Effects of different anti-asthmatic agents on induced sputum and eosinophil cationic protein in mild asthmatics

Theophylline for the management of respiratory disorders in adults in the 21st century: A scoping review from the American College of Clinical Pharmacy Pulmonary Practice and Research Network

Theophylline is an oral methylxanthine bronchodilator recommended as alternate therapy for the treatment of asthma and chronic obstructive pulmonary disease (COPD). However, it is not generally recommended for the treatment of other respiratory disorders such as obstructive sleep apnea (OSA) or hypoxia. Most clinical practice guidelines rely on evidence published prior to the year 2000 to make these recommendations. This scoping review aimed to gather and characterize evidence describing theophylline for the management of respiratory disorders in adults between January 1, 2000 and December 31, 2020. Databases searched included Ovid MEDLINE, Embase, CINAHL Complete, Scopus, and International Pharmaceutical Abstracts. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. Studies were included if they were published in English, theophylline was used for any respiratory disorder, and the study outcomes were disease- or patient-oriented. After removal of duplicates, 841 studies were screened and 55 studies were included. Results aligned with current clinical guideline recommendations relegating theophylline as an alternative therapy for the treatment of respiratory disorders, in favor of inhaled corticosteroids and inhaled bronchodilators. This scoping review identified the need for future research including: theophylline versus other medications deemed alternative therapies for asthma and COPD, meta-analyses of low-dose theophylline, and studies evaluating evidence-based patient-oriented outcomes for OSA, hypoxia, ventilator-induced diaphragmatic dysfunction, and spinal cord injury-related pulmonary function.

Sputum inflammatory, neural, and remodelling mediators in eosinophilic and non-eosinophilic asthma

BACKGROUND

Neural and remodelling mechanisms may play a role in asthma, particularly non-eosinophilic asthma (NEA).

OBJECTIVE

To assess sputum mediators associated with neural, remodelling, and inflammatory mechanisms in eosinophilic asthma (EA), NEA, and non-asthmatics.

METHODS

111 participants with and 62 without asthma (14-21 years) underwent sputum induction, exhaled nitric oxide (FeNO), atopy, and spirometry tests. Twenty-four mediators were measured in sputum using ELISA or bead array. EA (n=52) and NEA (n=59) were defined using a sputum eosinophil cut-point of ≥2.5%.

RESULTS

Elevated levels of nociceptin (median: 39.1 vs 22.4 ng/mL, p=0.03), periostin (33.8 vs 9.4 ng/mL, p=0.01), and eosinophil cationic protein (ECP); (220.1 vs 83.7 ng/mL, p=0.03) were found in asthmatics compared with non-asthmatics. Nociceptin was elevated in EA (54.8 vs 22.4 ng/mL, p=0.02) compared with non-asthmatics. EA had higher levels of inflammatory (ECP: 495.5 vs 100.3 ng/mL, p≤0.01; interleukin-1β: 285.3 vs 209.3 pg/mL, p=0.03; histamine: 5805.0 vs 3172.5 pg/mL, p=<0.01) and remodelling (vascular endothelial growth factor A (VEGF-A); 3.3 vs 2.5 ng/mL, p=0.03; periostin: 47.7 vs 22.1 ng/mL, p=0.04) mediators than NEA. Whilst macrophages were associated with neural mediators e.g. neurokinin A (r=0.27, p=0.01) and nociceptin (r=0.30, p=0.02), granulocytes were associated with inflammatory/remodelling mediators; e.g. ECP and VEGF-A correlated with neutrophils (r=0.53 & r=0.33 respectively, p=<0.01) and eosinophils (r=0.53 & r=0.29 respectively, p≤0.01).

CONCLUSION

Elevated levels of nociceptin and inflammatory/remodelling markers were found in EA, but no evidence for neural and remodelling pathways was found in NEA. Neural and remodelling mechanisms appear to coexist with inflammation.

Revisiting differences between atopic and non-atopic asthmatics: When age is shaping airway inflammatory profile

Background

Atopic asthma is one of the most common asthma phenotypes and is generally opposed to the non-atopic counterpart. There have been very few large-scale studies comparing atopic and non-atopic asthmatics in terms of systemic and airway inflammation across the age spectrum.

Methods

Here, we have undertaken a retrospective study investigating 1626 patients (924 atopic and 702 non-atopic asthmatics) recruited from our university asthma clinic who underwent extensive clinical investigations including induced sputum. Atopy was defined by any positive specific IgE to common aeroallergens (>0,35 kU/L). We performed direct comparisons between the groups and sought to appreciate the influence of age on the airway and systemic inflammatory components. The study was approved by the ethics committee of the University Hospital of Liege (Ref. 2016/276). Informed consents were obtained from healthy subjects.

Results

Atopic asthmatics were younger (P < .001), had a higher male/female ratio (P < .001), an earlier disease onset (P < .001) and a greater proportion of treated rhinitis (P < .001) while non-atopic asthmatics had greater smoke exposure (P < .001), lower FEV₁/FVC ratio (P = .01) and diffusing capacity (P < .001). There was no difference between the 2 groups regarding FEV₁ (% predicted), asthma control, asthma quality of life and exacerbations in the previous 12 months. Regarding inflammation, atopic patients had higher FeNO levels (median = 28 ppb, P < .001), were more eosinophilic both in blood (median = 2.8%, P < .001) and in sputum (median = 2.2%, P < .001) while non-atopic patients displayed greater blood (median = 57%, P = .01) and sputum (median = 58.8%, P = .01) neutrophilic inflammation. However, stratifying patients by age showed that non-atopic asthmatics above 50 years old became equally eosinophilic in the sputum (P = .07), but not in the blood, as compared to atopic patients. Likewise, FeNO rose in non-atopic patients after 50 years old but remained, however, lower than in atopic patients.

Conclusions

We conclude that, while sharing many features, atopic group still differentiates from non-atopic asthmatics by demographics, functional and inflammatory profiles. When atopic asthmatics showed a constant eosinophilic pattern across the age spectrum, non-atopic asthmatics were found to be neutrophilic before the age of 50 but eosinophilic above 50 years old.

The burden of exacerbations in mild asthma: a systematic review

Background

Although most patients with asthma have mild disease, data on how mild asthma is defined, and how frequently exacerbations occur in this patient population are scarce, so we aimed to redress this.

Methods

We searched Medline and Medline In-Process (PubMed), and Embase in OVID for English-language publications containing “mild asthma” plus at least one relevant therapy and outcome/keyword, limited to randomised controlled trials (RCTs) and observational studies published between January 1990 and February 2019. Publications were filtered to ensure appropriate data extraction. The main outcomes were the definitions of mild asthma and exacerbations, baseline exacerbation rates and exacerbation data for placebo recipients in prospective studies. Meta-analysis of exacerbation rates was planned.

Findings

Of 4064 articles identified, 64 were included in our review (49 743 subjects); 54 RCTs and 10 observational/other studies. Six main types of definitions of mild asthma were identified. While care was taken to ensure inclusion only of patients with mild asthma, marked heterogeneity was revealed in the definitions of mild asthma and hence the study populations. Reporting of exacerbations also varied widely between studies, precluding meta-analysis. Between 0–22% of patients were hospitalised for asthma or had a severe exacerbation in the previous year, according to baseline data from prospective studies. In RCTs, severe exacerbation rates in placebo recipients taking only short-acting β₂-agonist therapy ranged from 0.20–2.88 per year.

Conclusions

These data provide new evidence of the burden of exacerbations in mild asthma and highlight the need for standardised definitions of mild asthma and of exacerbations to progress further research.

This comprehensive literature review highlights the risk of exacerbations for patients with mild asthmahttps://bit.ly/3cauSb3

Effectiveness of inhaled corticosteroids in real life on clinical outcomes, sputum cells and systemic inflammation in asthmatics: a retrospective cohort study in a secondary care centre

OBJECTIVES

The impact of inhaled corticosteroids (ICS) on eosinophilic inflammation in asthma is well established, but their effect in a real-life setting has not been extensively studied. Our purpose was to investigate the effect of ICS on airway and systemic inflammation as well as on clinical outcomes in patients with asthma from clinical practice.

DESIGN, SETTING AND PARTICIPANTS

We conducted a retrospective analysis on asthmatics from a secondary care centre in whom ICS were initiated/increased (n=101), stopped/decreased (n=60) or remained stable (n=63, used as a control group) between two visits with available sputum and blood cell counts.

RESULTS

The median time between both visits ranged from 1 to 2 years. Initiating or increasing ICS (median variation (IQR): 800 (400-1200) µg beclomethasone equivalent dose per day) reduced sputum eosinophils and fractional exhaled nitric oxide (P<0.0001) and to a lesser extent blood eosinophils (P<0.0001), while withdrawing or decreasing ICS (median variation (IQR): 900 (500-1200) µg beclomethasone equivalentdose per day) resulted in increased sputum eosinophils (P=0.008). No change was found in patients with a stable dose. The effectiveness of ICS in improving asthma control, quality of life, forced expiratory volume in 1 s (FEV₁), bronchial hyper-responsiveness and exacerbation rate was only observed in the eosinophilic phenotype (sputum eosinophils ≥3%, n=79). In non-eosinophilic asthmatics, stepping-down ICS resulted in an improvement in asthma control and quality of life, without any significant change in FEV₁ (n=38).

CONCLUSIONS

Our results confirm the effectiveness of ICS on eosinophilic inflammation in real life and demonstrate that their clinical benefit seems to be restricted to eosinophilic asthmatics. Our data also support a try for stepping-down ICS in non-eosinophilic asthmatics.

Asthma in children and adolescents: a comprehensive approach to diagnosis and management

Asthma is a chronic disease that has a significant impact on quality of life and is particularly important in children and adolescents, in part due to the higher incidence of allergies in children. The incidence of asthma has increased dramatically during this time period, with the highest increases in the urban areas of developed countries. It seems that the incidence in developing countries may follow this trend as well. While our knowledge of the pathophysiology of asthma and the available of newer, safer medication have both improved, the mortality of the disease has undergone an overall increase in the past 30 years. Asthma treatment goals in children include decreasing mortality and improving quality of life. Specific treatment goals include but are not limited to decreasing inflammation, improving lung function, decreasing clinical symptoms, reducing hospital stays and emergency department visits, reducing work or school absences, and reducing the need for rescue medications. Non-pharmacological management strategies include allergen avoidance, environmental evaluation for allergens and irritants, patient education, allergy testing, regular monitoring of lung function, and the use of asthma management plans, asthma control tests, peak flow meters, and asthma diaries. Achieving asthma treatment goals reduces direct and indirect costs of asthma and is economically cost-effective. Treatment in children presents unique challenges in diagnosis and management. Challenges in diagnosis include consideration of other diseases such as viral respiratory illnesses or vocal cord dysfunction. Challenges in management include evaluation of the child’s ability to use inhalers and peak flow meters and the management of exercise-induced asthma.

Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children

BACKGROUND

Anti-leukotrienes (5-lipoxygenase inhibitors and leukotriene receptors antagonists) serve as alternative monotherapy to inhaled corticosteroids (ICS) in the management of recurrent and/or chronic asthma in adults and children.

OBJECTIVES

To determine the safety and efficacy of anti-leukotrienes compared to inhaled corticosteroids as monotherapy in adults and children with asthma and to provide better insight into the influence of patient and treatment characteristics on the magnitude of effects.

SEARCH METHODS

We searched MEDLINE (1966 to Dec 2010), EMBASE (1980 to Dec 2010), CINAHL (1982 to Dec 2010), the Cochrane Airways Group trials register, and the Cochrane Central Register of Controlled Trials (Dec 2010), abstract books, and reference lists of review articles and trials. We contacted colleagues and the international headquarters of anti-leukotrienes producers.

SELECTION CRITERIA

We included randomised trials that compared anti-leukotrienes with inhaled corticosteroids as monotherapy for a minimum period of four weeks in patients with asthma aged two years and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of trials and extracted data. The primary outcome was the number of patients with at least one exacerbation requiring systemic corticosteroids. Secondary outcomes included patients with at least one exacerbation requiring hospital admission, lung function tests, indices of chronic asthma control, adverse effects, withdrawal rates and biological inflammatory markers.

MAIN RESULTS

Sixty-five trials met the inclusion criteria for this review. Fifty-six trials (19 paediatric trials) contributed data (representing total of 10,005 adults and 3,333 children); 21 trials were of high methodological quality; 44 were published in full-text. All trials pertained to patients with mild or moderate persistent asthma. Trial durations varied from four to 52 weeks. The median dose of inhaled corticosteroids was quite homogeneous at 200 µg/day of microfine hydrofluoroalkane-propelled beclomethasone or equivalent (HFA-BDP eq). Patients treated with anti-leukotrienes were more likely to suffer an exacerbation requiring systemic corticosteroids (N = 6077 participants; risk ratio (RR) 1.51, 95% confidence interval (CI) 1.17, 1.96). For every 28 (95% CI 15 to 82) patients treated with anti-leukotrienes instead of inhaled corticosteroids, there was one additional patient with an exacerbation requiring rescue systemic corticosteroids. The magnitude of effect was significantly greater in patients with moderate compared with those with mild airway obstruction (RR 2.03, 95% CI 1.41, 2.91 versus RR 1.25, 95% CI 0.97, 1.61), but was not significantly influenced by age group (children representing 23% of the weight versus adults), anti-leukotriene used, duration of intervention, methodological quality, and funding source. Significant group differences favouring inhaled corticosteroids were noted in most secondary outcomes including patients with at least one exacerbation requiring hospital admission (N = 2715 participants; RR 3.33; 95% CI 1.02 to 10.94), the change from baseline FEV(1) (N = 7128 participants; mean group difference (MD) 110 mL, 95% CI 140 to 80) as well as other lung function parameters, asthma symptoms, nocturnal awakenings, rescue medication use, symptom-free days, the quality of life, parents' and physicians' satisfaction. Anti-leukotriene therapy was associated with increased risk of withdrawals due to poor asthma control (N = 7669 participants; RR 2.56; 95% CI 2.01 to 3.27). For every thirty one (95% CI 22 to 47) patients treated with anti-leukotrienes instead of inhaled corticosteroids, there was one additional withdrawal due to poor control. Risk of side effects was not significantly different between both groups.

AUTHORS' CONCLUSIONS

As monotherapy, inhaled corticosteroids display superior efficacy to anti-leukotrienes in adults and children with persistent asthma; the superiority is particularly marked in patients with moderate airway obstruction. On the basis of efficacy, the results support the current guidelines' recommendation that inhaled corticosteroids remain the preferred monotherapy. 

Comparison of inhaled corticosteroids and leukotriene receptor antagonists in adolescents and adults with mild to moderate asthma: a meta-analysis

INTRODUCTION

Inhaled corticosteroids (ICS) and oral leukotriene receptor antagonists (LTRA) are effective drugs used in the management of asthma as controller monotherapy in adolescents and adults, although there are debates as to which one is better.

OBJECTIVES

To thoroughly compare the efficacy and tolerability of ICS vs LTRA in adolescents and adults with mild to moderate asthma.

METHODS

Relative database were searched for the review. Randomized controlled trials of more than or equal to 4 weeks' treatment duration comparing ICS with LTRA were reviewed.

RESULTS AND CONCLUSION

Twenty-four trials with 6197 randomized adolescents and adults with mild to moderate asthma met the inclusion criteria with a minimum duration of 4 weeks' treatment. Significant differences favouring ICS were found in all indices of pulmonary function. Other significant benefits of ICS were shown in symptoms, nocturnal awakenings, rescue-medication use, symptom-free days and quality of life. As to each special symptom of adverse effects, ICS was similar to LTRA in the incidence of headache, nausea and throat discomfort, but significantly higher in the incidence of hoarseness and oral pharyngeal candidiasis. Concerning withdrawal because of adverse events potentially related to treatment, ICS was similar to LTRA but significantly superior to LTRA in decreasing the asthma exacerbations or attacks during the treatment period. These results show that ICS may be the better drug in terms of efficacy and tolerability, except hoarseness and oral pharyngeal candidiasis, and should thus have priority over LTRA in asthma monotherapy in adolescents and adults.

The Pediatric Asthmatic

The incidence of allergies and asthma in the Western world has been increasing over the past 30 years. However, more recent data suggests that over the past 5–10 years, the overall global trends of asthma incidence have begun to stabilize (1). Urbanization and industrialization has contributed to the increase in developed countries, but the reasons for this are still unclear. Asthma is estimated to be responsible for 1 in every 250 deaths worldwide. Many of these deaths are preventable, and specific issues have been identified that may contribute to this high mortality rate. Factors that contribute to high ­mortality and morbidity include slow access to care and medications, inadequate environmental control of allergens and irritants, dietary changes, genetic variations, cultural barriers, lack of education amongst patients and providers, insufficient resources, and improper use of health care dollars.

Eosinophil cationic protein: is it useful in asthma? A systematic review

INTRODUCTION

Eosinophil cationic protein (ECP) has been widely investigated as a potential biomarker of airway inflammation.

METHOD

A systematic review was performed using Medline with key terms eosinophil cationic protein and asthma, limiting the search to titles or abstracts. Out of 688 potential papers found, abstracts were reviewed based on the following criteria: (1) ECP was used as a biological marker, (2) asthma was the index disease studied, (3) it was a controlled clinical study and (4) ECP was assessed as a diagnostic, assessment or management tool. One hundred and sixty-nine articles satisfied the selection criteria and their full-text versions were reviewed. Only 53 papers were found to provide clinically useful information.

RESULTS

ECP has been measured in serum, plasma, sputum, saliva and broncho-alveolar lavage fluids but serum and sputum are the most established. Levels of ECP in normal and asthmatic subjects in various body fluids were identified. ECP correlates well with airway inflammation but not airway hyper-responsiveness. It is raised in other atopic diseases and hence is not diagnostic for asthma. However, it has been shown to be useful in assessing asthma severity, compliance with anti-inflammatory asthma therapy and as a guide to tailing down inhaled corticosteroid therapy. Although there is some evidence that ECP levels are affected by age, smoking, circadian rhythm and seasonal variation, only smoking appears to be of clinical significance.

DISCUSSION

Despite its limitations, ECP remains potentially useful in asthma management. Future research on ECP should focus on using serial measurements and combining it with other markers of asthma which may increase its clinical usefulness.