After asthma: redefining airways diseases

Care of the Patient With Asthma

Nearly 8% of the U.S. population is diagnosed with asthma, leading to more than 5 million office visits and 1 million emergency department visits annually. Both outpatient and inpatient internal medicine clinicians treat asthma frequently, but nuances in diagnosis and management have emerged. This article highlights many of these developments.

Inflammatory and clinical risk factors for asthma attacks (ORACLE2): a patient-level meta-analysis of control groups of 22 randomised trials

BACKGROUND

Clinical risk factors for severe asthma attacks have been identified, but their incremental prognostic values are unclear. Additionally, the incremental contribution of type 2 inflammation, a common, treatable process, is undetermined. We aimed to quantify the prognostic value of baseline characteristics and type 2 inflammatory biomarkers, specifically blood eosinophil count and fractional exhaled nitric oxide (FeNO), to predict asthma attacks.

METHODS

In this systematic review and meta-analysis of randomised controlled trials (RCTs), Oxford Asthma Attack Risk Scale 2 (ORACLE2), we searched MEDLINE from Jan 1, 1993, to April 1, 2021, for trials investigating fixed treatment regimen effects on asthma attack rates for at least 6 months with baseline blood eosinophil count and FeNO. Eligible participants were aged 12 years or older with asthma (any severity) who had been randomly assigned to the control group of an RCT. Relevant trials were manually retrieved and reviewed by two independent reviewers (SC and IDP). Disagreements were discussed with five reviewers. Individual patient data (IPD) for meta-analysis were requested from study authors. We investigated the rate of severe asthma attacks (≥3 days of systemic corticosteroids) for at least 6 months and prognostic effects of baseline blood eosinophil count and FeNO in control group participants. Rate ratios (RRs) with 95% CIs were derived for annualised asthma attack rates from negative binomial models adjusted for key variables, including blood eosinophil count and FeNO, and interactions between these type 2 inflammatory biomarkers were explored. Certainty of evidence was assessed using GRADE. The heterogeneity of the included studies and potential for ecological bias were quantified by the concordance statistic (C-statistic). This study was registered with PROSPERO, CRD42021245337.

FINDINGS

We identified 976 potentially eligible studies. After automated screening, we manually reviewed 219 full-text articles. Of these, 19 publications comprising 23 RCTs were eligible. 6513 participants (4140 [64%] female; 2370 [36%] male; three missing) spanning 22 RCTs were included for data analysis. 5972 (92%) of 6513 patients had moderate-to-severe asthma. 4615 asthma attacks occurred during 5482 person-years of follow-up (annualised rate 0·84 per person-year). Higher blood eosinophil count or FeNO was linked to higher asthma attack risk (per 10-fold increase, RR 1·48 [95% CI 1·30-1·68] for blood eosinophil count and 1·44 [1·26-1·65] for FeNO; high-certainty evidence). Other prognostic factors were attack history (yes vs no, RR 1·94 [1·61-2·32]); disease severity (severe vs moderate, RR 1·57 [1·22-2·03]); FEV1 percentage predicted (FEV1%; per 10% decrease, RR 1·11 [1·08-1·15]); and 5-item Asthma Control Questionnaire score (ACQ-5; per 0·5 increase, RR 1·10 [1·07-1·13]). High blood eosinophil count and FeNO combined were associated with greater risk than either prognostic factor separately. Bronchodilator reversibility was associated with lower risk of severe asthma attacks (per 10% increase, RR 0·93 [0·90-0·96]), with the reduction observed primarily between 0% and 25%. Regarding heterogeneity of the included studies, the C-statistic ranged from 0·58 to 0·95, indicating major differences in patient and disease characteristics between studies. In the univariable meta-analysis per trial, we found substantial heterogeneity in associations between studies, with I2 statistics ranging from 0·56 to 0·97.

INTERPRETATION

Blood eosinophil count, FeNO, asthma attack history, disease severity, low lung function (low FEV1%), and symptoms (ACQ-5 score) are key predictors of asthma attacks. Conversely, we found that moderate bronchodilator reversibility was associated with reduced risk. These findings from high-quality multinational RCTs support incorporation of blood eosinophils and FeNO into clinical risk stratification for targeted risk reduction. More individualised clinical decision-making models should be explored.

FUNDING

National Institute of Health and Care Research Oxford Biomedical Research Centre; Association pulmonaire du Québec; Fonds de recherche du Québec-Santé; Québec Air-Intersectorialité-Respiratoire-Son network; Stichting Astma Bestrijding; Leiden University Fund; and Academy of Medical Sciences.

Understanding Social Inequalities in Childhood Asthma: Quantifying the Mediating Role of Modifiable Early-Life Risk Factors in Seven European Birth Cohorts

BACKGROUND

Children growing up in disadvantaged socioeconomic circumstances (SECs) have an increased risk of asthma.

OBJECTIVE

To increase our understanding of the pathways to inequalities in asthma and potential targets for intervention by (1) examining how the social patterning of asthma and its early-life risk factors varies across countries and (2) quantifying the mediation of observed inequalities by early-life risk factors.

METHODS

We used data for 107,884 mother-child dyads from 7 European birth cohorts across 6 countries. Maternal education was the primary exposure measure of early-life SECs. The outcome was current asthma in childhood (3-12 years). Inequalities were examined using multivariable regression and random effects meta-analysis. The mediating effects of early-life risk factors (maternal smoking during pregnancy, adverse birth outcomes, and breastfeeding duration) were examined using counterfactual mediation analysis.

RESULTS

In meta-analysis, children of mothers with low/medium versus high education had a 17% (95% confidence interval: 8%-27%, I2 = 21.6%) increased risk of asthma. Cohort-specific risk ratios ranged between 1.07 (0.97-1.18, Danish National Birth Cohort, Denmark) and 1.61 (1.08-2.40, study on the pre- & early postnatal determinants of child health & development, France). The early-life risk factors were similarly socially patterned, but with greater heterogeneity across cohorts (I2 range = 66.2%-95.3%). The mediation analysis suggested that these factors play a relevant role in mediating observed inequalities (proportion mediated range: 0.08-0.72).

CONCLUSIONS

There was a consistent tendency for children from disadvantaged SECs to be at greater risk of asthma in the European cohorts examined. Our results suggest that early-life risk factors partially mediate these disparities and, therefore, that public health interventions in the perinatal period may help to address inequalities in asthma.

Catalase-encapsulated matrix metalloproteinase-9 responsive nanogels for modulation of inflammatory response and treatment of neutrophilic asthma

Asthma is a chronic disease with typical pathological features such as airflow limitation, airway inflammation and remodeling. Of these, neutrophilic asthma is considered to be the more severe and corticosteroid-resistant subtype of asthma. Increasing evidence suggests that patients with neutrophilic asthma often accompany with dysbiosis of the internal microbiota, where the increased abundance of non-typeable Haemophilus influenzae (NTHi) is closely related to the neutrophilic asthma phenotype. Furthermore, emerging evidence suggests that reactive oxygen species (ROS) are pivotal in the pathogenesis of neutrophilic asthma. In this study, matrix metalloproteinase-9 (MMP-9)-responsive, catalase-loaded nanogels (M-CAT-NGs) were synthesized, which was composed of MMP-9-sensitive peptide (VPMS), arginine-grafted chitosan and maleimide (CS-Arg-Mal), catalase (CAT), sodium citrate (SC) and ε-poly(L-lysine) (ε-PLL). The M-CAT-NGs showed potent antimicrobial effects and exerted excellent therapeutic effects in the presence of MMP-9 by causing VPMS rupture and responsive release of CAT. In vitro experiments revealed that M-CAT-NGs effectively inhibited the proliferation of NTHi, Staphylococcus aureus (S. aureus), and Escherichia coli (E. coli), while also demonstrating the capacity to modulate the inflammatory response induced by lipopolysaccharide (LPS) and hydrogen peroxide (H2O2) stimulation. In vivo experiments demonstrated that nebulized inhalation of M-CAT-NGs was effective in reducing airway hyperresponsiveness (AHR), alleviating inflammation, downregulating the expression level of ROS in the lung tissues, thus enabling the effective management of neutrophilic asthma. Thus, the development of M-CAT-NGs has shown strong potential for the clinical management of neutrophilic asthma by modulating the inflammatory response.

Treatable Traits as a Pathway to Remission in Asthma

In recent years, the significant impact of disease-modifying anti-asthmatic drugs has provided a chance to reevaluate goals in asthma treatment and consider remission as a more ambitious and achievable target. Clinical remission in asthma, both on- and off-treatment, has been characterized by the absence of asthma-related symptoms, attacks, and systemic corticosteroids, and the improvement or stabilization of lung function, all maintained over a minimum of 12 months. Targeting treatable traits has emerged as a promising strategy for the personalized treatment of chronic airway diseases in both primary and specialist care. This multidimensional approach involves the initial identification and tailored treatment of clinically essential characteristics in individual patients, called super-traits. Considering the heterogeneous and multifaceted nature of asthma and associated comorbidities, the novelty of this review is the proposal to use pulmonary, extrapulmonary, and behavioral treatable traits as a tool to reach remission.

Update in paediatric asthma

PURPOSE OF REVIEW

The field of paediatric asthma is rapidly moving, with the advent of new biologicals for severe asthma and increased understanding of preschool wheeze amongst other developments and insights.

RECENT FINDINGS

There is increasing evidence of efficacy in children for biologics directed against Type 2 inflammation (especially mepolizumab and dupilumab) as well encouraging evidence that Tezepelumab may be effective against Type 2 low phenotypes. The importance of airway remodelling and infection in the pathophysiology of preschool wheeze is increasingly appreciated. The treatment of preschool wheeze is moving from symptom-based to biomarker driven therapies. Other important areas are prediction of risk of asthma attacks, the SMART regime, the importance of climate change and reducing greenhouse gas emissions from inhalers while ensuring adequate therapy for young children, the association of early adverse environmental factors including childhood poverty and deprivation and the switch to race-neutral lung function equations.

SUMMARY

We are increasingly moving towards personalized medicine and the use of biomarkers to guide treatment of wheeze at all ages, but we need to move from counting cells to determining their functional status. Airway wall structural changes rather than inflammation may drive the progression of preschool wheeze to school age asthma.

Effects of Dupilumab in Children and Adolescents With Moderate-Severe Asthma: A Systematic Review of Clinical Trials

OBJECTIVE

To evaluate the benefits and harms of Dupilumab in children and adolescents with moderate to severe asthma.

METHODS

We conducted a systematic search in Medline, Embase, Cochrane Controlled Register of Trials, and Clinical Trials Registries up to August 18, 2024. Whenever possible, we performed meta-analyses of the studies. The certainty of the evidence for each outcome was assessed using the GRADE methodology.

RESULTS

Seven publications from two multicenter RCTs were included. These studies included 408 children (6-11 years old) and 134 adolescents (12-17 years old). Both studies were funded by the pharmaceutical company that manufactures Dupilumab. The evidence suggests that Dupilumab probably leads to a substantial reduction in the annual rate of severe exacerbations (incidence rate ratio [IRR]: 0.46, 95% CI: 0.31-0.67; moderate certainty), particularly in children with a Th2 phenotype. Dupilumab probably improves quality of life to a clinically meaningful extent (RR: 1.18, 95% CI: 1.01-1.29; moderate certainty). However, it probably does not lead to a substantial improvement in asthma control (mean difference: -0.43, 95% CI: -0.56 to -0.30; two studies; moderate certainty; minimal-important-difference: 0.5). The frequency of serious adverse events may be similar between Dupilumab and placebo (4.8% vs. 4.5%; RR: 1.05, 95% CI: 0.41-2.68; low certainty). Finally, at 52 weeks, Dupilumab lead to an important increase in the Z-score pre-BD FEV1/FVC (RR: 1.45, 95% CI: 1.22-1.63; high certainty).

CONCLUSION

In children and adolescents with uncontrolled moderate to severe asthma, particularly those with a Th2 inflammatory phenotype, the use of Dupilumab probably reduced the annual rate of severe exacerbations, increases both the percentage of children with good quality of life and pulmonary function parameters, with probably minimal serious adverse events.

Phenotyping the responses to systemic corticosteroids in the management of asthma attacks (PRISMA)

BACKGROUND

Asthma attacks are heterogeneous. It is not known whether the response to oral corticosteroids (OCS) in acute asthma varies according to type 2 (T2) inflammatory biomarkers, blood eosinophil count (BEC) and fractional exhaled nitric oxide (F ENO). We aimed to explore the relationship between T2 biomarkers and response to OCS in acute asthma.

METHODS

We conducted a longitudinal observational study of people experiencing an asthma attack evaluated before and after a 7-day OCS course. The primary outcome was post-bronchodilator change in forced expiratory volume in 1 s (FEV1) according to ordinal BEC-F ENO three-group categories (T2-Low/Low: BEC <0.15×109 cells·L-1 and F ENO <25 ppb; T2-High/High: BEC ≥0.30×109 cells·L-1 and F ENO ≥35 ppb; T2-Mid: not meeting Low/Low or High/High criteria). A key secondary outcome was the change in Asthma Control Questionnaire-5 score. Exploratory outcomes included OCS-attributable adverse events.

RESULTS

53 people were enrolled, with 16 (30%) T2-Low/Low, 27 (51%) T2-Mid and 10 (19%) T2-High/High asthma attacks. Post-bronchodilator FEV1 changes increased with combined BEC-F ENO elevation (p for interaction=0.007), peaking in the T2-High/High phenotype (0.390±0.512 L, p for trend<0.0001). Conversely, T2-Low/Low attacks showed nonsignificant FEV1 changes (0.017±0.153 L). In univariable and multivariable analyses, only ordinal BEC-F ENO stratification, not symptoms nor FEV1, predicted subsequent post-bronchodilator FEV1 improvement. All patients had improved Asthma Control Questionnaire-5 score, numerically peaking in the T2-High/High phenotype (-1.58±0.60, p for trend=0.08). All groups experienced similar OCS-attributable adverse events, with 33 patients (62%) reporting at least one event.

CONCLUSIONS

We found that objective improvement following OCS is confined to T2-High events. As in chronic asthma, greater T2 burden identifies a distinct clinical and therapeutic trajectory, whereas OCS‑related adverse events are uniformly distributed.

Global burden of asthma among children and adolescents with projections to 2050: a comprehensive review and forecasted modeling study

Understanding pediatric asthma is crucial to its effective diagnosis and intervention, as it may alleviate the adulthood disease burden. This epidemiological review describes the prevalence of asthma among individuals under 20 years of age by categorizing them into 3 age groups: 1-4, 5-9, and 10-19 years. Estimates were obtained from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, which covered the prevalence of asthma from 1990 to 2021 across 21 GBD regions with 95% uncertainty intervals (UIs). We also projected the prevalence of pediatric asthma in 2050 by using a logistic regression predictive model from the existing literature and incorporating body mass index as a covariate with fixed coefficients over time. Overall, a continuous decline in asthma prevalence rates among children and adolescents was observed from 1990 to 2021, with higher rates in males and a peak prevalence rate in the 5-9 years group. Central Europe showed significantly increased prevalence rates compared to those of other regions. Our projection suggests that the prevalence rate of pediatric asthma will decline to approximately 2,608.05 per 100,000 population by 2050 (95% UI, 1,632.94-3,868.26), representing a 39.5% decrease from the 2021 figures. Despite these trends, asthma remains a substantial health burden for children and adolescents that may persist into adulthood. Therefore, proactive diagnosis and intervention are essential to mitigating the associated disease burden.

Exacerbation burden in patients treated as intermittent or mild-persistent asthma using short-acting β2-agonist rescue

BACKGROUND

Most people in the United States with asthma use therapies for intermittent/mild-persistent disease; however, exacerbations and death occur in patients with infrequent symptoms or labeled as mild asthma.

OBJECTIVE

To evaluate relationships between short-acting β2-agonist (SABA) use, exacerbations, and maintenance adherence in intermittent/mild-persistent asthma.

METHODS

Retrospective cohort study using US Merative MarketScan administrative claims (January 2010 to December 2017) for patients aged 12 years or older treated as intermittent/mild-persistent asthma. Patients were indexed on a random SABA claim, with 12 months continuous enrollment pre- and post-index. Post-index SABA groups were defined as low (index fill only), medium (2-3 fills), and high (≥4 fills). Severe exacerbations were compared within the treatment, SABA fill, and adherence (medication possession ratio) groups through unadjusted comparison of proportions, χ2, and odds ratios (OR [95% CI]); P less than or equal to .05.

RESULTS

A total of 533,679 patients were included: 68.1% female; mean age (SD) 34.6 (18.3) years; 70.0% intermittent (SABA only) and 30.0% mild-persistent (8.6% low-dose inhaled corticosteroid [ICS]; 21.4% leukotriene modifier [LM]). The proportion of patients with high SABA fills differed among the treatments: SABA only (14.8%), low-dose ICS (37.0%), and LM (25.5%) (P < .001). The proportion experiencing 1 or more exacerbations was higher in SABA only (61.2%) vs low-dose ICS (40.4%) or LM (50.4%): OR (95% CI) 2.32 (2.28-2.37) and 1.55 (1.53-1.57), respectively (both P < .001). The medication possession ratio was less than 50% in 59.3% of patients with mild-persistent asthma; however, adherence was only related to exacerbations in the high SABA group.

CONCLUSION

Patients treated as intermittent/mild-persistent asthma rely on SABA and experience exacerbations. Shifting from SABA only to an anti-inflammatory rescue therapy could decrease morbidity.

Guidance for type 2 inflammatory biomarkers

Type 2 inflammation in the airways and lungs is inflammation induced by type 2 cytokines such as IL-4, IL-5, and IL-13, produced primarily by type 2 helper T cells and type 2 innate lymphoid cells, and causes changes in the physiology and structure of the airways. Type 2 inflammation is currently in the spotlight because of its direct link to the treatment of several airway and lung diseases. Abundant evidences have accumulated that inflammatory biomarkers such as blood eosinophils, fractional exhaled nitric oxide, and IgE are essential clinical tools in the diagnosis and management of asthma and COPD. It is well known that asthma and COPD have diverse inflammatory phenotypes even when clinical features are similar, and it has been demonstrated that assessment of airway inflammation with biomarkers can improve diagnostic accuracy, determine safer and more effective treatment strategies, and predict future risks such as exacerbations and lung function decline. The Japanese Respiratory Society has published clinical practice guidelines for the evaluation of type 2 inflammation in the airways and lungs. In addition to asthma and COPD, the guide covers a wide range of airway and lung diseases, including interstitial lung disease, allergic bronchopulmonary mycosis, allergic rhinitis, and eosinophilic chronic rhinosinusitis. It also provides comprehensive guidelines covering a variety of clinical biomarkers. The purpose of this guidance is to provide evidences for the interpretation of type 2 inflammation measurements and to promote the widespread use of inflammation assessment to further improve the efficiency of airway and respiratory disease management.

Geographic pattern of asthma prevalence in Brazilian adolescents: a systematic review with meta-analysis

OBJECTIVES

This study aimed to verify the prevalence of asthma in Brazilian adolescents and its geographic pattern carried through a systematic review and meta-analysis.

SOURCES

A survey of databases (Pubmed, Chocrane, LILACS, SCIELO and SCOPUS) was carried out, following the PRISMA statement, between the years 2013 and 2023 (PROSPERO-ID-CRD42023427988). Articles that presented a measure relative to the prevalence of asthma in adolescents were included. The methodological quality regarding risk of bias was assessed according to the approach proposed by the Joanna Brigg Institute.

SUMMARY OF THE FINDINGS

Ten of a total of 3140 studies were included. Six studies were collected before 2015. The prevalence of active asthma, severe asthma, and diagnosed asthma were 18 %, 6 %, and 14 %, respectively. The studies were presented in large urban centers and capitals, had a high methodological quality, and showed high heterogeneity. Subgroup analysis was carried out, separating the cities according to the different regions of Brazil (north, northeast, center-west, south, and southeast). The northeast was the region with the lowest prevalence of active asthma (14 %, 95 % CI = 12-17 %, p < 0.001). There was no difference between regions in terms of diagnosed asthma and severity.

CONCLUSION

A high proportion of Brazilian adolescents reported having active asthma, with the northeast region having the lowest prevalence. Most of the studies were collected more than eight years ago and regard capitals and large urban centers. The high heterogeneity found demonstrates uncertainty in asthma prevalence in Brazil and highlights the need for clearer protocols addressing the multifactorial nature of the disease.

Understanding the childhood origins of asthma and chronic obstructive pulmonary disease: Insights from birth cohorts and studies across the life-span

Birth cohorts have identified modifiable risk factors for asthma and respiratory health in children and adults, demonstrating the important role and pathways through which early-life events influence not only child outcomes but also adult health, disease, and mortality. This focused literature update from 2021 to 2024 summarizes birth cohort studies across the life-span that contribute to our understanding of risk factors for and the childhood origins of asthma and chronic obstructive pulmonary disease that may inform prevention efforts. We conclude that there are critical periods of developmental plasticity and susceptibility during which early-life events and exposures likely have the greatest impact on the development of asthma and chronic obstructive lung disease phenotypes, and that there are important prenatal and early childhood exposures, which, if modified, might be candidates for improving respiratory health across the life-span. Birth cohorts have been and will continue to be critical to advancing our understanding of lung health and disease across the life-span, including asthma and chronic obstructive pulmonary disease. As child mortality declines and the human population ages, data from birth cohort studies are needed to inform strategies for optimizing healthy longevity, including the investment in understanding the lifelong consequences of adverse prenatal and early childhood exposures.

The immunology of asthma and chronic rhinosinusitis

Asthma and chronic rhinosinusitis (CRS) are common chronic inflammatory diseases of the respiratory tract that have increased in prevalence over the past five decades. The clinical relationship between asthma and CRS has been well recognized, suggesting a common pathogenesis between these diseases. Both diseases are driven by complex airway epithelial cell and immune cell interactions that occur in response to environmental triggers such as allergens, microorganisms and irritants. Advances, including a growing understanding of the biology of the cells involved in the disease, the application of multiomics technologies and the performance of large-scale clinical studies, have led to a better understanding of the pathophysiology and heterogeneity of asthma and CRS. This research has promoted the concept that these diseases consist of several endotypes, in which airway epithelial cells, innate lymphoid cells, T cells, B cells, granulocytes and their mediators are distinctly involved in the immunopathology. Identification of the disease heterogeneity and immunological markers has also greatly improved the protocols for biologic therapies and the clinical outcomes in certain subsets of patients. However, many clinical and research questions remain. In this Review, we discuss recent advances in characterizing the immunological mechanisms of asthma and CRS, with a focus on the main cell types and molecules involved in these diseases.

Demographic and regional trends in asthma mortality in the United States, 1999-2020

BACKGROUND

Asthma remains a public health concern in the United States, with mortality disproportionately affecting demographic groups. This study aimed to describe national trends in asthma mortality from 1999 to 2020 and identify demographic and regional disparities.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed mortality data from the CDC WONDER database using International Classification of Diseases, Tenth Revision (ICD-10) codes J45 and J46. Age-adjusted mortality rates (AAMRs) were calculated by sex, race, age group, US Census region, state, and urban-rural classification. Joinpoint regression was employed to detect changes over time.

RESULTS

A total of 82,686 asthma-related deaths were identified (37.2% males, 62.8% females). Overall, the AAMR declined from 1.72 in 1999 to 1.14 in 2020. Joinpoint analysis revealed a significant decline from 1999 to 2009, a plateau from 2009 to 2014, a further decline from 2014 to 2018, and a significant increase from 2018 to 2020. Non-Hispanic Black individuals (AAMR 2.73) and older adults (≥65 years) had the highest mortality rates, with females exhibiting higher rates than males (1.30 vs 0.95).

CONCLUSIONS

Despite declining trends, persistent disparities in asthma mortality underscore the need for targeted interventions, improved healthcare access, and ongoing surveillance.

What We Know to Date About Early Treatment With Biologics in Severe Asthma: A Scoping Review About the Use of Biologics in Severe Asthma and Possible Parallels With Early Rheumatoid Arthritis

Introduction

Theoretically, an early intervention with biologics in severe asthma (SA) patients may attenuate inflammatory processes and potentially halt disease progression and remodeling. Changing the approach to a more preventive one could alter the course of the disease, avoid its progression, and improve the likelihood of achieving clinical remission. The aims of this study were to gather scientific evidence on this topic, to draw a parallel between SA and rheumathoid arthritis (RA) and to analyze the potential benefits of establishing early treatment in SA.

Material and methods

A systematic scoping review, conducted in accordance with the methodological guidance of the Arksey and O'Malley framework and focusing on early treatment intervention with biological drugs in SA and RA is presented.

Results

Evidence supports the early intervention with biologics in RA to improve outcomes. Evidence regarding early intervention with biologics in SA is scarce. To date, the literature reviewed suggests that better clinical condition of the patient and more preserved lung function at the onset of biological treatment, together with a shorter duration of asthma, are associated with better response to biologics.

Conclusions

Data suggests that the more preventive approach may lead to improved results. The scarcity of scientific evidence highlights the importance of pursuing this line of research.

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.

Unveiling the Complexities of Pediatric Asthma Treatment: Evidence, Controversies, and Emerging Approaches

Pediatric asthma remains a prevalent and challenging chronic condition globally, affecting quality of life and imposing significant burdens on families and healthcare systems. Despite advancements in understanding asthma pathophysiology and treatment, key controversies persist in optimizing management strategies. Inhaled corticosteroids (ICS) are the cornerstone of treatment, reducing inflammation and preventing exacerbations. While concerns about growth suppression exist, evidence suggests that this effect is primarily associated with high doses and prolonged use, rather than standard maintenance therapy. Nonetheless, adherence to ICS remains suboptimal, necessitating strategies to ensure effective and sustained treatment. The introduction of maintenance and reliever therapy (MART) with ICS-formoterol has offered improved outcomes by simplifying regimens and reducing reliance on short-acting beta-agonists (SABA). However, evidence supporting MART and ICS-SABA regimens in younger children is limited, highlighting gaps in pediatric-focused research. Biologics targeting inflammatory pathways, such as omalizumab, mepolizumab, and dupilumab, represent a personalized approach for severe asthma but face challenges including high costs, limited long-term safety data, and uncertainty regarding their ability to modify disease progression. In addition, the complexity of treatment decisions is compounded by insufficient biomarkers and age-specific evidence to guide therapy. Addressing these gaps requires robust clinical studies and improved adherence strategies tailored to pediatric populations. This review critically examines current pharmacological strategies, unresolved issues, and evolving approaches in asthma management, emphasizing the need for personalized and evidence-based care. Enhancing treatment outcomes for pediatric asthma necessitates balancing therapeutic benefits with minimal adverse effects and leveraging ongoing research to inform future practice.

Dysfunctional Breathing and Depression Are Core Extrapulmonary and Behavior/Risk Factor Traits in Type 2-High Severe Asthma

BACKGROUND

Obesity and smoking are core treatable traits (TTs) in type 2 (T2)-low asthma, contributing to its pathophysiology. In contrast, core extrapulmonary and behavior/risk factor traits remain unclear in T2-high asthma.

OBJECTIVE

This study aimed to identify core extrapulmonary and behavior/risk factor traits for T2-high asthma.

METHODS

A cross-sectional study was conducted on 187 people (aged ≥18 years) with severe asthma who completed a multidimensional assessment. T2-high asthma was defined as blood eosinophils ≥150 cells/μL and/or fractional exhaled nitric oxide ≥20 ppb. Core TTs in T2-high asthma were identified among 9 extrapulmonary traits and 4 behavior/risk factor traits, using network analysis and dominance analysis for the Asthma Control Questionnaire scores, the Asthma Quality of Life Questionnaire scores, exacerbation frequency, and lung function. Associations between the identified core TTs and biomarkers were examined in participants with T2-high asthma.

RESULTS

Of 187 participants, 151 (80.7%) had T2-high severe asthma. Dysfunctional breathing and depression had higher values of node strength than other TTs, contributing most to worse asthma symptoms, poorer quality of life, and frequent exacerbations in T2-high asthma. These conditions in T2-high asthma were associated with elevated systemic inflammation, including blood neutrophils, neutrophil-lymphocyte ratio, and serum high-sensitivity C-reactive protein, independent of obesity, oral corticosteroid dose, and anxiety.

CONCLUSIONS

Core extrapulmonary and behavior/risk factor traits in T2-high severe asthma were dysfunctional breathing and depression, contributing to worse asthma outcomes, suggesting that core TTs may differ between asthma inflammatory phenotypes. Elevated systemic inflammation may help in recognizing the presence of dysfunctional breathing and depression in T2-high severe asthma.

Qualitative insights into planning implementation of FeNO-guided asthma management in primary care

Fractional exhaled nitric oxide (FeNO) testing is used in primary care in some areas of the UK to aid asthma diagnosis but is used less frequently for managing asthma. A randomised controlled trial (RCT) is investigating whether an intervention, including FeNO testing and a clinical algorithm, improves outcomes for patients with asthma. This study was conducted to explore potential for implementation of the intervention. The study aim was to explore views of those with a vested interest in implementing the FeNO intervention into primary care asthma reviews. In-depth, semi-structured interviews were conducted online with individuals, including those with experience in policymaking, healthcare management, National Health Service commissioning, as healthcare professionals (HCPs) with extended roles, and patients and advocates. Inductive thematic analysis was conducted for nineteen interviews. Findings suggest complex interplay of barriers, contextual issues and facilitators. Overall, participants perceived FeNO-informed asthma management would enhance care, if used appropriately and flexibly according to context, for example planning implementation alongside remote reviews. Easier, equitable access to funded FeNO equipment would be needed for national implementation. Participants suggested motivation of all involved in future implementation may be increased by guidelines recommending FeNO, and by use of financial incentives and champions sharing best practice examples. In conclusion, financial obstacles were reiterated as a primary barrier to FeNO use. Despite barriers, facilitating implementation by harnessing prominent cost-benefits could persuade decision makers and clinicians. Findings lay early foundations for development of an implementation strategy.

Evaluation of a disease-state education program in asthma: Application of the Knowledge-to-Action Framework

Background: In patients with asthma, bronchoconstriction and airway inflammation both contribute to airway narrowing and airflow limitations, which lead to symptoms and exacerbations. Short-acting β₂-agonist (SABA)-only rescue therapy addresses only bronchoconstriction and is associated with increased morbidity and mortality. Current asthma management guidelines recommend concomitant treatment of symptoms and inflammation with a fast-acting bronchodilator and inhaled corticosteroid (ICS) as rescue therapy for patients ≥12 years of age. However, there is an education and outreach gap for the wider adoption of anti-inflammatory rescue therapy in clinical practice. Objective: AstraZeneca has developed an education program for health-care practitioners (HCPs) based on a Knowledge-to-Action Framework, with the aim of increasing HCPs' understanding of key disease-state concepts related to evidence-based management of asthma. Methods: A multichannel, evidence-based education program was presented at medical conferences across the United States between December 2022 and December 2023. Before and after each event, attendees were asked to complete a survey that rated their agreement with six disease-state concepts on a five-point Likert scale. These concepts related to the role of airway inflammation, fluctuations in inflammation, SABA and ICS therapy, and the risk of exacerbations. Postevent responses to the survey were assessed relative to pre-event responses and longitudinally over 12 months by using calculated odds ratios and 95% confidence intervals. Acceptance and/or understanding of a concept was defined as a rating of "agree" or "strongly agree" from at least 80% of respondents. Results: The proportion of respondents who agreed or strongly agreed with each concept was significantly higher postevent versus pre-event (p < 0.001). The 80% acceptance and/or understanding threshold was surpassed for all concepts after the event. Conclusion: The medical education program improved understanding and/or acceptance of key disease-state concepts related to asthma management among participating HCPs. Effective communication of disease management concepts may lead to improved patient health outcomes through more rapid acceptance of guideline-recommended medical therapies.

Welcome to Asthma Neverland

Asthma is a multifactorial disease with heterogeneous clinical and pathophysiological phenotypes. Classical symptoms of asthma are wheeze, cough and breathlessness, and occasionally chest tightness. These symptoms are common to many respiratory and non-respiratory conditions, and misdiagnosis of asthma is frequent. There is no definitive test for the diagnosis of asthma, but a combination of a suggestive medical history, physical examination, lung function tests, and additional investigations will maximize the chances of making a correct diagnosis. Despite clear statements in international asthma guidelines, there are many gaps when performing diagnostic steps in current medical practice. An incomplete medical history, poor attention to the nature of respiratory sounds, failure to carry out objective tests, and inadequate estimation of the response to anti-asthma therapy are the main factors responsible for misdiagnosis of asthma. The use of wrong and potentially dangerous therapies, and high consumption of healthcare resources are the inevitable consequences of misdiagnosis. The main alternative diagnoses to asthma, clinical clues and objective tests useful for specific diagnoses are critically discussed.

Lung-on-a-chip: From design principles to disease applications

To address the growing need for accurate lung models, particularly in light of respiratory diseases, lung cancer, and the COVID-19 pandemic, lung-on-a-chip technology is emerging as a powerful alternative. Lung-on-a-chip devices utilize microfluidics to create three-dimensional models that closely mimic key physiological features of the human lung, such as the air-liquid interface, mechanical forces associated with respiration, and fluid dynamics. This review provides a comprehensive overview of the fundamental components of lung-on-a-chip systems, the diverse fabrication methods used to construct these complex models, and a summary of their wide range of applications in disease modeling and aerosol deposition studies. Despite existing challenges, lung-on-a-chip models hold immense potential for advancing personalized medicine, drug development, and disease prevention, offering a transformative approach to respiratory health research.

Effects of biologic therapy on novel indices of lung inhomogeneity in patients with severe type-2 high asthma

INTRODUCTION/AIM

Lung inhomogeneity measures obtained using computed cardiopulmonography (CCP) are sensitive to small-airways disease. Here, we assessed changes in lung inhomogeneity in patients with type-2 high asthma treated with biological therapy and explored the relationship between inhomogeneity measures and conventional asthma disease markers.

METHODS

This was an observational study of 91 severe type-2 high asthma patients recruited from a tertiary asthma clinic, of whom 67 subsequently started anti-IL5 or anti-IL5R biologics. Patients were evaluated at baseline and, 54 of those commencing biologics, at their fourth injection with either mepolizumab or benralizumab. Assessments included prebronchodilator and postbronchodilator CCP and spirometry, and measurements of blood eosinophil count (BEC), fractional exhaled nitric oxide and Asthma-Symptom Questionnaire (ACQ-5).

RESULTS

Bronchodilation significantly reduced σlnCl, a novel CCP-derived ventilation inhomogeneity index, (ΔσlnCl -0.08, 95% CI (-0.10 to -0.05), p<0.001). Baseline σlnCl, but not forced expiratory volume in 1 s (FEV1) % predicted, was significantly associated with BEC (linear mixed-effects (LME) regression coefficient for BEC 0.18, 95% CI (0.04, 0.32), p=0.01). Following biologics, improvements in σlnCl were significantly dependent on BEC (LME regression coefficient +0.19, 95% CI (0.11, 0.27), p<0.001) whereas improvements in FEV1 % predicted related to both BEC and ACQ-5 responses (LME coefficients: BEC -10.8 % pred, 95% CI (-16.1,-5.5); ACQ-5 -3.5 % pred, 95% CI (-5.1 to -1.9), p<0.001). Following biologics, the change in σlnCl followed a bimodal distribution that dichotomised patients into σlnCl-Responders and σlnCl-Non-Responders. Responders, unlike Non-Responders, experienced significant improvements in symptoms and FEV1 % predicted (Δ pre-BD FEV115±15% pred, p<0.001) and included a higher proportion of patients in clinical remission at 1 year.

CONCLUSION

σlnCl is strongly associated with systemic eosinophilic inflammation in severe type-2 high asthma. An early σlnCl response following anti-IL5 biologics identifies patients more likely to experience improvements in symptoms and lung function when systemic eosinophils are depleted. σlnCl may provide a sensitive route for tracking inflammation involving the small airways.

Association between cadherin-related family member 3 rs6967330-A and human rhinovirus-C induced wheezing in children

BACKGROUND

The heterogeneity of childhood wheezing illnesses is associated with viral and host factors. Human rhinoviruses (HRV) are the major pathogens in severe wheezing in young children. The single nucleotide polymorphism (SNP) rs6967330 G > A proved to heighten the risk of wheezing. However, the relation between rs6967330 variants of cadherin-related family member 3 (CDHR3) and wheezing induced by human rhinovirus (HRV)-C has not been determined.

METHODS

A total of 11,756 respiratory specimens collected from hospitalized children with acute respiratory infections (ARIs) between September 2017 and March 2023 were screened for enterovirus (EV)/HRVs by the capillary electrophoresis-based multiplex PCR (CEMP) assay, and those positive only for HRVs were amplified and sequenced for HRV and CDHR3 genotyping. The clinical data of the enrolled patients were obtained and analyzed.

RESULTS

EV/HRVs (15.2%; 1,616/10,608) were the more common viruses detected in inpatients with ARIs. Among the enrolled samples, 148 were positive for HRV-A (49.83%; 148/297), 129 for HRV-C (43.4%; 129/297), and 20 for HRV-B (6.7%; 20/297). More patients infected with HRV-C had history of allergy (P = 0.004), family history of asthma (P = 0.001), wheezing (P = 0.005) and asthma (P = 0.001) than those infected with HRV-A or HRV-B, while patients infected with HRV-C were less likely to have older siblings compared to those infected with HRV-A (P = 0.014). The rs6967330-A variant was related to a high incidence of the three concave signs (P = 0.047), asthma exacerbation (P = 0.025), a higher risk of HRV-C infection determined by the dominant model (OR 1.91, 95% confidence interval 1.05-3.48; P = 0.033), and a high proportion of wheezing (56.67%) in patients infected with HRV-C.

CONCLUSIONS

HRV-C is the dominant species responsible for HRV-induced wheezing. The rs6967330-A variant is a risk factor for HRV-C infection, and was associated with the high rate of wheezing induced by HRV-C.

Allergen Immunotherapy for the Prevention and Treatment of Asthma

Allergic asthma is the predominant phenotype among asthmatics. Although conventional pharmacotherapy is a central component in the management of asthma, it does not enable control of asthma symptoms in all patients. In recent decades, some uncontrolled asthmatic patients, especially those with allergic asthma, have benefited from biological therapies. However, biologics do not address all the unmet needs left by conventional pharmacotherapy. Furthermore, it is noteworthy that neither conventional pharmacotherapy nor biological therapies have disease-modifying properties. In this context, allergen immunotherapy (AIT) represents an indispensable component of the therapeutic arsenal against allergic asthma, due to its disease-modifying immunological effects. In this review article, funded by an AIT manufacturer, we find clinical trials support AIT as the only treatment option able both to improve allergic asthma symptoms and to prevent the onset and worsening of the condition. For patients with severe asthma or other safety concerns, the combination of AIT and biologics offers very promising new treatment modalities for the management of allergic asthma. Trial Registration: clinicaltrials.gov identifier: NCT06027073.

Choosing the Right Biologic for the Right Patient With Severe Asthma

In this installment of the How I Do It series on severe asthma, we tackle the clinical conundrum of choosing the right biologic for the right patient with severe asthma. With six biologics now approved for use in this area comprising four different targeting strategies (anti-Ig E: omalizumab; anti-IL-5 and anti-IL-5-receptor: mepolizumab, reslizumab, and benralizumab; anti-IL-4-receptor: dupilumab; anti-thymic stromal lymphopoietin: tezepelumab), this question is increasingly complex. Recognizing that no head-to-head trial has compared biologics, we based our review on the expected effects of inhibiting different aspects of type 2 airway inflammation, supported whenever possible by clinical trial and real-world data. We use four variations of a case of severe uncontrolled asthma to develop concepts and considerations introduced in the previous installment ("Workup of Severe Asthma") and discuss pregnancy-related, biomarker-related, comorbidity-related, and corticosteroid dependency-related considerations when choosing a biologic. The related questions of deciding when, why, and how to switch from one biologic to another also are discussed. Overall, we consider that the choice of biologics should be based on the available clinical trial data for the desired efficacy outcomes, the biomarker profile of the patient, safety profiles (eg, when pregnancy is considered), and opportunities to target two comorbidities with one biologic. Using systemic and airway biomarkers (blood eosinophils and exhaled nitric oxide [Feno]) and other phenotypic characteristics, we suggest a framework to facilitate therapeutic decision-making. Post hoc studies and new comparative studies are needed urgently to test this framework and to determine whether it allows us to make other clinically useful predictions.

Global, regional, and national epidemiology of allergic diseases in children from 1990 to 2021: findings from the Global Burden of Disease Study 2021

BACKGROUND

Asthma and atopic dermatitis (AD) represent significant global health challenges in children. This study aimed to investigate trends in incidence, prevalence, and disability-adjusted life years (DALYs) for childhood asthma and AD from 1990 to 2021.

METHODS

The study utilized information from the Global Burden of Disease (GBD), Injuries, and Risk Factors Study 2021. The sample size for this study consisted of children with asthma or AD between the ages of 0 and 14. From 1990-2021, we calculated asthma and AD's age-standardized incidence, prevalence, and DALYs by area, age, sex, and socio-demographic index.

RESULTS

In 2021, global childhood asthma prevalence reached 95.7 million cases (age-standardized rate: 4,758 per 100,000), with the Low SDI region recording 25.4 million cases. For AD, global prevalence was 72.4 million cases (age-standardized rate: 3,600 per 100,000), predominantly in Middle SDI regions (19.7 million cases). Between 1990 and 2021, age-standardized incidence rates decreased for both conditions. Geographic variations were notable: High-income North America showed the highest asthma incidence, while Western Europe led in AD prevalence. The global burden of asthma-related DALYs declined from 6.9 million in 1990 to 4.6 million in 2021, with significant regional disparities.

CONCLUSIONS

Despite decreasing age-standardized rates, childhood asthma and AD continue to pose substantial health burdens globally, with marked variations across regions and socioeconomic strata. These findings emphasize the need for targeted, region-specific interventions.

Total alkaloids in Fritillaria cirrhosa D. Don alleviate OVA-induced allergic asthma by inhibiting M2 macrophage polarization

ETHNOPHARMACOLOGICAL RELEVANCE

Fritillaria cirrhosa D. Don (FCD) is a traditional Chinese medicine used to treat respiratory disorders, known for its effects in clearing heat, moistening the lungs, resolving phlegm, and relieving cough. Additionally, the total alkaloids extracted from FCD can alleviate asthma symptoms and reduce airway inflammation. However, no studies have investigated the effects of total alkaloids on lung macrophages.

AIM OF THE STUDY

This study explored whether the total alkaloids of FCD (TAs-FCD) reduce M2 macrophage polarization and, consequently, attenuate airway remodeling in asthmatic mice. This study further elucidated its mechanism of action in treating allergic asthma.

MATERIALS AND METHODS

The extracted TAs-FCD was analyzed for its composition using UPLC-Q-TOF/MS. Network pharmacology was employed to identify the active ingredients and potential mechanisms of TAs-FCD in the treatment of allergic asthma. A mouse model of ovalbumin-induced allergic asthma was established, adopted, and validated through in vivo experiments. Hematoxylin-eosin staining (H&E), immunohistochemistry (IHC), immunofluorescence staining (IF), enzyme-linked immunosorbent assay (ELISA), Western blotting (WB), and real-time fluorescence quantitative polymerase chain reaction (q-PCR) were used to investigate the role of TAs-FCD in inhibiting M2 macrophage polarization in the context of allergic asthma.

RESULTS

A total of 66 active ingredients were screened from 116 compounds using SWISSADME. The targets of these 66 compounds were predicted by SwissTargetPrediction, resulting in 808 unique drug targets after excluding duplicates. Additionally, 1756 targets related to allergic asthma were identified from the DisGeNET, Genecard, and OMIM databases. This led to 267 cross-targets between the active ingredient targets and allergic asthma targets, including interleukin (IL)-1β, tumor necrosis factor (TNF), and STAT3. Animal experiments demonstrated that TAs-FCD improved histopathological injury in mouse lungs, reduced peri-airway collagen fiber accumulation, airway mucus secretion, and airway smooth muscle proliferation. TAs-FCD also lowered IL-1β, TNF-α and IL-4 levels in lung tissues and alleviated airway inflammation. Furthermore, TAs-FCD significantly reduced levels of Arg1 and CD206, which are closely associated with M2 macrophages, and downregulated the expression of p-STAT3 and p-JAK2.

CONCLUSION

TAs-FCD may inhibit M2 macrophage polarization by regulating the JAK2/STAT3 pathway, thereby alleviating airway remodeling and inflammation in allergic asthmatic mice.

Dupilumab Effectiveness in Patients with Severe Allergic Asthma Non-Responsive to Omalizumab

Background/Objectives: Severe allergic asthma is usually treated with omalizumab; however, this drug may not be effective for every patient. By its action, dupilumab could be an alternative in these patients. The objective of this study was to evaluate the efficacy of dupilumab in patients with severe allergic asthma, non-responsive to omalizumab, according to the maintenance of their oral corticosteroid (OCS) dose, an exacerbation rate decrease, or poor control of the disease, despite optimized treatment. Methods: A retrospective analysis of data from severe asthma clinics was performed, observing the efficacy of the switch to dupilumab in patients who experienced a failed treatment with omalizumab. Results: Forty-two patients were included. Dupilumab proved to be effective in patients who experienced a failed omalizumab treatment, with a significant reduction in the exacerbation number and OCS use. Furthermore, remission of the disease, according to the Severe Asthma Network of Italy (SANI) criteria, was achieved in 35 patients, with complete remission in 19 (45%) and partial remission in 16 (38%). The analysis of the predictors of the success of dupilumab therapy in achieving clinical remission, through univariate analysis of the data at baseline, showed that complete remission was more easily reached in patients with concomitant aspirin (ASA) intolerance or in those with nasal polyposis. Conclusions: Dupilumab is an effective drug for the treatment of patients with severe asthma with an allergic component, with better benefits in patients with an ASA intolerance or nasal polyposis.

Molecular allergy diagnosis enabling personalized medicine

Allergic patients are characterized by complex and patient-specific IgE sensitization profiles to various allergens, which are accompanied by different phenotypes of allergic disease. Molecular allergy diagnosis establishes the patient's IgE reactivity profile at a molecular allergen level and has moved allergology into the era of precision medicine. Molecular allergology started in the late 1980s with the isolation of the first allergen-encoding DNA sequences. Already in 2002, the first allergen microarrays were developed for the assessment of complex IgE sensitization patterns. Recombinant allergens are used for a precise definition of personal IgE reactivity profiles, identification of genuine IgE sensitization to allergen sources for refined prescription of allergen-specific immunotherapy and allergen avoidance diagnosis of co- versus cross-sensitization, epidemiologic studies, and prediction of symptoms, phenotypes, and development of allergic disease. For example, molecular IgE sensitization patterns associated with more severe respiratory allergies, severe food allergy, and allergy to honeybee or vespids are already established. The implementation of molecular allergy diagnosis into daily clinical practice requires continuous medical education and training doctors in molecular allergy diagnosis, and may be facilitated by clinical decision support systems such as diagnostic algorithms that may take advantage of artificial intelligence.

Screening of cytokines-cytokine receptor-associated genes in childhood asthma based on bioinformatics

PURPOSE

To develop efficient diagnostic and treatment approaches, gaining an in-depth knowledge of the molecular mechanisms and potential targets causing childhood asthma is of utmost significance.

METHODS

Childhood asthma datasets were obtained from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) between asthmatic child and healthy people were screened by the Limma package. DEGs were subjected to further analyses utilizing GO, KEGG and GSEA analysis. The hub genes associated with childhood asthma were discovered by PPI analysis. The drugs target hub genes were accessed from the DrugBank database. Autodock vina was used to explore the binding ability of targeted drugs to hub genes.

RESULTS

Total 80 DEGs were selected from GSE152004 and GSE65204 datasets. The cytokine-cytokine receptor interaction was the key pathway identified by functional enrichment analysis of shared DEGs. A total of 4 hub genes (CCL26, CXCR6, IL18RAP and CCL20) were identified by the constructed PPI network, among which CXCR6, IL18RAP and CCL20 were significantly decreased in childhood asthma datasets. Whereas, the CCL26 was significantly increased in childhood asthma datasets. Additionally, the extra dataset GSE19187 and GSE240567 were employed for validation. Ultimately, drugs (Cimetidine, Cefaclor and Propofol) that target hub genes have favorable combination ability.

CONCLUSIONS

We have determined that CCL26, CXCR6, IL18RAP and CCL20 might have crucial involvement in the advancement of childhood asthma, thus having the potential to be targeted therapeutically in order to enhance treatment choices for childhood asthma. Statement of Integration, Innovation and Insight: The cytokine-cytokine receptor interaction is a key pathway in the occurrence of childhood asthma. The hub genes (CCL26, CXCR6, IL18RAP and CCL20) affect the development of childhood asthma. The drugs (Cimetidine, Cefaclor and Propofol) that target hub genes have favorable combination ability.

The role of biologics in inducing remission in asthma

Asthma remissions have been identified as a new treatment outcome and as based on experience with biologics. Remissions are defined as no symptoms, no exacerbations, no use of systemic corticosteroids, and stabilization (optimization) of lung functions; all these criteria need to be sustained for at least 1 year. This study discussed the evolution of remissions, the evolving criteria, and experiences in achieving remission after treatment with biologics. In severe, uncontrolled asthma, treatment with biologics has led to remissions in 20% to 35% of the subjects treated. It is proposed that remissions will become a new and important treatment outcome for asthma.

Predicting dupilumab effectiveness with Type-2 biomarkers: A real-world study of severe asthma

BACKGROUND

The therapeutic effectiveness of dupilumab for severe asthma in real-world settings is yet to be prospectively investigated across multiple institutions, and uncertainties persist regarding predictive factors for its effectiveness. We aimed to assess the effectiveness of dupilumab and identify predictors of its effectiveness in real-world settings using two type-2 biomarkers: FeNO concentration and blood eosinophil count.

METHODS

This prospective multicenter study included 103 patients with severe asthma. Exacerbations and respiratory functions were monitored for 24 weeks. Asthma control was evaluated using the Asthma Control Questionnaire-5. Clinical symptoms and their impact on cough and sputum were assessed using the Cough and Sputum Assessment Questionnaire (CASA-Q). Subgroup analyses of type-2 biomarkers were conducted based on FeNO levels and blood eosinophil counts at baseline.

RESULTS

Treatment with dupilumab led to a reduction in exacerbations and enhancement in asthma control, FEV1, and CASA-Q scores. FEV1 improvement was correlated with enhancement in the sputum domain of the CASA-Q. Patients exhibiting elevated FeNO levels and blood eosinophil counts demonstrated more significant enhancements in FEV1. CASA-Q sputum domain scores were significantly higher in the group with elevated eosinophil counts. Regression analysis revealed that FeNO levels and blood eosinophil counts are significant predictors of FEV1 improvement, with blood eosinophil counts also predicting sputum improvement in patients treated with dupilumab.

CONCLUSIONS

Type-2 biomarkers may act as indicators of improvement in FEV1 and sputum outcomes among patients with severe asthma undergoing dupilumab treatment in real-world settings.

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

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

Treating eosinophilic exacerbations of asthma and COPD with benralizumab (ABRA): a double-blind, double-dummy, active placebo-controlled randomised trial

BACKGROUND

Exacerbations of asthma and chronic obstructive pulmonary disease (COPD) are important events and are associated with critical illness. Eosinophilic inflammation is a treatable trait commonly found during acute exacerbations of asthma and COPD. We hypothesised that for patients with eosinophilic exacerbations, a single injection of benralizumab, a humanised monoclonal antibody against interleukin-5 receptor-α, alone or in combination with prednisolone, will improve clinical outcomes compared with prednisolone, the standard of care.

METHODS

The Acute exacerbations treated with BenRAlizumab trial (ABRA) was a multicentre, phase 2, double-blind, double-dummy, active placebo-controlled randomised trial completed in the UK at Oxford University Hospitals NHS Foundation Trust and Guy's and St Thomas' NHS Foundation Trust. Patients were recruited from urgent care clinics and emergency departments of these two hospitals. At the time of an acute exacerbation of asthma or COPD, adults with blood eosinophil counts of equal to or more than 300 cells per μL were randomly assigned in a 1:1:1 ratio to receive acute treatment with: prednisolone 30 mg once daily for 5 days and 100 mg benralizumab subcutaneous injection once (BENRA plus PRED group); placebo tablets once daily for 5 days and 100 mg benralizumab subcutaneous injection once (BENRA group); or prednisolone 30 mg once daily for 5 days and placebo subcutaneous injection once (PRED group). Randomisation was performed with a centralised interactive computer randomisation service. All patients and study research staff involved in data collection were masked to study blood results and treatment allocation. The co-primary outcomes were proportion of treatment failures over 90 days and total visual analogue scale (VAS) symptoms at day 28 in the pooled benralizumab groups compared with the prednisolone alone group and analysed in the intention-to-treat population. The trial was registered on Clinicaltrials.govNCT04098718.

FINDINGS

Between May 13, 2021, and Feb 5, 2024, 287 patients were screened for study inclusion. 129 were excluded due to not having an exacerbation captured or not meeting the eosinophil exclusion criteria. 158 patients were randomly assigned at acute eosinophilic exacerbation of asthma or COPD where 86 (54%) patients were female and 72 (46%) were male with a mean age of 57 years (range, 18-84). 53 patients were randomly assigned to the PRED group, 53 were randomly assigned to the BENRA group, and 52 were assigned to the BENRA plus PRED treatment group. At 90 days, treatment failures occurred in 39 (74%) of 53 in the PRED group, and 47 (45%) of 105 in the pooled-BENRA group (OR 0·26 [95% CI 0·13-0·56]; p=0·0005). The 28-day total VAS mean difference was 49 mm (95% CI 14-84; p=0·0065), favouring the pooled-BENRA group. There were no fatal adverse events and benralizumab was well tolerated. Notably, hyperglycaemia and sinusitis or sinus infection adverse events were related to the prednisolone study drug only.

INTERPRETATION

Benralizumab can be used as a treatment of acute eosinophilic exacerbations and achieves better outcomes than the current standard of care with prednisolone alone. These results offer a new way of treating eosinophilic endotypes of asthma and COPD exacerbations.

FUNDING

AstraZeneca.

Early and Sustained Response to Benralizumab in Severe, Eosinophilic Asthma: A Real-World Observational Study

Purpose

Although studies have evaluated benralizumab, a monoclonal IL-5 receptor α antibody in severe eosinophilic asthma (SEA), in real-world settings, additional evidence is needed to further characterize its effectiveness in specific patient populations. Our study aimed to evaluate asthma control over 56 weeks in patients treated with benralizumab in Swiss real-world settings.

Patients and Methods

Conducted across 13 centres, this prospective, observational, non-interventional study involved 73 adults with physician confirmed SEA. Benralizumab 30 mg was administered according to the Swiss label at baseline and up to week 56. Primary outcome was the change in Asthma Control Questionnaire (ACQ-5) scores at week 8 compared to baseline. Exacerbations, use of oral corticosteroids (OCS), and lung function were assessed descriptively.

Results

At baseline, the mean ACQ-5 score was 2.76 (SD 1.26), with 82.2% of patients showing not well-controlled asthma (ACQ-5 > 1.5). At week 8, the mean change in ACQ-5 compared to baseline was -0.95 (95% CI: -1.25, -0.66; p < 0.001). More than half of patients (59.1%) reached a clinically relevant improvement (MCID ≥ 0.5) at week 8, with 40.9% of patients doing so at week 1 and 87.2% at week 56. The annualized exacerbation rate (AER) of 3.65 (95% CI: 3.18, 4.18) at baseline was reduced to 0.68 (95% CI: 0.39, 1.19) at week 56. The relative reduction in AER from baseline to week 56 was 81.3%. Maintenance usage of OCS at baseline (median 25.0 mg/day) decreased over the study leading to a median change of 17.50 mg/day (95% CI: 10.0; 40.0) from baseline compared to week 56. The mean pre-bronchodilator FEV1 change from baseline to week 56 was 0.23 L (95% CI: 0.08; 0.38, p = 0.003).

Conclusion

Benralizumab demonstrated significant, rapid improvements in asthma control within one week of treatment initiation, with sustained benefits over 56 weeks.

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

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

Clinical importance of patient-reported outcome measures in severe asthma: results from U-BIOPRED

RATIONALE

Knowledge about the clinical importance of patient-reported outcome measures (PROMs) in severe asthma is limited.

OBJECTIVES

To assess whether and to what extent asthma exacerbations affect changes in PROMS over time and asthma-specific PROMs can predict exacerbations in adult patients with severe asthma in usual care.

METHODS

Data of 421 patients with severe asthma (62% female; mean age 51.9 ± 13.4 years; mean FEV1 67.5 ± 21.3%pred) from the U-BIOPRED cohort were analyzed. The included PROMs were: Asthma Control Questionnaire (ACQ5); Asthma Quality of Life Questionnaire (AQLQ); Hospital Anxiety and Depression scale (HADS); Epworth Sleepiness Scale (ESS); Medication Adherence Report Scale (MARS); Sino-Nasal Outcomes Test (SNOT20). Participants were assessed at baseline and after 12-18 months of usual care.

RESULTS

PROMs showed very weak to weak correlations with clinical characteristics such as age, body mass index, FEV1, FeNO and eosinophilic cell count. Patients presenting no exacerbations during follow-up showed a statistically significant improvement in all PROMs (except for MARS), whereas individuals experiencing > 2 exacerbations showed a deterioration. Baseline ACQ5 was a predictor of exacerbations with an AUC of 0.590 (95%CI 0.514-0.666).

CONCLUSIONS

The association of PROMs with clinical measures was poor in severe asthmatics. Moreover, PROMs were prone to changes in usual care, with exacerbations playing a key role. PROMs need to be systematically evaluated in severe asthma to improve clinical care based on specific patient's needs.

Characterization of Serum Cytokine Patterns in Frequent-Exacerbation Asthma: Implications for Phenotyping and Management

(1) Background: Asthma exacerbations represent significant clinical events, however, the underlying inflammatory mechanisms and cytokine profiles in patients with frequent exacerbations remain incompletely understood; (2) Methods: In this prospective, cross-sectional study of 120 stable asthma patients, we compared the serum concentrations of eight key cytokines (IL-4, IL-12, IL-13, IL-17, IFN-α, IFN-γ, TNF-α, and IL-1β) between two groups: 60 patients with frequent exacerbations (≥ 2 events per year) and 60 matched controls with few exacerbations (1 event per year); (3) Results: Patients with frequent exacerbations showed significantly higher serum concentrations of IL-4 and IL-13 (p < 0.05), along with an increased prevalence of allergic history and comorbidities (chronic rhinosinusitis, GERD, OSA; all p < 0.05). The IgE levels correlated positively with IFN-α (rh = 0.26) and TNF-α (rh = 0.29), while the FeNO levels correlated with IL-17 (rh = 0.26) and IL-1β (rh = 0.33) (all p < 0.05); (4) Conclusions: Our findings identify a distinct cytokine signature in frequent exacerbators characterized by elevated IL-4 and IL-13 levels. The correlations between specific cytokines and established biomarkers suggest potential mechanisms underlying exacerbation susceptibility, which may inform targeted therapeutic strategies for this high-risk population.

When patient-reported respiratory symptoms shed light on pathophysiology in adult asthma: a cross-sectional study

While studies have demonstrated the impact of asthma symptoms on quality of life, very few studies have investigated the relationship between detailed asthma symptoms, as reported by the patient, and lung function and inflammation. A cross-sectional study was conducted on treated (ICS/LABA) adult (> 18 years) asthma patients recruited from the Liege University Hospital Asthma Clinic (Belgium) between 2018 and 2023 (n = 505). The intensity of asthma symptoms (dyspnea, wheezing, chest tightness, cough, and airway secretion) was measured using five-point Likert scales (5 expressing the greatest intensity). Multiple linear regression models including all independent variables were carried out to evaluate whether lung function and inflammatory parameters were independently associated with distinct symptoms. Cough associated with female gender (p < 0.05), smoking (p < 0.01), low FeNO (p < 0.05) and FEV1% pred. (p < 0.05), and high blood and sputum eosinophils (p < 0.05 for both). Airway secretion associated with smoking (p < 0.05). Chest tightness associated with young age (p < 0.001), female gender (p < 0.05) and low FEV1% pred. (p < 0.01). Dyspnea associated with female gender (p < 0.001), high BMI (p < 0.05), low FEV1% pred. (p < 0.0001) and high FEV1/FVC % (p < 0.01). Wheezing associated with young age (p < 0.01), high BMI (p < 0.05), smoking (p < 0.01), low FEV1% pred. (p < 0.0001) and high FEV1/FVC % (p < 0.05). Different respiratory symptoms are associated with distinct demographic, functional and inflammatory features paving the way for personalized therapeutic interventions.

Run-in periods and treatment outcomes in asthma trials: A narrative review

Background

The run-in period is an important element of randomized controlled trials, and is often used in respiratory disease trials. The design of the run-in period can greatly impact results and data interpretation, and as such should be designed carefully.

Methods

In this review, we describe the design of run-in periods across six phase 3A trials of triple therapy in asthma, and discuss how differences in run-in period design (specifically the duration, treatment, and reporting of run-in results) may have the potential to alter the interpretation of study outcomes.

Results

We found that the duration of run-in periods ranged between 2 and 7 weeks, with some studies including a combination of screening, run-in and stabilization periods, and others including a run-in period only. Run-in treatment also varied, with some studies running in patients on their previous inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) therapy, and others harmonizing treatment by switching to the same ICS/LABA combination used in the on-treatment phase, or a different ICS/LABA combination entirely. Most of the studies included did not report any changes to study outcomes seen prior to randomization.

Conclusion

We discuss the potential implications associated with the various trial designs, and propose that run-in periods should be consciously designed to meet the goals of the specific study. We also propose that standardized reporting of run-in changes would further allow for differentiation between improvements due to improved adherence and true treatment benefits, and aid with comparing data from different clinical trials.

Preschool wheeze and asthma endotypes- implications for future therapy

INTRODUCTION

Preschool wheeze and school-aged asthma present a large healthcare burden. Both conditions are now recognized to be heterogeneous, with similar symptom presentation but likely different underlying lung pathology.

AREAS COVERED

Current treatment options for preschool wheeze are constrained by extrapolations from the management of school-aged children with asthma. While most cases of asthma at school age are caused by classical atopic, eosinophilic, Type-2 driven asthma, only a quarter of preschool children with wheeze fall into this category. Targeting treatment to specific underlying mechanisms resulting in preschool wheeze may alter the progression to school age asthma. Novel biologics have revolutionized the management of severe, treatment-resistant school age asthma, but a limited evidence base limits their use in young children. There are several potential future non-steroid-based treatment options in development, of which bacterial lysates show the most promise.

EXPERT OPINION

Effective treatment of preschool wheeze may preserve lung function into later life, which may alter the progression trajectory toward school age asthma. Endotype-driven management will enable more effective treatment of both preschool wheeze and school age asthma.

Does lung function in preschoolers help to predict asthma in later life?

The earliest respiratory function assessments, within or close to the neonatal period, consistently show correlations with lung function and with the development of asthma into adulthood. Measurements of lung function in infancy reflect the in utero period of lung development, and if early enough, show little influence of postnatal environmental exposures. Later in the preschool and school age periods, influences of the environment are superimposed on initial levels. Fetal exposures before birth such as maternal smoking during pregnancy, lead to reduced lung function and an increased risk of asthma in females particularly those with certain glutathione S-transferase genotypes. Lung function measurements later in the preschool period are also associated with development of asthma. Although lung function in preschoolers does help predict asthma in later life and these observations have increased our understanding of the physiology underlying asthma, the findings have not led to thewidespread use of lung function measurements being in preschoolers as clinical predictors of asthma due to the practicalities of testing in this age group.

Association of urinary eosinophilic protein X at age 3 years and subsequent persistence of wheezing and asthma diagnosis in adolescence

BACKGROUND

Wheezing is common in early life, but most children stop wheezing by school age. However, the prediction of course of wheezing through childhood is difficult.

OBJECTIVE

To investigate whether urinary EPX (a marker of eosinophil activation) in children at age 3 years may be useful for the prediction of wheeze persistence and future asthma diagnosis.

METHODS

U-EPX was measured at age 3 years (radioimmunoassay) in 906 participants in the population-based birth cohort. Children attended follow-ups to age 16 years. We investigate the discriminative ability of u-EPX and other factors in predicting asthma diagnosis at age 16 using receiver operating characteristic [ROC] curves.

RESULTS

Of 613 children with follow-up information at age 16, 511 had data on u-EPX at age 3 and asthma diagnosis at age 16 years; of those; 133 (21.7%) had asthma. Based on longitudinal data, children were assigned to wheeze clusters: No wheeze (NWZ), early transient (ETW), late-onset (LOW), intermittent (INT) and persistent wheeze (PEW). U-EPX levels differed significantly between different wheeze clusters (p = .003), with clusters characterised with persistent symptoms having higher u-EPX. In the whole cohort, the best performing classification model for asthma diagnosis at age 16 years included sex, u-EPX, sensitisation and wheeze (area under the curve (AUC) = 0.82, 95% CI: 0.76-0.88). u-EPX and allergic sensitisation alone had similar predictive power (AUC [95%CI]: 0.64 [0.58-0.71] and 0.65 [0.60-0.71]). The best performing classification model for asthma prediction among children with doctor-confirmed wheeze in the first 3 years included child's u-EPX and sensitisation at age 3 years, sex, gestational age and maternal atopy (AUC: 0.76, 95%CI: 0.67-0.85).

CONCLUSIONS

Early-life u-EPX may be a useful non-invasive marker for asthma prediction in adolescence.