafoate (FLU/SAL) and FLU/SAL+ Tiotropium in Patients with Asthma

Background

Once-daily, single-inhaler mometasone furoate/indacaterol acetate/glycopyrronium bromide (MF/IND/GLY, an ICS/LABA/LAMA) and MF/IND (an ICS/LABA) via Breezhaler® have been approved for the maintenance treatment of patients with asthma inadequately controlled with medium-or high-dose ICS or medium-or high-dose ICS/LABA treatment.

Objective

Once-daily (o.d.) formulations of MF/IND/GLY and MF/IND at different MF dose strengths have been compared with twice-daily (b.i.d.) fluticasone propionate/salmeterol xinafoate (FLU/SAL), and b.i.d. FLU/SAL+ o.d. tiotropium (TIO) in the PALLADIUM, IRIDIUM and ARGON studies.

Methods

The similarity in study design and consistent outcomes in these studies prompted the pooling of data in this review to better characterise these novel once-daily controller formulations.

Results

Pooled data from PALLADIUM and IRIDIUM studies showed comparable or greater efficacy with o.d. MF/IND formulations versus b.i.d. FLU/SAL. The o.d. MF/IND/GLY was superior to b.i.d. FLU/SAL in the IRIDIUM study, and similar to, if not more efficacious than b.i.d. FLU/SAL + o.d. TIO in the ARGON study.

Conclusion

These formulations therefore provide novel once-daily treatment options for patients across asthma severity and flexibility for clinicians to step-up or step-down the treatment using the same device and formulations.

Epidemiology of Asthma: Prevalence and Burden of Disease

Asthma, a common airway disease, results in a significant burden to both patients and society worldwide. Yet, despite global political commitment backed by the United Nations, progress to reduce the burden of asthma remains inadequate. This is particularly true in low-income countries. To date, progress has been delayed by the lack of uniform data collection, imperfect surveillance methods, inadequate resources, poor access to effective therapies, substandard asthma education, ineffective governmental policies, rapid urbanization, progressive increase in asthma prevalence, increased life expectancy and obesity rates worldwide, asthma heterogeneity and disease complexity, smoking, and environmental exposures to allergens and pollution. A thorough understanding of the challenges facing the international community is essential to define future strategies to improve the burden of asthma.

Characteristics of Oral Corticosteroid Users Among Persons with Asthma on GINA Step 3 Therapy and Above: A Cross-Sectional Study in Portuguese Community Pharmacies

PURPOSE

Oral corticosteroids (OCS) are frequently used in asthma management but have an important risk-profile. The aim of the study is to characterize and compare the sociodemographic and clinical characteristics, treatment regimen and asthma control between OCS users and non-users among the population of asthma patients (≥18 years) at GINA step 3 and above treated with a fixed combination of an inhaled corticosteroid and a long-acting beta-agonist (ICS/LABA).

METHODS

Cross-sectional study in Portuguese community pharmacies. Data was collected via paper-based interview delivered at the pharmacy (sociodemographic characteristics and asthma treatment regimen, namely ICS/LABA and OCS utilization), followed by a telephonic interview collecting smoking history, comorbidities, body mass index (BMI), history of exacerbations and asthma-related healthcare resource utilization (HCRU) in the previous 12 months, as well as asthma control using the Control of Allergic Rhinitis and Asthma Test (CARAT®).

RESULTS

A total of 347 patients recruited in 98 pharmacies were included in the analysis. Of those, 328 had completed both questionnaires. A quarter of the individuals reported OCS use in the previous 12 months (OCS users), either as add-on therapy (6%) or exacerbation treatment (19%). Patients were mostly females (72%), with an average age of 59.5 years (SD=15.4). OCS users were significantly older and reported more frequently having conjunctivitis (25.9% vs 15.0%), osteoporosis (25.9% vs 13.4%), arthritis (14.6% vs 6.9%), and gastrointestinal disease (16.1% vs 8.1%). OCS users also reported greater urgent HCRU: unscheduled consultations (33.3% vs 9.3%) and emergency department (ED) visits (32.1% vs 12.1%). Both groups presented poor disease control (85.2% of OCS users vs 72.9% of non-OCS users).

CONCLUSION

These results highlight the burden of OCS therapy to asthma patients and the need to improve asthma management, by adopting OCS sparing strategies in this subgroup of patients.

Development, validation and application of a questionnaire to qualify the indoor environmental exposure of patients with respiratory allergy

Objective: Environmental control includes measures to prevent exposure to common aeroallergens in an individual's home. Questionnaires are part of the clinical practice of health assessment, and are also widely used in research. Our aim was to develop and validate a questionnaire to identify possible sources of aeroallergens present in the indoor environment. Methods: This study describes the development, validation and application of a questionnaire. For content validation the Content Validation Index and Ordinal Cronbach's Alpha Index have been used; Polychoric Correlations for the agreement between judges; and an Exploratory Factor Analysis for the structure of the questionnaire, while for reliability assessment, Intraclass Correlation Coefficient has been applied. Results: Twenty-one doctors participated as judges to validate the questionnaire, which 204 patients answered. The Content Validity Index for all the questions on the "Clarity" aspect was 0.846 ± 0.152 and on the "Relevance" aspect, 0.954 ± 0.080. Cronbach's alpha coefficient for the "Clarity" aspect was 0.88 with a 95% confidence intervals (CI) and the "Relevance" aspect, 0.94 with a 95% CI. The average Intraclass Correlation Coefficient was 0.94 and all the F tests were highly significant. Conclusions: The questionnaire developed by our group was considered valid and reliable, and is capable of portraying the home environment without the need for a personal visit to the patient's home. This questionnaire would be a good tool to use in research or during patient consultations to assess the patient's home environment, as this latter assessment is essential for the management of patients with respiratory allergies.

The emerging role of NOTCH3 receptor signalling in human lung diseases

The mammalian respiratory system or lung is a tree-like branching structure, and the main site of gas exchange with the external environment. Structurally, the lung is broadly classified into the proximal (or conducting) airways and the distal alveolar region, where the gas exchange occurs. In parallel with the respiratory tree, the pulmonary vasculature starts with large pulmonary arteries that subdivide rapidly ending in capillaries adjacent to alveolar structures to enable gas exchange. The NOTCH signalling pathway plays an important role in lung development, differentiation and regeneration post-injury. Signalling via the NOTCH pathway is mediated through activation of four NOTCH receptors (NOTCH1-4), with each receptor capable of regulating unique biological processes. Dysregulation of the NOTCH pathway has been associated with development and pathophysiology of multiple adult acute and chronic lung diseases. This includes accumulating evidence that alteration of NOTCH3 signalling plays an important role in the development and pathogenesis of chronic obstructive pulmonary disease, lung cancer, asthma, idiopathic pulmonary fibrosis and pulmonary arterial hypertension. Herein, we provide a comprehensive summary of the role of NOTCH3 signalling in regulating repair/regeneration of the adult lung, its association with development of lung disease and potential therapeutic strategies to target its signalling activity.

Trends and predictors of specialist assessments in oral corticosteroid treated asthma among young adults

Background

Repeated oral corticosteroid use indicates uncontrolled disease among asthma patients and referral for asthma specialist assessment is recommended. We aimed to describe trends and predictors associated with specialist contacts among young adults with asthma and repeated oral corticosteroid use.

Methods

Individuals aged 18–45 years with ≥2 dispensed asthma medication prescriptions and two dispended oral corticosteroid prescriptions (including short-term and long-term treatments) within 12 months during 1999–2018 were identified by use of Danish healthcare registers. The frequency of specialist contacts within 1 year of follow-up was assessed among individuals without previous specialist contacts within 5 years of inclusion. Factors associated with specialist contact were identified by logistic regression models. Furthermore, oral corticosteroid prescriber sources were assessed.

Results

For the 11 223 individuals included, 2444 (22%) had previous specialist contacts care within 5 years prior of inclusion and additionally 926 (8.3%) within 1 year of follow-up. Among those without previous specialist contacts (n 8779), the frequency of incident specialist contacts within 1 year of follow-up increased from 6.3% in 1999 to 18% in 2017. Factors associated with incident specialist contacts included dispensing ≥12 SABA canisters and previous asthma-related emergency department visits and hospitalisations. The majority of oral corticosteroid prescriptions at baseline (71%) were prescribed by general practitioners, though with decreasing proportions from 1999–2018.

Conclusions

The majority (70%) of young adults with asthma and repeated oral corticosteroid use do not seem to receive specialist assessment in Denmark. This highlights a potential room for improvement in the patient referral pathway for at-risk asthma patients.