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Goleij P, Rahimi M, Pourshahroudi M, Tabari MAK, Muhammad S, Suteja RC, Daglia M, Majma Sanaye P, Hadipour M, Khan H, Sadeghi P. The role of IL-2 cytokine family in asthma. Cytokine 2024; 180:156638. [PMID: 38761716 DOI: 10.1016/j.cyto.2024.156638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/25/2024] [Accepted: 05/02/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND The interleukin-2 (IL-2) family of cytokines, including IL-2, IL-4, IL-7, IL-9, IL-15, and IL-21, are pivotal regulators of the immune response, impacting both innate and adaptive immunity. Understanding their molecular characteristics, receptor interactions, and signalling pathways is essential for elucidating their roles in health and disease. OBJECTIVES This review provides a comprehensive overview of the IL-2 family of cytokines, highlighting their molecular biology, receptor interactions, and signalling mechanisms. Furthermore, it explores the involvement of IL-2 family cytokines in the pathogenesis of chronic respiratory diseases, with a specific focus on chronic obstructive pulmonary disease (COPD) and asthma. METHODS A thorough literature review was conducted to gather insights into the molecular biology, receptor interactions, and signalling pathways of IL-2 family cytokines. Additionally, studies investigating the roles of these cytokines in chronic respiratory diseases, particularly COPD and asthma, were analysed to discern their implications in wider pathophysiology of disease. RESULTS IL-2 family cytokines exert pleiotropic effects on immune cells, modulating cellular proliferation, differentiation, and survival. Dysregulation of IL-2 family cytokines has been implicated in the pathogenesis of chronic respiratory illnesses, including COPD and asthma. Elevated levels of IL-2 and IL-9 have been associated with disease severity in COPD, while IL-4 and IL-9 play crucial roles in asthma pathogenesis by promoting airway inflammation and remodelling. CONCLUSION Understanding the intricate roles of IL-2 family cytokines in chronic respiratory diseases provides valuable insights into potential therapeutic targets for these conditions. Targeting specific cytokines or their receptors may offer novel treatment modalities to attenuate disease progression and improve clinical outcomes in patients with COPD and asthma.
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Affiliation(s)
- Pouya Goleij
- USERN Office, Kermanshah University of Medical Sciences, Kermanshah, Iran; Immunology Board for Transplantation and Cell-Based Therapeutics (ImmunoTACT), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Mohammad Rahimi
- Student Research Committee, School of Medicine, Mazandaran University of Medical Sciences, Mazandaran, Iran.
| | - Motahareh Pourshahroudi
- Department of Public Health, Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, United Kingdom.
| | - Mohammad Amin Khazeei Tabari
- Student Research Committee, School of Medicine, Mazandaran University of Medical Sciences, Mazandaran, Iran; Network of Interdisciplinarity in Neonates and Infants (NINI), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Syed Muhammad
- Farooqia College of Pharmacy, Mysuru, Karnataka, India.
| | | | - Maria Daglia
- Department of Pharmacy, University of Naples "Federico II", Via D. Montesano 49, 80131 Naples, Italy; International Research Center for Food Nutrition and Safety, Jiangsu University, Zhenjiang 212013, China.
| | | | - Mahboube Hadipour
- Department of Biochemistry, School of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.
| | - Haroon Khan
- Department of Pharmacy, Faculty of Chemical and Life Sciences, Abdul Wali Khan University Mardan, Mardan 23200, Pakistan.
| | - Parniyan Sadeghi
- Network of Interdisciplinarity in Neonates and Infants (NINI), Universal Scientific Education and Research Network (USERN), Tehran, Iran; School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Pavord ID, Casale TB, Corren J, FitzGerald MJ, Deniz Y, Altincatal A, Gall R, Pandit-Abid N, Radwan A, Jacob-Nara JA, Rowe PJ, Busse WW. Dupilumab Reduces Exacerbations Independent of Changes in Biomarkers in Moderate-to-Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1763-1772. [PMID: 38555079 DOI: 10.1016/j.jaip.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Changes from baseline in fractional exhaled nitric oxide (FeNO) and blood eosinophil count (Eos) may be related to efficacy outcomes in dupilumab-treated patients with moderate-to-severe asthma. OBJECTIVE This post hoc analysis investigated biomarker changes in placebo- and dupilumab-treated patients with uncontrolled moderate-to-severe asthma enrolled in QUEST (NCT02414854). METHODS Spline analyses of annualized severe exacerbation rate (AER) and change from baseline in pre-bronchodilator (BD) forced expiratory volume in 1 second (FEV1) at week 52 were performed as a function of the fold change in FeNO at week 52 and the maximum fold change in Eos over weeks 0-12 (also change from baseline in pre-BD FEV1 at week 12). RESULTS The combined placebo and dupilumab groups comprised 638 and 1264 patients, respectively. FeNO levels declined rapidly by week 2 and then gradually to week 52 in patients treated with dupilumab versus placebo; Eos, after initially increasing with dupilumab, declined slightly from baseline in both treatment groups. AER during QUEST showed no significant association with the change in biomarkers in either treatment group. The change from baseline in pre-BD FEV1 at week 52 was inversely associated with the fold change in FeNO in both groups, with a significant difference between the dupilumab and placebo curves (P = .014), and was positively associated with the fold change in Eos in both groups (P = .022). CONCLUSIONS Relative changes in FeNO and Eos were not associated with AER, regardless of treatment arm. However, changes in both biomarkers showed a predictive value for lung function improvement; for FeNO, this was specific to the dupilumab treatment arm.
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Affiliation(s)
- Ian D Pavord
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.
| | - Thomas B Casale
- Division of Allergy and Immunology, University of South Florida, Tampa, Fla
| | - Jonathan Corren
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | | | - Yamo Deniz
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY
| | | | | | | | - Amr Radwan
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY
| | | | | | - William W Busse
- UW Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Pasha MA, Hopp RJ, Habib N, Tang DD. Biomarkers in asthma, potential for therapeutic intervention. J Asthma 2024:1-16. [PMID: 38805392 DOI: 10.1080/02770903.2024.2361783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/26/2024] [Indexed: 05/30/2024]
Abstract
Asthma is a heterogeneous disease characterized by multiple phenotypes with varying risk factors and therapeutic responses. This Commentary describes research on biomarkers for T2-"high" and T2-"low" inflammation, a hallmark of the disease. Patients with asthma who exhibit an increase in airway T2 inflammation are classified as having T2-high asthma. In this endotype, Type 2 cytokines interleukins (IL)-4, IL-5, and IL-13, plus other inflammatory mediators, lead to increased eosinophilic inflammation and elevated fractional exhaled nitric oxide (FeNO). In contrast, T2-low asthma has no clear definition. Biomarkers are considered valuable tools as they can help identify various phenotypes and endotypes, as well as treatment response to standard treatment or potential therapeutic targets, particularly for biologics. As our knowledge of phenotypes and endotypes expands, biologics are increasingly integrated into treatment strategies for severe asthma. These treatments block specific inflammatory pathways or single mediators. While single or composite biomarkers may help to identify subsets of patients who might benefit from these treatments, only a few inflammatory biomarkers have been validated for clinical application. One example is sputum eosinophilia, a particularly useful biomarker, as it may suggest corticosteroid responsiveness or reflect non-compliance to inhaled corticosteroids. As knowledge develops, a meaningful goal would be to provide individualized care to patients with asthma.
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Affiliation(s)
- M Asghar Pasha
- Department of Medicine, Division of Allergy and Immunology, Albany Medical College, Albany, NY, USA
| | - Russell J Hopp
- Department of Pediatrics, University of NE Medical Center and Children's Hospital and Medical Center, Omaha, NE, USA
| | - Nazia Habib
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Dale D Tang
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
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Wen J, Xia J, He Q, Giri M, Guo S. Association between protein intake, serum albumin and blood eosinophil in US asthmatic adults. Front Immunol 2024; 15:1383122. [PMID: 38835754 PMCID: PMC11148351 DOI: 10.3389/fimmu.2024.1383122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/30/2024] [Indexed: 06/06/2024] Open
Abstract
Background Presently, numerous studies have indicated that protein consumption and levels of blood albumin serve as important biomarkers for a range of respiratory illnesses. However, there have been few investigations into the correlation between protein consumption, serum albumin, and asthma. Methods Our analysis incorporated 2509 asthmatics from the 2011-2018 NHANES dataset. The investigation employed three linear regression models and XGBoost model to investigate the potential link between protein intake, serum albumin levels, and blood eosinophil counts (BEOC) in patients with asthma. The trend test, generalized additive model (GAM), and threshold effect model were utilized to validate this correlation. As well, we undertook stratified analyses to look at the correlation of serum albumin with BEOC among distinct populations. Results In the univariable regression model, which did not account for any covariates, we observed a positive correlation between protein intake and BEOC. However, univariable and multivariable regression analyses all suggested a negative connection of serum albumin with BEOC in asthma populations. In Model C, which took into account all possible factors, BEOC dropped by 2.82 cells/uL for every unit increase in serum albumin (g/L). Additionally, the GAM and threshold effect model validated that serum albumin and BEOC showed an inverted U-shaped correlation. Conclusion Our investigation discovered there was no independent link between asthmatics' protein intake and BEOC. However, we observed an inverted U-shaped relationship between serum albumin levels and BEOC, suggesting a possible relationship between the overall nutritional status of asthmatics and immune system changes. Our findings provide new directions for future research in the field of asthma management and therapy.
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Affiliation(s)
- Jun Wen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Jing Xia
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Qingliu He
- Department of Urology, The Second Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fujian, China
| | - Mohan Giri
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Shuliang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
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Bourdin A, Brusselle G, Couillard S, Fajt ML, Heaney LG, Israel E, McDowell PJ, Menzies-Gow A, Martin N, Mitchell PD, Petousi N, Quirce S, Schleich F, Pavord ID. Phenotyping of Severe Asthma in the Era of Broad-Acting Anti-Asthma Biologics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:809-823. [PMID: 38280454 DOI: 10.1016/j.jaip.2024.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/20/2023] [Accepted: 01/01/2024] [Indexed: 01/29/2024]
Abstract
Severe asthma is associated with significant morbidity and mortality despite the maximal use of inhaled corticosteroids and additional controller medications, and has a high economic burden. Biologic therapies are recommended for the management of severe, uncontrolled asthma to help to prevent exacerbations and to improve symptoms and health-related quality of life. The effective management of severe asthma requires consideration of clinical heterogeneity that is driven by varying clinical and inflammatory phenotypes, which are reflective of distinct underlying disease mechanisms. Phenotyping patients using a combination of clinical characteristics such as the age of onset or comorbidities and biomarker profiles, including blood eosinophil counts and levels of fractional exhaled nitric oxide and serum total immunoglobulin E, is important for the differential diagnosis of asthma. In addition, phenotyping is beneficial for risk assessment, selection of treatment, and monitoring of the treatment response in patients with asthma. This review describes the clinical and inflammatory phenotypes of asthma, provides an overview of biomarkers routinely used in clinical practice and those that have recently been explored for phenotyping, and aims to assess the value of phenotyping in severe asthma management in the current era of biologics.
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Affiliation(s)
- Arnaud Bourdin
- PhyMedExp, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Simon Couillard
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Merritt L Fajt
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Elliot Israel
- Pulmonary and Critical Care Medicine, Allergy & Immunology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - P Jane McDowell
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Andrew Menzies-Gow
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom; Royal Brompton and Harefield Hospitals, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Neil Martin
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom; University of Leicester, Leicester, United Kingdom
| | | | - Nayia Petousi
- Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Florence Schleich
- Department of Respiratory Medicine, CHU Liege, GIGA I3 Lab, University of Liege, Liege, Belgium
| | - Ian D Pavord
- Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
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Petousi N, Pavord ID, Kent BD. Type-2 inflammation: a key treatable trait associated with lung function decline in chronic airways disease. Thorax 2024; 79:291-292. [PMID: 38373823 DOI: 10.1136/thorax-2023-221329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 02/21/2024]
Affiliation(s)
- Nayia Petousi
- Nuffield Department of Medicine & NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Ian D Pavord
- Nuffield Department of Medicine & NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Brian Daniel Kent
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
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Ramlal M, van der Meer R, Bendien S. Treatable Traits in Pregnant Women with Asthma. Respiration 2024; 103:217-232. [PMID: 38471469 PMCID: PMC10997272 DOI: 10.1159/000536455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/19/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Asthma is the most common chronic respiratory disease in pregnancy, affecting approximately 8-10% of pregnant women. Uncontrolled asthma is associated with adverse perinatal outcomes, including low birth weight, preterm birth, and maternal complications such as pre-eclampsia. SUMMARY A current approach to the management of chronic airway diseases is based on targeting treatable traits. The aim of this review was to define treatable traits in pregnant women with asthma based on recent literature and to determine personalized treatment options according to these traits. Traits addressed in this review that may improve asthma control and pregnancy outcomes are fractional exhaled nitric oxide-based asthma monitoring and treatment, medication adherence and inhalation technique, impaired lung function, smoking cessation and comorbidity including psychological conditions (depression and anxiety), obesity, rhinitis, gastroesophageal reflux disease, chronic rhinosinusitis with or without nasal polyps, and sleep apnea. KEY MESSAGES All the treatable traits discussed have the potential to improve asthma control and pregnancy outcomes in pregnant women with asthma. Further research is needed to determine which management approaches are best to improve asthma control during pregnancy, to identify other relevant treatable traits, and to determine whether the treatable trait approach is feasible and beneficial in pregnant women with asthma.
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Affiliation(s)
- Meera Ramlal
- Department of Biomedical Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Renske van der Meer
- Department of Pulmonology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Sarah Bendien
- Department of Pulmonology, Haga Teaching Hospital, The Hague, The Netherlands
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Matera MG, Rinaldi B, Annibale R, De Novellis V, Cazzola M. The pharmacological management of asthma in adults: 2023 update. Expert Opin Pharmacother 2024; 25:383-393. [PMID: 38497368 DOI: 10.1080/14656566.2024.2332627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/14/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION The pharmacotherapy of asthma is a dynamic process that changes as our knowledge of the underlying pathophysiology and treatment of this disease continues to evolve. This implies the need for continuous revision of the recommendations of asthma guidelines and strategies. AREAS COVERED This review summarizes the latest key practical information on the pharmacological management of asthma in adults. We provide the background to the 2023 update of the GINA strategy report, focusing on changes and discussing areas of uncertainty. We review current and emerging pharmacotherapy for uncontrolled asthma, including synthetic agents and new biologics, and provide expert perspectives and opinions on the treatment of uncontrolled asthma. EXPERT OPINION The current pharmacological treatment of asthma, based on a step-by-step, control-based approach, with ICSs, LABAs and LAMAs being the mainstay generally provides good symptom control. Biologic therapies are often effective in treating T2high severe asthma. However, there is still room for improvement, such as the discovery of new molecules that specifically target chronic inflammation and, most importantly, the ability to provide solutions to the various areas of uncertainty that still exist. Also finding solutions to improve the accessibility and affordability of rescue ICS in resource-constrained settings is critical.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Barbara Rinaldi
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Rosa Annibale
- Pharmacy Unit, "Luigi Vanvitelli" University Hospital, Naples, Italy
| | - Vito De Novellis
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Phinyo P, Krikeerati T, Vichara-Anont I, Thongngarm T. Efficacy and Safety of Biologics for Oral Corticosteroid-Dependent Asthma: A Systematic Review and Network Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:409-420. [PMID: 37972921 DOI: 10.1016/j.jaip.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/26/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND A maintenance oral corticosteroid (OCS) in addition to high-dose inhaled corticosteroids plus long-acting β2-agonists in patients with severe asthma leads to long-term adverse events. Oral corticosteroid-sparing agents are of high priority. OBJECTIVE This network meta-analysis assessed biologics' comparative efficacy and safety in OCS-dependent patients with asthma. METHODS We performed a systematic search through PubMed, Scopus, Embase, the Cochrane Center of Controlled Trials, and Google Scholar for randomized controlled trials that addressed the efficacy and safety of biologics compared with placebo in OCS-dependent patients with asthma from inception to July 2023. The primary outcome was an overall reduction in the OCS dose while asthma control was maintained. RESULTS We included seven randomized controlled trials involving 1,052 OCS-dependent patients with asthma. Compared with placebo, benralizumab every 8 weeks, benralizumab every 4 weeks, dupilumab, and mepolizumab were efficacious in achieving a reduction in the OCS dose with low to moderate confidence (odds ratio [95% CI]: 4.12 [2.22-7.64]; 4.09 [2.22-7.55]; 3.25 [1.90-5.55]; and 2.39 [1.25-4.57], respectively) whereas tralokinumab, tezepelumab, and subcutaneous reslizumab were ineffective. An indirect comparison found no significant differences among benralizumab, dupilumab, and mepolizumab. Efficacy in reducing exacerbations was consistent with the primary analysis. High baseline blood eosinophil counts benefit from anti-IL-5 therapies, whereas high FeNO levels favor dupilumab regardless of blood eosinophil counts. Adverse events between biologics and placebo were comparable, except for eosinophilia with dupilumab. CONCLUSIONS In OCS-dependent patients with asthma, benralizumab, dupilumab, and mepolizumab were superior to placebo in reducing the OCS dose. Evaluating baseline biomarkers helps in choosing the proper biologics to maximize treatment effects.
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Affiliation(s)
- Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Musculoskeletal Science and Translational Research Center, Chiang Mai University, Chiang Mai, Thailand
| | - Thanachit Krikeerati
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Irin Vichara-Anont
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Torpong Thongngarm
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Pham DD, Lee JH, Kwon HS, Song WJ, Cho YS, Kim H, Kwon JW, Park SY, Kim S, Hur GY, Kim BK, Nam YH, Yang MS, Kim MY, Kim SH, Lee BJ, Lee T, Park SY, Kim MH, Cho YJ, Park C, Jung JW, Park HK, Kim JH, Moon JY, Bhavsar P, Adcock I, Chung KF, Kim TB. Predictors of Early and Late Lung Function Improvement in Severe Eosinophilic Asthma on Type2-Biologics in the PRISM Study. Lung 2024; 202:41-51. [PMID: 38252134 DOI: 10.1007/s00408-024-00670-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND The determinants linked to the short- and long-term improvement in lung function in patients with severe eosinophilic asthma (SEA) on biological treatment (BioT) remain elusive. OBJECTIVE We sought to identify the predictors of early and late lung function improvement in patients with SEA after BioT. METHODS 140 adult patients with SEA who received mepolizumab, dupilumab, or reslizumab were followed up for 6 months to evaluate improvement in forced expiratory volume in one second (FEV1). Logistic regression was used to determine the association between potential prognostic factors and improved lung function at 1 and 6 months of treatment. RESULTS More than a third of patients with SEA using BioT showed early and sustained improvements in FEV1 after 1 month. A significant association was found between low baseline FEV1 and high blood eosinophil count and sustained FEV1 improvement after 1 month (0.54 [0.37-0.79] and 1.88 [1.28-2.97] odds ratios and 95% confidence interval, respectively). Meanwhile, among patients who did not experience FEV1 improvement after 1 month, 39% exhibited improvement at 6 months follow-up. A high ACT score measured at this visit was the most reliable predictor of late response after 6 months of treatment (OR and 95% CI 1.75 [1.09-2.98]). CONCLUSION Factors predicting the efficacy of biological agents that improve lung function in SEA vary according to the stage of response.
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Affiliation(s)
- Duong Duc Pham
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Hyunkyoung Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jae-Woo Kwon
- Department of Allergy and Clinical Immunology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - So-Young Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Byung Keun Kim
- Department of Internal Medicine, Korea University Medical Center Anam Hospital, Seoul, Korea
| | - Young-Hee Nam
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Mi-Yeong Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung-Jae Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taehoon Lee
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - So-Young Park
- Department of Internal Medicine, Eulji University School of Medicine, Seoul, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Young-Joo Cho
- Department of Allergy and Clinical Immunology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - ChanSun Park
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Han Ki Park
- Department of Allergy and Clinical Immunology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji-Yong Moon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Pankaj Bhavsar
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ian Adcock
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
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11
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Lavoie G, Pavord ID. Which biologic? New findings from a real-world study. Respirology 2023; 28:1091-1092. [PMID: 37735863 DOI: 10.1111/resp.14606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023]
Abstract
See related article
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Affiliation(s)
- Gabriel Lavoie
- Respiratory Medicine Unit and NIHR Respiratory BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and NIHR Respiratory BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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12
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McDowell PJ, McDowell R, Busby J, Eastwood MC, Patel PH, Jackson DJ, Mansur A, Patel M, Burhan H, Doe S, Chaudhuri R, Gore R, Dodd JW, Subramanian D, Brown T, Heaney LG. Clinical remission in severe asthma with biologic therapy: an analysis from the UK Severe Asthma Registry. Eur Respir J 2023; 62:2300819. [PMID: 37857423 PMCID: PMC10719453 DOI: 10.1183/13993003.00819-2023] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Novel biologic therapies have revolutionised the management of severe asthma with more ambitious treatment aims. Here we analyse the definition of clinical remission as a suggested treatment goal and consider the characteristics associated with clinical remission in a large, real-world severe asthma cohort. METHODS This was a retrospective analysis of severe asthma patients registered in the UK Severe Asthma Registry (UKSAR) who met strict national access criteria for biologics. Patients had a pre-biologics baseline assessment and annual review. The primary definition of clinical remission applied included Asthma Control Questionnaire (ACQ)-5 <1.5 and no oral corticosteroids for disease control and forced expiratory volume in 1 s above lower limit of normal or no more than 100 mL less than baseline. RESULTS 18.3% of patients achieved the primary definition of remission. The adjusted odds of remission on biologic therapy were 7.44 (95% CI 1.73-31.95)-fold higher in patients with type 2 (T2)-high biomarkers. The adjusted odds of remission were lower in patients who were female (OR 0.61, 95% CI 0.45-0.93), obese (OR 0.49, 95% CI 0.24-0.65) or had ACQ-5 ≥1.5 (OR 0.19, 95% CI 0.12-0.31) pre-biologic therapy. The likelihood of remission reduced by 14% (95% CI 0.76-0.97) for every 10-year increase in disease duration. 12-21% of the cohort attained clinical remission depending on the definition applied; most of those who did not achieve remission failed to meet multiple criteria. CONCLUSIONS 18.3% of patients achieved the primary definition of clinical remission. Remission was more likely in T2-high biomarker patients with shorter duration of disease and less comorbidity. Further research on the optimum time to commence biologics in severe asthma is required.
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Affiliation(s)
- P. Jane McDowell
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
- Belfast Health and Social Care NHS Trust, Belfast, UK
| | - Ron McDowell
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - M. Chad Eastwood
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
- Belfast Health and Social Care NHS Trust, Belfast, UK
| | | | - David J. Jackson
- Guy's Severe Asthma Centre, Guy's Hospital, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Adel Mansur
- University of Birmingham and Heartlands Hospital, Birmingham, UK
| | - Mitesh Patel
- Department of Respiratory Medicine, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | | | - Simon Doe
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rekha Chaudhuri
- NHS Greater Glasgow and Clyde Health Board, Gartnavel Hospital, Glasgow, UK
| | - Robin Gore
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James W. Dodd
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Deepak Subramanian
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Liam G. Heaney
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
- Belfast Health and Social Care NHS Trust, Belfast, UK
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13
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Kappen J, Diamant Z, Agache I, Bonini M, Bousquet J, Canonica GW, Durham SR, Guibas GV, Hamelmann E, Jutel M, Papadopoulos NG, Roberts G, Shamji MH, Zieglmayer P, Gerth van Wijk R, Pfaar O. Standardization of clinical outcomes used in allergen immunotherapy in allergic asthma: An EAACI position paper. Allergy 2023; 78:2835-2850. [PMID: 37449468 DOI: 10.1111/all.15817] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION In allergic asthma patients, one of the more common phenotypes might benefit from allergen immunotherapy (AIT) as add-on intervention to pharmacological treatment. AIT is a treatment with disease-modifying modalities, the evidence for efficacy is based on controlled clinical trials following standardized endpoint measures. However, so far there is a lack of a consensus for asthma endpoints in AIT trials. The aim of a task force (TF) of the European Academy of Allergy and Clinical Immunology (EAACI) is evaluating several outcome measures for AIT in allergic asthma. METHODS The following domains of outcome measures in asthmatic patients have been evaluated for this position paper (PP): (i) exacerbation rate, (ii) lung function, (iii) ICS withdrawal, (iv) symptoms and rescue medication use, (v) questionnaires (PROMS), (vi) bronchial/nasal provocation, (vii) allergen exposure chambers (AEC) and (viii) biomarkers. RESULTS Exacerbation rate can be used as a reliable objective primary outcome; however, there is limited evidence due to different definitions of exacerbation. The time after ICS withdrawal to first exacerbation is considered a primary outcome measure. Besides, the advantages and disadvantages and clinical implications of further domains of asthma endpoints in AIT trials are elaborated in this PP. CONCLUSION This EAACI-PP aims to highlight important aspects of current asthma measures by critically evaluating their applicability for controlled trials of AIT.
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Affiliation(s)
- Jasper Kappen
- Department of Pulmonology, STZ Centre of Excellence for Asthma, COPD and Respiratory Allergy, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
| | - Zuzana Diamant
- Departmentt of Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium
- Department of Respiratory Medicine & Allergology, Institute for Clinical Science, Skane University Hospital, Lund University, Lund, Sweden
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | | | - Matteo Bonini
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- Department of Cardiovascular and Thoracic Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Clinical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Jean Bousquet
- Charite Universitatsmedizin Berlin Campus Berlin Buch, MASK-air, Montpellier, France
| | - G Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic Humanitas University & Research Hospital-IRCCS, Milan, Italy
| | - Stephen R Durham
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - George V Guibas
- Department of Allergy and Clinical Immunology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- School of Biological Sciences, Medicine and Health, University of Manchester, Manchester, UK
| | - Eckard Hamelmann
- Children's Center Bethel, University Hospital Bielefeld, University Bielefeld, Bielefeld, Germany
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
| | | | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, UK
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Paediatric Allergy and Respiratory Medicine (MP803), Clinical & Experimental Sciences & Human Development in Health Academic Units University of Southampton Faculty of Medicine & University Hospital Southampton, Southampton, UK
| | - Mohamed H Shamji
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Petra Zieglmayer
- Karl Landsteiner University, Competence Center for Allergology and Immunology, Krems, Austria
| | - Roy Gerth van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
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Celis-Preciado CA, Leclerc S, Duval M, Cliche DO, Larivée P, Lemaire-Paquette S, Lévesque S, Côté A, Lachapelle P, Couillard S. Phenotyping the Responses to Systemic Corticosteroids in the Management of Asthma Attacks (PRISMA): protocol for an observational and translational pilot study. BMJ Open Respir Res 2023; 10:e001932. [PMID: 37940357 PMCID: PMC10632890 DOI: 10.1136/bmjresp-2023-001932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023] Open
Abstract
INTRODUCTION Asthma and its associated exacerbation are heterogeneous. Although severe asthma attacks are systematically prescribed corticosteroids and often antibiotics, little is known about the variability of response to these therapies. Blood eosinophils and fractional exhaled nitric oxide (FeNO) are type 2 inflammation biomarkers that have established mechanistic, prognostic and theragnostic values in chronic asthma, but their utility in acute asthma is unclear. We speculate that the clinical and biological response to those treatments varies according to inflammometry and microbiological test results. METHODS AND ANALYSIS An observational longitudinal pilot study with multimodal clinical and translational assessments will be performed on 50 physician-diagnosed ≥12-year-old asthmatics presenting with an asthma attack and 12 healthy controls, including blood eosinophil count (venous and point-of-care (POC) capillary blood), FeNO and testing for airway infection (sputum cultures and POC nasopharyngeal swabs). People with asthma will be assessed on day 0 and after a 7-day corticosteroid course, with home monitoring performed in between. The primary analysis will be the change in the forced expiratory volume in 1 s according to type 2 inflammatory status (blood eosinophils ≥0.15×109/L and/or FeNO ≥25 ppb) after treatment. Key secondary analyses will compare changes in symptom scores and the proportion of patients achieving a minimal clinically important difference. Exploratory analyses will assess the relationship between clinical, lung function, inflammatory and microbiome parameters; satisfaction plus reliability indices of POC tests; and sex-gender variability in treatment response. Ultimately, this pilot study will serve to plan a larger trial comparing the clinical and biological response to systemic corticosteroids according to inflammatory biomarkers, offering valuable guidance for more personalised therapeutic strategies in asthma attacks. ETHICS AND DISSEMINATION The protocol has been approved by the Research Ethics Committee of the CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada (#2023-4687). Results will be communicated in an international meeting and submitted to a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05870215).
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Affiliation(s)
- Carlos Andrés Celis-Preciado
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Internal Medicine-Pulmonary Unit, Faculty of Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Simon Leclerc
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Martine Duval
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Dominic O Cliche
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Pierre Larivée
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Samuel Lemaire-Paquette
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Simon Lévesque
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Laboratoire de Microbiologie, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Andréanne Côté
- Department of Medicine, Faculty of Medicine, Centre de Recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Philippe Lachapelle
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Simon Couillard
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Rogers L, Jesenak M, Bjermer L, Hanania NA, Seys SF, Diamant Z. Biologics in severe asthma: A pragmatic approach for choosing the right treatment for the right patient. Respir Med 2023; 218:107414. [PMID: 37776915 DOI: 10.1016/j.rmed.2023.107414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/20/2023] [Accepted: 09/15/2023] [Indexed: 10/02/2023]
Abstract
The development of monoclonal antibody therapies targeting specific components of the pathways relevant to asthma pathophysiology has revolutionized treatment of severe asthma both in adults and children and helped to further unravel the heterogeneity of this disease. However, the availability of multiple agents, often with overlapping eligibility criteria, creates a need for pragmatic guidance for specialists undertaking care of patients with severe asthma. In this review, we provide an overview of the data supporting the clinical efficacy of biologics in distinct asthma phenotypes/endotypes. We also focus on the role of biomarkers and treatable traits, including comorbidities, in the choice of asthma biologics, highlight which treatments have been demonstrated to be steroid sparing in corticosteroid dependent asthma, and provide practical guidance that can drive shared decision making on treatment choice with patients. In addition, we summarize what is known to date regarding long-term safety of these drugs, and lastly, discuss future directions in biologics research.
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Affiliation(s)
- Linda Rogers
- Mount Sinai National Jewish Health Respiratory Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Milos Jesenak
- Department of Pediatrics, Department of Pulmonology and Phthisiology, Department of Allergology and Clinical Immunology, Jessenius Faculty of Medicine, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovakia
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Nicola A Hanania
- Section of Pulmonary /Critical Care/Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Zuzana Diamant
- Department Clin Pharm & Pharmacol, Univ Groningen, Univ Med Ctr Groningen, Groningen, Netherlands; Department of Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Belgium; Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic; Department of Respiratory Medicine & Allergology, Institute for Clinical Science, Skane University Hospital, Lund University, Lund, Sweden
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Cosío BG, Shafiek H, Mosteiro M, Iglesias A, Gómez C, Toledo-Pons N, Martinez R, Lopez M, Escribano Gimeno I, Pérez de Llano L. Redefining the Role of Bronchoscopy in the Workup of Severe Uncontrolled Asthma in the Era of Biologics: A Prospective Study. Chest 2023; 164:837-845. [PMID: 36921895 DOI: 10.1016/j.chest.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/19/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Severe uncontrolled asthma (SUA) is frequently treated with biologic therapy if a T2 phenotype is found. Bronchoscopy is not routinely recommended in these patients unless a specific indication to rule out comorbidities is present. RESEARCH QUESTION Is routine bronchoscopy safe and useful in phenotyping and endotyping patients with SUA before the indication of a biologic therapy? STUDY DESIGN AND METHODS Prospective study of consecutive patients with SUA who were referred to a specialized asthma clinic to assess the indication of a biologic therapy. Patients were clinically phenotyped as T2-allergic, T2-eosinophilic, and non-T2. All patients underwent bronchoscopy, and systematic data collection of endoscopic findings, microbiology of bronchial aspirate, and presence of eosinophils in bronchial biopsy were recorded and compared between asthma phenotypes. Cluster analysis was performed accordingly. RESULTS One hundred patients were recruited and classified as T2-allergic (28%), T2-eosinophilic (64%), and non-T2 (8%). On bronchoscopy, signs of gastroesophageal reflux disease were detected in 21%, vocal cord dysfunction in 5%, and tracheal abnormalities in 3%. Bronchial aspirate culture isolated bacteria in 27% of patients and fungi in 14%. Three clusters were identified: nonspecific, upper airway, and infection, the latter being less frequently associated with submucosal eosinophilia. Eosinophils were detected in 91% of bronchial biopsies. Despite a correlation to blood eosinophils, five patients with T2-phenotypes showed no eosinophils in bronchial biopsy, and three patients with non-T2 showed eosinophils in bronchial biopsy. Only one patient had moderate bleeding. INTERPRETATION Routine bronchoscopy in SUA eligible for biologic therapy is a safe procedure that can help to better phenotype and personalize asthma management.
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Affiliation(s)
- Borja G Cosío
- Department of Respiratory Medicine, Hospital Universitario Son Espases. Palma de Mallorca, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), Madrid, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain.
| | - Hanaa Shafiek
- Department of Chest Diseases, Faculty of Medicine, University of Alexandria, Egypt
| | - Mar Mosteiro
- Department of Respiratory Medicine, Hospital Alvaro Cunqueiro, Vigo, Spain
| | - Amanda Iglesias
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), Madrid, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
| | - Cristina Gómez
- Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain; Department of Pathology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Nuria Toledo-Pons
- Department of Respiratory Medicine, Hospital Universitario Son Espases. Palma de Mallorca, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
| | - Rocio Martinez
- Department of Respiratory Medicine, Hospital Universitario Son Espases. Palma de Mallorca, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
| | - Meritxell Lopez
- Department of Respiratory Medicine, Hospital Universitario Son Espases. Palma de Mallorca, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), Madrid, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
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Pérez-de-Llano L, Veiga-Teijeiro I, Dacal-Rivas D. Contribution of the Remission Concept to the Treatment of Asthma. Arch Bronconeumol 2023; 59:550-551. [PMID: 37005151 DOI: 10.1016/j.arbres.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Luis Pérez-de-Llano
- Pneumology Service, Lucus Augusti University Hospital. EOXI Lugo, Cervo e Monforte, Lugo, Spain.
| | - Iria Veiga-Teijeiro
- Pneumology Service, Lucus Augusti University Hospital. EOXI Lugo, Cervo e Monforte, Lugo, Spain
| | - David Dacal-Rivas
- Pneumology Service, Lucus Augusti University Hospital. EOXI Lugo, Cervo e Monforte, Lugo, Spain
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Padró-Casas C, Basagaña M, Rivera-Ortún ML, García-Olivé I, Pollan-Guisasola C, Teniente-Serra A, Martínez-Cáceres E, Navarro JT, Abad-Capa J, Rosell A, Roger A, Martínez-Rivera C. Characterization and Factors Associated with Poor Asthma Control in Adults with Severe Eosinophilic Asthma. J Pers Med 2023; 13:1173. [PMID: 37511786 PMCID: PMC10381894 DOI: 10.3390/jpm13071173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
A study was conducted in 98 adult patients diagnosed with severe eosinophilic asthma (73.5% women, mean age 47.2 years) and followed prospectively for 1 year. The aim of the study was to characterize this population and to identify factors associated with poor prognosis at 1 year of follow-up. At the initial visit, uncontrolled severe asthma was diagnosed in 87.7% of patients. Allergic sensitization was observed in 81.7% (polysensitization in 17.3%), with clinically significant allergic asthma in 45%. The mean percentage of sputum eosinophils was 4.7% (standard deviation(SD) 6.3%) and the mean (SD) blood eosinophil count 467 (225) cells/µL. Almost half of the patients (48.3%) had sputum eosinophilia (>3% eosinophils). Sputum eosinophils correlated significantly with peripheral eosinophilia (p = 0.004) and, to a lesser extent, with fractional exhaled nitric oxide (FeNO) (p = 0.04). After 1 year, 48 patients (49%) had uncontrolled asthma in all visits, and 50 (51%) had controlled asthma in some visits. Airway obstruction (FEV1 < 80% predicted) was the main reason for uncontrolled asthma. In the multivariate analysis, an obstructive pattern (odds ratio (OR) 7.45, 95% confidence interval (CI) 2.41-23.03, p < 0.0001) and the patient's age (OR 1.045, 95% CI 1.005-1.086, p = 0.026) were independent predictors of poor asthma control. In adult-onset and long-standing asthma, serum interleukin (IL) IL-17 was higher in the uncontrolled asthma group. This study contributes to characterizing patients with severe eosinophilic asthma in real-world clinical practice.
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Affiliation(s)
- Clara Padró-Casas
- Severe Asthma Unit, Allergy Section, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - María Basagaña
- Severe Asthma Unit, Allergy Section, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - María Luisa Rivera-Ortún
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Ignasi García-Olivé
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Carlos Pollan-Guisasola
- Severe Asthma Unit, Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Aina Teniente-Serra
- Severe Asthma Unit, Immunology Department, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Eva Martínez-Cáceres
- Severe Asthma Unit, Head of the Immunology Department, Department of Cell Biology, Physiology and Immunology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Associate Professor of Immunology, Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - José-Tomás Navarro
- Department of Hematology, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Jorge Abad-Capa
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Antoni Rosell
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Albert Roger
- Severe Asthma Unit, Allergy Section, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Carretera de Canyet s/n, E-08916 Badalona, Spain
| | - Carlos Martínez-Rivera
- Severe Asthma Unit, Department of Pneumology, Hospital Universitari Germans Trias i Pujol, The Germans Trias i Pujol Research Institute (IGTP), Universitat Autònoma de Barcelona, Carretera de Canyet s/n, E-08916 Badalona, Spain
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19
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Yan B, Zhang L. Biomarkers guiding biological therapeutic strategies in chronic rhinosinusitis with nasal polyps: an emerging challenge. Expert Rev Clin Immunol 2023; 19:827-830. [PMID: 37114372 DOI: 10.1080/1744666x.2023.2207822] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/24/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Bing Yan
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Otolaryngology, Beijing Laboratory of Allergic Diseases, Beijing Key Laboratory of Nasal Diseases, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University, Beijing, China
- Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Luo Zhang
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Otolaryngology, Beijing Laboratory of Allergic Diseases, Beijing Key Laboratory of Nasal Diseases, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University, Beijing, China
- Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China
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20
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Frøssing L, Klein DK, Hvidtfeldt M, Obling N, Telg G, Erjefält JS, Bodtger U, Porsbjerg C. Distribution of type 2 biomarkers and association with severity, clinical characteristics and comorbidities in the BREATHE real-life asthma population. ERJ Open Res 2023; 9:00483-2022. [PMID: 36949964 PMCID: PMC10026007 DOI: 10.1183/23120541.00483-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Background Type 2 (T2) high asthma is recognised as a heterogenous entity consisting of several endotypes; however, the prevalence and distribution of the T2 biomarkers in the general asthma population, across asthma severity, and across compartments is largely unknown. The objective of the present study was to describe expression and overlaps of airway and systemic T2 biomarkers in a clinically representative asthma population. Methods Patients with asthma from the real-life BREATHE cohort referred to a specialist centre were included and grouped according to T2 biomarkers: blood and sputum eosinophilia (≥0.3×109 cells·L-1 and 3% respectively), total IgE (≥150 U·mL-1), and fractional exhaled nitric oxide (≥25 ppb). Results Patients with mild-to-moderate asthma were younger (41 versus 49 years, p<0.001), had lower body mass index (25.9 versus 28.0 kg·m-2, p=0.002) and less atopy (47% versus 58%, p=0.05), higher forced expiratory volume in 1 s (3.2 versus 2.8 L, p<0.001) and forced vital capacity (4.3 versus 3.9 L, p<0.001) compared with patients with severe asthma, who had higher blood (0.22×109 versus 0.17×109 cells·L-1, p=0.01) and sputum (3.0% versus 1.5%, p=0.01) eosinophils. Co-expression of all T2 biomarkers was a particular characteristic of severe asthma (p<0.001). In patients with eosinophilia, sputum eosinophilia without blood eosinophilia was present in 45% of patients with mild-to-moderate asthma and 35% with severe asthma. Conclusion Severe asthma is more commonly associated with activation of several T2 pathways, indicating that treatments targeting severe asthma may need to act more broadly on T2 inflammatory pathways. Implementation of airway inflammometry in clinical care is of paramount importance, as the best treatable trait is otherwise is overlooked in a large proportion of patients irrespective of disease severity.
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Affiliation(s)
- Laurits Frøssing
- Respiratory Research Unit, Dept of Respiratory Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
- Contributed equally
- Corresponding author: Laurits Frøssing ()
| | - Ditte K. Klein
- Respiratory Research Unit, Dept of Respiratory Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
- Contributed equally
| | - Morten Hvidtfeldt
- Respiratory Research Unit, Dept of Respiratory Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Nicolai Obling
- Respiratory Research Unit PLUZ, Dept of Respiratory Medicine, Zealand University Hospital, Naestved, Denmark
| | | | | | - Uffe Bodtger
- Respiratory Research Unit PLUZ, Dept of Respiratory Medicine, Zealand University Hospital, Naestved, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Celeste Porsbjerg
- Respiratory Research Unit, Dept of Respiratory Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
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21
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Nopsopon T, Lassiter G, Chen ML, Alexander GC, Keet C, Hong H, Akenroye A. Comparative efficacy of tezepelumab to mepolizumab, benralizumab, and dupilumab in eosinophilic asthma: A Bayesian network meta-analysis. J Allergy Clin Immunol 2023; 151:747-755. [PMID: 36538979 PMCID: PMC9992307 DOI: 10.1016/j.jaci.2022.11.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/05/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND It is unclear how the efficacy of tezepelumab, approved for the treatment of type 2 high and low asthma, compares to the efficacy of other biologics for type 2-high asthma. OBJECTIVES We sought to conduct an indirect comparison of tezepelumab to dupilumab, benralizumab, and mepolizumab in the treatment of eosinophilic asthma. METHODS The investigators conducted a systematic review and Bayesian network meta-analyses. They identified randomized controlled trials indexed in PubMed, Embase, or Cochrane Central Register of Controlled Trials (CENTRAL) between January 1, 2000, and August 12, 2022. Outcomes included exacerbation rates, prebronchodilator FEV1, and the Asthma Control Questionnaire. RESULTS Ten randomized controlled trials (n = 9201) met eligibility. Tezepelumab (relative risk: 0.63; 95% credible interval [CI]: 0.46-0.86) was associated with significantly lower exacerbation rates than benralizumab and larger improvements in FEV1 compared to mepolizumab (mean difference [MD]: 66; 95% CI: -33 to 170) and benralizumab (MD: 62; 95% CI: -22 to 150), though the 95% CI crossed the null value of 0. Mepolizumab improved the Asthma Control Questionnaire score the most, but this improvement was not significantly different from that of tezepelumab (tezepelumab vs mepolizumab; MD: 0.14; 95% CI: -0.10 to 0.38). For efficacy by clinically important thresholds, tezepelumab, mepolizumab, and dupilumab achieved a >99% probability of reducing exacerbation rates by ≥50% compared to placebo, but benralizumab had only a 66% probability of doing so. Tezepelumab and dupilumab had a probability of 1.00 of improving prebronchodilator FEV1 by ≥100 mL above placebo. Compared to mepolizumab, dupilumab had >90% chance for improving FEV1 by ≥50 mL, but none of the differences between biologics exceeded 100 mL. CONCLUSIONS In individuals with eosinophilic asthma, tezepelumab and dupilumab were associated with greater improvements (although below clinical thresholds) in exacerbation rates and lung function than benralizumab or mepolizumab.
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Affiliation(s)
- Tanawin Nopsopon
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; Harvard T.H. Chan School of Public Health, Boston, Mass; Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Grace Lassiter
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center
| | - Ming-Li Chen
- Harvard T.H. Chan School of Public Health, Boston, Mass; Chung Shan Medical University, Taichung, Taiwan
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; Center for Drug Safety and Effectiveness, Baltimore, Md; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Corinne Keet
- Division of Pediatric Allergy and Immunology, University of North Carolina, Chapel Hill, NC
| | - Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Ayobami Akenroye
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass.
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22
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Couillard S, Petousi N, Smigiel KS, Molfino NA. Toward a Predict and Prevent Approach in Obstructive Airway Diseases. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:704-712. [PMID: 36682536 DOI: 10.1016/j.jaip.2023.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/22/2023]
Abstract
Asthma and chronic obstructive pulmonary disease are currently diagnosed and treated after the demonstration of variable airflow limitation and symptoms. Under this framework, undiagnosed and unchecked airway inflammation is associated with recurrent acute attacks, airway remodeling, airflow limitation, adverse effects of corticosteroids, and impaired quality of life, ultimately leading to the collection of side effects termed "people remodeling." This one-size-fits-all damage control approach aims to control symptoms and treat exacerbations rather than modify the underlying disease process. The advent of highly effective therapies targeting proximal drivers of airway inflammation calls for a paradigm shift; upstream-acting therapies offer potential to alter the disease course and achieve clinical remission. We propose moving away from downstream firefighting and toward a "predict and prevent" model, measuring inflammation and providing anti-inflammatory therapy early, without waiting for further clinical deterioration. Much in the same way that high blood pressure and cholesterol are used to predict and prevent heart attacks, in asthma, elevated blood eosinophils and/or exhaled nitric oxide can be used to predict and prevent asthma attacks. We also advocate moving research further upstream by identifying patients with subclinical airway inflammation or disease who may be at risk of progressing to airflow limitation and associated morbidities and intervening early to prevent them. In summary, we call for a predict and prevent approach in obstructive airway disease.
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Affiliation(s)
- Simon Couillard
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Nayia Petousi
- Respiratory Medicine Unit and NIHR Oxford Respiratory BRC, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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23
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Pianigiani T, Alderighi L, Meocci M, Messina M, Perea B, Luzzi S, Bergantini L, D’Alessandro M, Refini RM, Bargagli E, Cameli P. Exploring the Interaction between Fractional Exhaled Nitric Oxide and Biologic Treatment in Severe Asthma: A Systematic Review. Antioxidants (Basel) 2023; 12:antiox12020400. [PMID: 36829959 PMCID: PMC9952501 DOI: 10.3390/antiox12020400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a biomarker of airway inflammation associated with airway hyper-responsiveness and type-2 inflammation. Its role in the management of severe asthmatic patients undergoing biologic treatment, as well as FeNO dynamics during biologic treatment, is largely unexplored. PURPOSE The aim was to evaluate published data contributing to the following areas: (1) FeNO as a predictive biomarker of response to biologic treatment; (2) the influence of biologic treatment in FeNO values; (3) FeNO as a biomarker for the prediction of exacerbations in patients treated with biologics. METHODS The systematic search was conducted on the Medline database through the Pubmed search engine, including all studies from 2009 to the present. RESULTS Higher baseline values of FeNO are associated with better clinical control in patients treated with omalizumab, dupilumab, and tezepelumab. FeNO dynamics during biologic treatment highlights a clear reduction in FeNO values in patients treated with anti-IL4/13 and anti-IL13, as well as in patients treated with tezepelumab. During the treatment, FeNO may help to predict clinical worsening and to differentiate eosinophilic from non-eosinophilic exacerbations. CONCLUSIONS Higher baseline FeNO levels appear to be associated with a greater benefit in terms of clinical control and reduction of exacerbation rate, while FeNO dynamics during biologic treatment remains a largely unexplored issue since few studies have investigated it as a primary outcome. FeNO remains detectable during biologic treatment, but its potential utility as a biomarker of clinical control is still unclear and represents an interesting research area to be developed.
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24
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Guida G, Carriero V, Bertolini F, Pizzimenti S, Heffler E, Paoletti G, Ricciardolo FLM. Exhaled nitric oxide in asthma: from diagnosis to management. Curr Opin Allergy Clin Immunol 2023; 23:29-35. [PMID: 36539380 DOI: 10.1097/aci.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Exhaled nitric oxide (FENO) is a noninvasive marker of eosinophilic airway inflammation, therefore, highly informative in asthma. Although FENO measurement is a potentially accessible tool to many physicians, recommendations regarding its clinical utility in diagnosing or tailoring treatment have not reached the expected diffusion. More recently FENO emerged as a biomarker for type-2 asthma phenotyping and a predictor of response to biologics. RECENT FINDINGS The physiological discoveries and relevant acquisitions in clinical practice regarding FENO in asthma are presented. The FENO story draw a wavy path, characterized by promising findings, exciting confirmations and periods of low visibility. FENO emerged as a tool to increase the probability of asthma diagnosis. FENO predicts response to inhaled glucocorticoids (ICS), favoring the development of tailored treatment strategies and unrevealing nonadherence to ICS in difficult-to-treat or uncontrolled asthma. Finally, FENO was associated with a more severe phenotype and became a consolidated biomarker of type-2 inflammation. SUMMARY FENO demonstrated to be a noninvasive and very reproducible test, encompassing many applications in the field of asthma management. Its routinely use, according to international guidelines, may improve the quality of patient assistance, from difficult-to-treat cases to biologic monitoring.
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Affiliation(s)
- Giuseppe Guida
- Severe Asthma and Rare Lung Disease Unit, San Luigi Gonzaga University Hospital, Orbassano
- Department of Clinical and Biological Sciences, University of Turin, Turin
| | - Vitina Carriero
- Department of Clinical and Biological Sciences, University of Turin, Turin
| | | | - Stefano Pizzimenti
- Severe Asthma and Rare Lung Disease Unit, San Luigi Gonzaga University Hospital, Orbassano
| | | | | | - Fabio L M Ricciardolo
- Severe Asthma and Rare Lung Disease Unit, San Luigi Gonzaga University Hospital, Orbassano
- Department of Clinical and Biological Sciences, University of Turin, Turin
- Institute of Translational Pharmacology, National Research Council (IFT-CNR), section of Palermo, Italy
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25
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Baseline FeNO Independently Predicts the Dupilumab Response in Patients With Moderate-to-Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 11:1213-1220.e2. [PMID: 36535524 DOI: 10.1016/j.jaip.2022.11.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND FeNO may have a role as both a prognostic and predictive biomarker in combination with eosinophils for assessing responsiveness to some biological therapies. OBJECTIVE We evaluated the value of baseline FeNO, adjusted for baseline blood eosinophil levels and other clinical characteristics, as an independent predictor of treatment response to dupilumab in patients with uncontrolled moderate-to-severe asthma. METHODS We performed a post hoc analysis of LIBERTY ASTHMA QUEST (NCT02414854), a phase 3, double-blind study in patients aged 12 years and older with uncontrolled moderate-to-severe asthma, who received dupilumab 200 or 300 mg, or placebo every 2 weeks up to 52 weeks. We assessed the annualized event rate of severe exacerbations and least-squares mean change from baseline in prebronchodilator FEV1 at weeks 12 and 52 in relationship to baseline FeNO, adjusted for eosinophils and other clinical characteristics. RESULTS The annualized event rate increased with increasing baseline FeNO in placebo and decreased in dupilumab groups. The relative risk of severe exacerbations was 22·7%, 58·3%, and 69·3% lower for dupilumab versus placebo for the FeNO less than 25, 25 to less than 50, and 50 and greater parts per billion subgroups. The magnitude of FEV1 improvement increased with higher baseline FeNO for dupilumab and was consistent across the continuum of FeNO levels in placebo. Both findings were independent of blood eosinophil levels. Significant differences were observed between FeNO subgroups. CONCLUSIONS Increased baseline FeNO was associated with greater clinical effects in dupilumab versus placebo independently of eosinophil levels and other clinical characteristics.
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26
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Menigoz C, Dirou S, Chambellan A, Hassoun D, Moui A, Magnan A, Blanc F. Use of FeNO to predict anti-IL-5 and IL-5R biologics efficacy in a real-world cohort of adults with severe eosinophilic asthma. J Asthma 2022; 60:1162-1170. [PMID: 36301080 DOI: 10.1080/02770903.2022.2136526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Severe eosinophilic asthma (SEA) is associated with multiple exacerbations. Fractional exhaled nitric oxide (FeNO), a biomarker of airway T2 inflammation, is known to be correlated with the risk of exacerbations. While the use of FeNO is well established to predict the therapeutic response to dupilumab (anti-IL-4/IL-13), it remains uncertain for biologics targeting the IL-5 pathway. METHODS We conducted an observational, retrospective, monocentric analysis of adults with SEA who started mepolizumab (anti-IL-5) or benralizumab (anti-IL-5R) between January 1, 2016 and December 31, 2020. RESULTS Data were collected for 109 patients. All participants reported uncontrolled asthma with a median of 3 annual exacerbations and a median Asthma Control Test score of 12. They all had an initial blood eosinophilia >300/mm3, with a median at 610/mm3 (IQR 420-856). Patients with a baseline FeNO ≥50 ppb reported more exacerbations in the previous year than those with a FeNO <50 ppb (p = 0.02). After initiation of treatment, change in FeNO was not associated with therapeutic response. However, decrease in the annual number of exacerbations was significantly greater in patients with a baseline FeNO ≥50 ppb than in those with a baseline FeNO <50 ppb (-3.3 ± 2.7 vs -0.9 ± 2.4, respectively; p = 0.01). There was no association between baseline FeNO values and subsequent lung function, asthma control or reduction of oral corticosteroids use. CONCLUSION In this real-world cohort, adults with SEA who had a baseline FeNO ≥50 ppb experienced a greater decrease in exacerbations after 12 months of anti-IL-5 or IL-5R biologics than those with a FeNO <50 ppb.
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Affiliation(s)
- C. Menigoz
- Nantes Université, CHU Nantes, Service de Pneumologie, L’institut du thorax, Nantes, France.
| | - S. Dirou
- Nantes Université, CHU Nantes, Service de Pneumologie, L’institut du thorax, Nantes, France.
| | - A. Chambellan
- Nantes Université, CHU Nantes, Service d’Explorations Fonctionnelles, L’institut du thorax, Nantes, France.
| | - D. Hassoun
- Nantes Université, CHU Nantes, CNRS, INSERM, L’institut du Thorax, Nantes, France.
| | - A. Moui
- Nantes Université, CHU Nantes, Service de Pneumologie, L’institut du thorax, Nantes, France.
| | - A. Magnan
- Université de Versailles Saint-Quentin Paris-Saclay, Hôpital Foch, INRAe UMR 0892, Suresnes, France
| | - F.X. Blanc
- Nantes Université, CHU Nantes, Service de Pneumologie, L’institut du thorax, Nantes, France.
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27
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Crossingham I, Richardson R, Hinks TSC, Spencer S, Couillard S, Maynard-Paquette AC, Thomassen D, Howell I. Biologics for chronic severe asthma: a network meta‐analysis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015411. [PMCID: PMC9535695 DOI: 10.1002/14651858.cd015411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the benefits and harms of biological agents targeting type‐2 inflammation (benralizumab, dupilumab, mepolizumab, omalizumab, reslizumab, tezepelumab) in people with severe asthma, with a network meta‐analysis and to rank agents by effectiveness.
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Affiliation(s)
| | - Iain Crossingham
- Department of Respiratory MedicineEast Lancashire Hospitals NHS TrustBlackburnUK
| | - Rebekah Richardson
- Department of Respiratory MedicineEast Lancashire Hospitals NHS TrustBlackburnUK
| | - Timothy SC Hinks
- Respiratory Medicine Unit and NIHR Oxford Biomedical Research Centre, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Sally Spencer
- Health Research InstituteEdge Hill UniversityOrmskirkUK
| | - Simon Couillard
- Faculté de Médecine et des Sciences de la SantéUniversité de SherbrookeSherbrookeCanada
| | | | - Doranne Thomassen
- Department of Biomedical Data Sciences (Medical Statistics section)Leiden University Medical CenterLeidenNetherlands
| | - Imran Howell
- Respiratory Medicine Unit, Nuffield Department of MedicineUniversity of OxfordOxfordUK
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28
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Mohan A, Lugogo NL. Phenotyping, Precision Medicine, and Asthma. Semin Respir Crit Care Med 2022; 43:739-751. [PMID: 36220058 DOI: 10.1055/s-0042-1750130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The traditional one-size-fits all approach based on asthma severity is archaic. Asthma is a heterogenous syndrome rather than a single disease entity. Studies evaluating observable characteristics called phenotypes have elucidated this heterogeneity. Asthma clusters demonstrate overlapping features, are generally stable over time and are reproducible. What the identification of clusters may have failed to do, is move the needle of precision medicine meaningfully in asthma. This may be related to the lack of a straightforward and clinically meaningful way to apply what we have learned about asthma clusters. Clusters are based on both clinical factors and biomarkers. The use of biomarkers is slowly gaining popularity, but phenotyping based on biomarkers is generally greatly underutilized even in subspecialty care. Biomarkers are more often used to evaluate type 2 (T2) inflammatory signatures and eosinophils (sputum and blood), fractional exhaled nitric oxide (FeNO) and serum total and specific immunoglobulin (Ig) E reliably characterize the underlying inflammatory pathways. Biomarkers perform variably and clinicians must be familiar with their advantages and disadvantages to accurately apply them in clinical care. In addition, it is increasingly clear that clinical features are critical in understanding not only phenotypic characterization but in predicting response to therapy and future risk of poor outcomes. Strategies for asthma management will need to leverage our knowledge of biomarkers and clinical features to create composite scores and risk prediction tools that are clinically applicable. Despite significant progress, many questions remain, and more work is required to accurately identify non-T2 biomarkers. Adoption of phenotyping and more consistent use of biomarkers is needed, and we should continue to encourage this incorporation into practice.
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Affiliation(s)
- Arjun Mohan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Njira L Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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29
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Sesé L, Mahay G, Barnig C, Guibert N, Leroy S, Guilleminault L. [Markers of severity and predictors of response to treatment in severe asthma]. Rev Mal Respir 2022; 39:740-757. [PMID: 36115752 DOI: 10.1016/j.rmr.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/19/2022] [Indexed: 10/14/2022]
Abstract
Asthma is a multifactorial disease with complex pathophysiology. Knowledge of its immunopathology and inflammatory mechanisms is progressing and has led to the development over recent years of increasingly targeted therapeutic strategies. The objective of this review is to pinpoint the different predictive markers of asthma severity and therapeutic response. Obesity, nasal polyposis, gastroesophageal reflux disease and intolerance to aspirin have all been considered as clinical markers associated with asthma severity, as have functional markers such as bronchial obstruction, low FEV1, small daily variations in FEV1, and high FeNO. While sinonasal polyposis and allergic comorbidities are associated with better response to omalizumab, nasal polyposis or long-term systemic steroid use are associated with better response to antibodies targeting the IL5 pathway. Elevated total IgE concentrations and eosinophil counts are classic biological markers regularly found in severe asthma. Blood eosinophils are predictive biomarkers of response to anti-IgE, anti-IL5, anti-IL5R and anti-IL4R biotherapies. Dupilumab is particularly effective in a subgroup of patients with marked type 2 inflammation (long-term systemic corticosteroid therapy, eosinophilia≥150/μl or FENO>20 ppb). Chest imaging may help to identify severe patients by seeking out bronchial wall thickening and bronchial dilation. Study of the patient's environment is crucial insofar as exposure to tobacco, dust mites and molds, as well as outdoor and indoor air pollutants (cleaning products), can trigger asthma exacerbation. Wider and more systematic use of markers of severity or response to treatment could foster increasingly targeted and tailored approaches to severe asthma.
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Affiliation(s)
- L Sesé
- AP-HP, service de physiologie, hôpital Avicenne, Bobigny, France
| | - G Mahay
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU Rouen, Rouen, France
| | - C Barnig
- INSERM, EFS BFC, LabEx LipSTIC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, University Bourgogne Franche-Comté, Besançon, France; Service de pneumologie, oncologie thoracique et allergologie respiratoire, CHRU Besançon, Besançon, France
| | - N Guibert
- AP-HP, service de physiologie, hôpital Avicenne, Bobigny, France
| | - S Leroy
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, CNRS UMR 7275-FHU OncoAge, service de pneumologie oncologie thoracique et soins intensifs respiratoires, CHU de Nice, hôpital Pasteur, Nice, France
| | - L Guilleminault
- AP-HP, service de physiologie, hôpital Avicenne, Bobigny, France; Institut Toulousain des maladies infectieuses et inflammatoires (Infinity) inserm UMR1291-CNRS UMR5051-université Toulouse III, CRISALIS F-CRIN, Toulouse, France.
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Marcos MC, Cisneros Serrano C. What is the added value of FeNO as T2 biomarker? FRONTIERS IN ALLERGY 2022; 3:957106. [PMID: 36032508 PMCID: PMC9403133 DOI: 10.3389/falgy.2022.957106] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022] Open
Abstract
There is increasing evidence about the role of nitric oxide in type 2 (T2) immune response. Fraction of exhaled nitric oxide (FeNO) is a product of airways inflammation and it is increased in patients with asthma. Since Gustaffson published the first article about this biomarker in the 1990s, interest has continued to grow. Compared with other T2 biomarkers such as blood eosinophil count, induced sputum, or serum periostin, FeNO has some remarkable advantages, including its not invasive nature, easy repeatability, and possibility to be performed even in patients with severe airway obstruction. It is considered as an indicator of T2 inflammation and, by the same token, a useful predictor for inhaled steroid response. It is difficult to determine the utility of nitric oxide (NO) for initial asthma diagnosis. In such a heterogenous disease, a single parameter would probably not be enough to provide a complete picture. There is also an important variability among authors concerning FeNO cutoff values and the percentage of sensibility and specificity for diagnosis. Its high specificity indicates a potential role to “rule in” asthma; however, its lower sensibility could suggest a lower capacity to “rule out” this pathology. For this reason, if a diagnosis of asthma is being considered, FeNO should be considered along with other tests. FeNO has also shown its utility to detect response to steroids, adherence to treatment, and risk of exacerbation. Even though there is not enough quality of evidence to establish overall conclusions, FeNO could be an alternative procedure to diagnose or exclude asthma and also a predictive tool in asthma treated with corticosteroids.
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Moss MH, Lugogo NL, Castro M, Hanania NA, Ludwig-Sengpiel A, Saralaya D, Dobek R, Ojanguren I, Vyshnyvetskyy I, Bruey JM, Osterhout R, Tompkins CA, Dittrich K, Raghupathi K, Ortega H. Results of a Phase 2b Trial With GB001, a Prostaglandin D2 Receptor 2 Antagonist, in Moderate to Severe Eosinophilic Asthma. Chest 2022; 162:297-308. [DOI: 10.1016/j.chest.2022.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 10/19/2022] Open
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Radonjic-Hoesli S, Pavlov N, Simon HU, Simon D. Are blood cytokines reliable biomarkers of allergic disease diagnosis and treatment responses? J Allergy Clin Immunol 2022; 150:251-258. [DOI: 10.1016/j.jaci.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 10/16/2022]
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Couillard S, Pavord ID, Heaney LG, Petousi N, Hinks TSC. Sub-stratification of type-2 high airway disease for therapeutic decision-making: A 'bomb' (blood eosinophils) meets 'magnet' (FeNO) framework. Respirology 2022; 27:573-577. [PMID: 35591794 PMCID: PMC9541235 DOI: 10.1111/resp.14294] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Simon Couillard
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of MedicineUniversity of Oxford, Old Road CampusOxfordUK
- Faculté de Médecine et des Sciences de la SantéUniversité de SherbrookeSherbrookeQuébecCanada
| | - Ian D. Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of MedicineUniversity of Oxford, Old Road CampusOxfordUK
| | - Liam G. Heaney
- Centre for Experimental MedicineQueen's University Belfast School of Medicine Dentistry and Biomedical SciencesBelfastUK
| | - Nayia Petousi
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of MedicineUniversity of Oxford, Old Road CampusOxfordUK
| | - Timothy S. C. Hinks
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of MedicineUniversity of Oxford, Old Road CampusOxfordUK
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Chan R, Lipworth BJ. Determinants of asthma control and exacerbations in moderate to severe asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:2758-2760.e1. [PMID: 35803537 DOI: 10.1016/j.jaip.2022.06.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/17/2022] [Accepted: 06/24/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Rory Chan
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland, UK
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland, UK.
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Targeting Downstream Type 2 Cytokines or Upstream Epithelial Alarmins for Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1497-1505. [PMID: 35131510 DOI: 10.1016/j.jaip.2022.01.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/18/2022] [Accepted: 01/24/2022] [Indexed: 12/29/2022]
Abstract
Biologics, including omalizumab, mepolizumab, benralizumab, and dupilumab, targeting downstream IgE, cytokines IL-5, and IL-4/13, respectively, have shown promising effects in terms of reduction in annualized asthma exacerbation rates (AER), oral corticosteroid-sparing effects, improvements in forced expiratory volume in 1 second, and improved Asthma Control Questionnaire scores. However, despite these welcome advances, approximately 30% of patients with severe asthma receiving biologics tailored to their specific downstream type 2 biomarkers, including total IgE, peripheral blood eosinophils, and fractional exhaled nitric oxide, do not experience meaningful improvements in their AER. Instead of blocking downstream cytokines, targeting upstream epithelial alarmins, including IL-33, thymic stromal lymphopoietin, and IL-25, has been proposed to tackle the immunologic heterogeneity of asthma. This review article aims to pragmatically summarize the latest key clinical data on antialarmin therapies in severe asthma and put these findings into context with regard to currently available downstream cytokine blockers.
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Jackson DJ, Burhan H, Menzies-Gow A, Pfeffer P, Nanzer A, Garcia Gil E, Morris T, Tran TN, Hirsch I, Dube S. Benralizumab Effectiveness in Severe Asthma Is Independent of Previous Biologic Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1534-1544.e4. [PMID: 35202871 DOI: 10.1016/j.jaip.2022.02.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Benralizumab is an IL-5 receptor alpha-directed cytolytic mAb that depletes eosinophils, reducing exacerbations and oral corticosteroid (OCS) use, and improves asthma control for patients with severe eosinophilic asthma (SEA). Data on response in patients previously treated with other biologic therapies are limited. OBJECTIVE To describe real-world clinical outcomes with benralizumab for patients with and without prior biologic use for uncontrolled SEA. METHODS This retrospective study compared clinical outcomes before and after benralizumab initiation in adults with uncontrolled SEA with 3 or more asthma exacerbations in the previous 12 months or on maintenance OCS treatment. Outcomes included exacerbations, OCS use, patient-reported outcomes, and health care resource utilization, including emergency department visits and hospitalizations. RESULTS In all, 208 patients were enrolled, including 90 (43.3%) with previous experience with an alternate biologic for SEA. Benralizumab led to an 81% reduction in exacerbation rate, with 48% of patients with previous exacerbations experiencing none after 48 weeks. Overall, 67% of patients requiring baseline maintenance OCS achieved greater than or equal to 50% reduction in daily OCS dosage, and 53% eliminated maintenance OCS. Clinically meaningful improvements in patient-reported outcomes were seen, with response at 4 weeks predicting longer-term benefits. Health care resource utilization also decreased. Improvements were observed irrespective of previous biologic experience, fractional exhaled nitric oxide concentrations, atopic status, or other baseline characteristics. CONCLUSIONS In a multicenter real-world setting, patients with uncontrolled SEA achieved substantial improvements in all clinical outcome measures with benralizumab irrespective of previous biologic use, atopic status, or baseline fractional exhaled nitric oxide concentration.
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Affiliation(s)
- David J Jackson
- Guy's Severe Asthma Centre, Guy's & St Thomas' NHS Trust, London, United Kingdom; Asthma UK Centre, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom.
| | - Hassan Burhan
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | | | | | - Alexandra Nanzer
- Guy's Severe Asthma Centre, Guy's & St Thomas' NHS Trust, London, United Kingdom
| | - Esther Garcia Gil
- Global Medical Respiratory, BioPharmaceuticals Medical, AstraZeneca, Barcelona, Spain
| | - Tamsin Morris
- UK Medical and Scientific Affairs, AstraZeneca, Luton, United Kingdom
| | | | - Ian Hirsch
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, United Kingdom
| | - Sabada Dube
- UK Medical and Scientific Affairs, AstraZeneca, Luton, United Kingdom
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Couillard S, Steyerberg E, Beasley R, Pavord I. Blood eosinophils, fractional exhaled nitric oxide and the risk of asthma attacks in randomised controlled trials: protocol for a systemic review and control arm patient-level meta-analysis for clinical prediction modelling. BMJ Open 2022; 12:e058215. [PMID: 35365539 PMCID: PMC8977743 DOI: 10.1136/bmjopen-2021-058215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/25/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The reduction of the risk of asthma attacks is a major goal of guidelines. The fact that type-2 inflammatory biomarkers identify a higher risk, anti-inflammatory responsive phenotype is potentially relevant to this goal. We aim to quantify the relation between blood eosinophils, exhaled nitric oxide (FeNO) and the risk of severe asthma attacks. METHODS AND ANALYSIS A systematic review of randomised controlled trials (RCTs) will be conducted by searching MEDLINE from January 1993 to April 2021. We will include RCTs that investigated the effect of fixed treatment(s) regimen(s) on severe asthma exacerbation rates over at least 24 weeks and reported a baseline value for blood eosinophils and FeNO. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the methodological appraisal of the studies will be assessed by the Cochrane Risk-of-Bias Tool for RCTs. Study authors will be contacted to request anonymised individual participant data (IPD) for patients randomised to the trial's control arm. An IPD meta-analysis will be performed for multivariable prognostic modelling with performance assessment (calibration plots and the c-statistic) in a cross-validation by study procedure. The outcome to predict is the absolute number of severe asthma attacks to occur in the following 12 months if anti-inflammatory therapy is not changed (ie, annualised number of attacks requiring ≥3 days of systemic corticosteroids and/or hospitalisation if the patient was randomised to the control arm of an RCT). A summary prognostic equation and risk stratification chart will be reported as a basis for further analyses of individualised treatment benefit. ETHICS AND DISSEMINATION The protocol has been reviewed by the relevant Oxford academic ethics committee and found to comprise fully anonymised data not requiring further ethical approbation. Results will be communicated in an international meeting and submitted to a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021245337.
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Affiliation(s)
- Simon Couillard
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ewout Steyerberg
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Richard Beasley
- Respiratory medicine, Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ian Pavord
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Oppenheimer J, Hoyte FCL, Phipatanakul W, Silver J, Howarth P, Lugogo NL. Allergic and eosinophilic asthma in the era of biomarkers and biologics: similarities, differences and misconceptions. Ann Allergy Asthma Immunol 2022; 129:169-180. [PMID: 35272048 DOI: 10.1016/j.anai.2022.02.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Severe asthma is associated with substantial personal and economic burden; maintaining disease control is the key management goal. Increased understanding of asthma heterogeneity and development of type 2 (T2)-targeting biologics has substantially advanced disease management and outcomes; however, despite both being driven by T2 inflammation, allergic and eosinophilic asthma have different treatment recommendations. We sought to better understand the similarities and differences between allergic and eosinophilic asthma and highlight where misconceptions may arise. DATA SOURCES Published articles, pivotal trials, post hoc analyses, and asthma clinical guidelines sourced from PubMed. STUDY SELECTIONS Sources reporting allergic and eosinophilic asthma classifications, disease mechanisms, and biomarkers associated with treatment response. RESULTS This review highlights that severe allergic and eosinophilic asthma are both driven by T2 inflammation with eosinophils playing a cardinal role. Despite this overlap, treatment recommendations differ based on asthma classification. T2 cytokine gene expression is a reasonably well-established research tool, but not a well-established biomarker in clinical practice, unlike blood eosinophil counts, fractional exhaled nitric oxide, and immunoglobulin E; the clinical relevance of immunoglobulin E as a predictive biomarker remains unclear. CONCLUSION Asthma classifications that can be easily characterized at patient level to ensure accurate diagnosis, predict disease trajectory, and treatment response are required. The current dichotomy of allergic and eosinophilic asthma classifications is likely too simplistic, given the similar eosinophil-mediated disease pathophysiology in both classifications. Our results provide future directions to guide clinically meaningful interpretation of asthma endophenotypes, which may improve understanding of severe asthma characterization and aid future advances in defining responders more precisely with personalized medicine approaches.
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Affiliation(s)
| | - Flavia C L Hoyte
- National Jewish Health and University of Colorado, Denver, Colorado
| | - Wanda Phipatanakul
- Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Jared Silver
- US Medical Affairs-Respiratory, GlaxoSmithKline, Research Triangle Park, North Carolina
| | - Peter Howarth
- Respiratory Medical Franchise, GlaxoSmithKline, Brentford, United Kingdom
| | - Njira L Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
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Loewenthal L, Menzies-Gow A. FeNO in Asthma. Semin Respir Crit Care Med 2022; 43:635-645. [DOI: 10.1055/s-0042-1743290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractAsthma is a common disease affecting 350 million people worldwide, which is characterized by airways inflammation and hyperreactivity. Historically diagnosis and treatment have been mainly based on symptoms, which have the potential to result in misdiagnosis and inappropriate treatment. Nitric oxide (NO) is exhaled in human breath and is a marker of airways inflammation. Levels of NO are increased in the exhaled breath of patients with type 2 asthma and fractional exhaled nitric oxide (FeNO) provides an objective biomarker of airway inflammation. FeNO testing is an accessible, noninvasive, and easy-to-use test. Cut-off values have been established by the American Thoracic Society (ATS), the Global Initiative for Asthma (GINA), and the National Institute for Health and Care Excellence (NICE) but vary between guidance. FeNO levels have been shown to be predictive of blood and sputum eosinophil levels but should not be used in isolation and current guidance emphasizes the importance of incorporating clinical symptoms and testing when utilizing FeNO results. The inclusion of FeNO testing can increase diagnostic accuracy of asthma, while high levels in asthmatic patients can help predict response to inhaled corticosteroids (ICS) and suppression of levels with ICS to monitor adherence. FeNO levels are also a predictor of asthma risk with increased exacerbation rates and accelerated decline in lung function associated with high levels as well as having an emerging role in predicting response to some biologic therapies in severe asthma. FeNO testing is cost-effective and has been shown, when combined with clinical assessment, to improve asthma management.
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Affiliation(s)
- Lola Loewenthal
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, United Kingdom
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40
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Pavord ID, Hanania NA, Corren J. Controversies in Allergy: Choosing a Biologic for Patients with Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:410-419. [PMID: 34958982 DOI: 10.1016/j.jaip.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/11/2021] [Accepted: 12/15/2021] [Indexed: 01/20/2023]
Abstract
The availability of a range of new biological treatments targeting type-2 inflammation has provided new opportunities for patients with more severe asthma. Treatment has a bigger effect on exacerbations than day-to-day symptoms, and efficacy increases with increasing intensity of type-2 airway inflammation as reflected by the blood eosinophil count and fractional exhaled nitric oxide. The similarity of the clinical effects and target populations coupled with the absence of direct head-to-head comparative data makes it difficult to choose the right biologic for a given patient. In this review, we summarize the key efficacy data from phase 3 trials; discuss indirect comparisons; review clinical and laboratory variables that may be associated with a differential response to treatment; outline practical considerations that might be important to individual patients; and suggest an algorithm for choosing the most appropriate biologic to start with and the first choice to switch to.
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Affiliation(s)
- Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Tex
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41
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Couillard S, Do WIH, Beasley R, Hinks TS, Pavord ID. Predicting the benefits of type-2 targeted anti-inflammatory treatment with the prototype Oxford Asthma Attack Risk Scale (ORACLE). ERJ Open Res 2022; 8:00570-2021. [PMID: 35141315 PMCID: PMC8819242 DOI: 10.1183/23120541.00570-2021] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/17/2021] [Indexed: 11/05/2022] Open
Abstract
The prototype ORACLE scale based on two simple measures of type 2 airway inflammation (blood eosinophils and F ENO) quantifies the excess risk conferred by raised biomarkers that is removed by type-2 anti-inflammatory treatment in trial populations https://bit.ly/3F1gnUl.
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Affiliation(s)
- Simon Couillard
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - William Il Hoon Do
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Timothy S.C. Hinks
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Ian D. Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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Klimek L, Hagemann J, Welkoborsky HJ, Cuevas M, Casper I, Förster-Rurmann U, Klimek F, Hintschich CA, Huppertz T, Bergmann KC, Tomazic PV, Bergmann C, Becker S. T2-Inflammation bei entzündlichen Atemwegserkrankungen: Grundlage neuer Behandlungsoptionen. Laryngorhinootologie 2021; 101:96-108. [PMID: 34937094 DOI: 10.1055/a-1709-7899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- L Klimek
- Zentrum für Rhinologie und Allergologie, Wiesbaden.,Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Universitätsmedizin Mainz
| | - J Hagemann
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Universitätsmedizin Mainz
| | | | - M Cuevas
- Klinik und Poliklinik für HNO-Heilkunde, Universitätsklinikum Carl Gustav Carus, TU Dresden
| | - I Casper
- Zentrum für Rhinologie und Allergologie, Wiesbaden
| | | | - F Klimek
- Zentrum für Rhinologie und Allergologie, Wiesbaden
| | - C A Hintschich
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Regensburg
| | - T Huppertz
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Universitätsmedizin Mainz
| | - K-Ch Bergmann
- Klinik für Dermatologie, Venerologie und Allergie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - P V Tomazic
- HNO-Universitätsklinik Graz, Medizinische Universität Graz
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43
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Bush A, Pavord ID. Forthcoming UK asthma guidelines: an opportunity to improve asthma outcomes. Lancet 2021; 398:1856-1858. [PMID: 34656285 DOI: 10.1016/s0140-6736(21)02244-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Andy Bush
- Imperial Centre for Paediatrics and Child Health and Paediatric Respiratory Medicine, National Heart and Lung Institute, Imperial College, London, UK; Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NP, UK.
| | - Ian D Pavord
- NIHR Respiratory Biomedical Research Centre and Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Effective Management of Severe Asthma with Biologic Medications in Adult Patients: A Literature Review and International Expert Opinion. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:422-432. [PMID: 34763123 DOI: 10.1016/j.jaip.2021.10.059] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 12/11/2022]
Abstract
Severe asthma often remains uncontrolled despite effective treatments and evidence-based guidelines. A group of global experts in asthma and biologic medications from 9 countries considered the most relevant clinical variables to manage severe asthma in adult patients and guide treatment choice. The resulting recommendations address the investigation of biomarker levels (blood eosinophil count along with fractional concentration of exhaled nitric oxide [FeNO]), clinical features (oral corticosteroid [OCS] dependence, specific comorbid disease entities associated with severe type 2 asthma), and safety considerations. Current evidence suggests that biomarkers, including both blood or sputum eosinophil counts as well as FeNO, add prognostic and predictive value and should be measured in all patients with severe asthma. OCS use is an important factor in biologic selection, especially given the documented ability of some biologics to reduce OCS dependence. Comorbid diseases and relevant safety considerations to each biologic should also be considered. More data are needed to determine whether biomarker profiles identify patients suited to one biologic versus another as limited data support differential predictors of response. Further prospective head-to-head trials and post hoc analyses of clinical trial data are warranted. The authors believe that these recommendations have value as they offer expert opinion to assist health care providers in making difficult decisions regarding the quality of care in severe, type 2 asthma with biologic medications. They remain conditional and are based on limited data owing to a lack of head-to-head comparisons.
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45
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Using FeNO Measurement in Clinical Asthma Management. Chest 2021; 161:906-917. [PMID: 34673021 DOI: 10.1016/j.chest.2021.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/30/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Abstract
Asthma is a common and heterogeneous disease, characterised by lower airway inflammation and airflow limitation. Critical factors in asthma management include establishing an accurate diagnosis and ensuring appropriate selection and dosage of anti-inflammatory therapies. The majority of asthma patients exhibit type 2 (T2) inflammation, with increased interleukin (IL)-4, IL-5, and IL-13 signalling, often with associated eosinophilia. Identifying lower airway eosinophilia with sputum induction improves asthma outcomes, but is time consuming and costly. Increased T2-inflammation leads to upregulation of nitric oxide (NO) release into the airway, with increasing fractional exhaled NO (FeNO) reflecting greater T2-inflammation. FeNO can be easily and quickly measured in the clinic, offering a point of care surrogate measure of the degree of lower airway inflammation. FeNO testing can be used to help confirm an asthma diagnosis, to guide inhaled corticosteroid therapy, to assess adherence to treatment, and to aid selection of appropriate biologic therapy. However, FeNO levels may also be influenced by a variety of intrinsic and extrinsic factors other than asthma, including nasal polyposis and cigarette smoking, and must be interpreted in the broader clinical context rather than viewed in isolation. This review discusses the clinical application of FeNO measurement in asthma care, from diagnosis to treatment selection, and describes its place in current international expert guidelines.
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Li H, Zhang Q, Wang J, Gao S, Li C, Wang J, Zhang S, Lin J. Variability of Type 2 inflammatory markers guiding biologic therapy of severe asthma: A 5-year retrospective study from a single tertiary hospital. World Allergy Organ J 2021; 14:100547. [PMID: 34611471 PMCID: PMC8463912 DOI: 10.1016/j.waojou.2021.100547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/15/2021] [Accepted: 04/23/2021] [Indexed: 11/26/2022] Open
Abstract
Background Currently, biotherapy is mainly administered to treat patients with severe asthma with the Type 2 (T2) inflammation phenotype. The variability of T2 inflammatory markers remains poorly understood. Objective We aimed to describe the individual distributions of different biomarkers at varying thresholds and their variation patterns in participants with severe asthma. Methods We retrospectively reviewed the data of participants who had completed 2 or more fraction of exhaled nitric oxide (FeNO) and peripheral blood eosinophil counts in our centre within 5 years. The individual distribution of biomarkers (blood or sputum eosinophils, FeNO, and serum total IgE) with repeated measurements at different thresholds was analysed. The varied patterns of biomarkers were analysed by cluster analysis. Results A total of 241 eligible participants were screened. Through long-term longitudinal multiple measurements, we found that approximately 50% of severe asthmatics had blood eosinophil levels fluctuating around the threshold defined by biological agents. FeNO persisted at levels >19.5 ppb or 25 ppb in more than half of patients; about 30% of participants crossed this threshold. In our centre, 47.4% of participants consistently exceeded sputum eosinophils >3%, and 47.4% of patients crossed this threshold. Approximately 66.7% of participants had more than 50% alterations of serum total IgE, and 98.1% of participants continued to have IgE levels greater than 30 IU/mL. We used cluster analysis to classify variability and levels of FeNO and blood eosinophils and identified 4 patient clusters. Cluster 1 can be summarised as T2 severe asthma with low blood eosinophil levels and stability. Cluster 2 can be summarised as asthma with continuous increase and small fluctuations in various T2 inflammatory markers. Cluster 3 can be summarised as a non/low-T2 inflammatory phenotype. Cluster 4 can be summarised as a stable, moderate T2 inflammatory phenotype. Conclusion We identified the distributions and variable patterns of the T2 inflammatory markers currently used to guide asthma biotherapy in clinical practice. The longitudinal comprehensive multiple assessments of T2 inflammatory markers provide support for initiating biologic therapy patients with severe asthma whose biomarker levels vary.
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Affiliation(s)
- Hongwen Li
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Qing Zhang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.,Graduate School of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingru Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Shengnan Gao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.,Graduate School of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunxiao Li
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Jianxin Wang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.,Graduate School of Beijing University of Chinese Medicine, Beijing, China
| | - Shuhua Zhang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.,Graduate School of Beijing University of Chinese Medicine, Beijing, China
| | - Jiangtao Lin
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
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Harrison OK, Marlow L, Finnegan SL, Ainsworth B, Pattinson KTS. Dissociating breathlessness symptoms from mood in asthma. Biol Psychol 2021; 165:108193. [PMID: 34560173 PMCID: PMC9355895 DOI: 10.1016/j.biopsycho.2021.108193] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 09/09/2021] [Accepted: 09/16/2021] [Indexed: 12/21/2022]
Abstract
It is poorly understood why asthma symptoms are often discordant with objective medical tests. Differences in interoception (perception of internal bodily processes) may help explain symptom discordance, which may be further influenced by mood and attention. We explored inter-relationships between interoception, mood and attention in 63 individuals with asthma and 30 controls. Questionnaires, a breathing-related interoception task, two attention tasks, and standard clinical assessments were performed. Questionnaires were analysed using exploratory factor analysis, and linear regression examined relationships between measures. K-means clustering also defined asthma subgroups. Two concordant asthma subgroups (symptoms related appropriately to pathophysiology, normal mood) and one discordant subgroup (moderate symptoms, minor pathophysiology, low mood) were found. In all participants, negative mood correlated with decreased interoceptive ability and faster reaction times in an attention task. Our findings suggest that interpreting bodily sensations relates to mood, and this effect may be heightened in subgroups of individuals with asthma.
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Affiliation(s)
- Olivia K Harrison
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Switzerland; Department of Psychology, University of Otago, Dunedin, New Zealand; Wellcome Centre for Integrative Neuroimaging, and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Lucy Marlow
- Wellcome Centre for Integrative Neuroimaging, and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Sarah L Finnegan
- Wellcome Centre for Integrative Neuroimaging, and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Ben Ainsworth
- Department of Psychology, University of Bath, United Kingdom
| | - Kyle T S Pattinson
- Wellcome Centre for Integrative Neuroimaging, and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom.
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Eosinophils as Drivers of Severe Eosinophilic Asthma: Endotypes or Plasticity? Int J Mol Sci 2021; 22:ijms221810150. [PMID: 34576313 PMCID: PMC8467265 DOI: 10.3390/ijms221810150] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 01/04/2023] Open
Abstract
Asthma is now recognized as a heterogeneous disease, encompassing different phenotypes driven by distinct pathophysiological mechanisms called endotypes. Common phenotypes of asthma, referred to as eosinophilic asthma, are characterized by the presence of eosinophilia. Eosinophils are usually considered invariant, terminally differentiated effector cells and have become a primary therapeutic target in severe eosinophilic asthma (SEA) and other eosinophil-associated diseases (EADs). Biological treatments that target eosinophils reveal an unexpectedly complex role of eosinophils in asthma, including in SEA, suggesting that "not all eosinophils are equal". In this review, we address our current understanding of the role of eosinophils in asthma with regard to asthma phenotypes and endotypes. We further address the possibility that different SEA phenotypes may involve differences in eosinophil biology. We discuss how these differences could arise through eosinophil "endotyping", viz. adaptations of eosinophil function imprinted during their development, or through tissue-induced plasticity, viz. local adaptations of eosinophil function through interaction with their lung tissue niches. In doing so, we also discuss opportunities, technical challenges, and open questions that, if addressed, might provide considerable benefits in guiding the choice of the most efficient precision therapies of SEA and, by extension, other EADs.
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Rupani H, Fong WCG, Kyyaly A, Kurukulaaratchy RJ. Recent Insights into the Management of Inflammation in Asthma. J Inflamm Res 2021; 14:4371-4397. [PMID: 34511973 PMCID: PMC8421249 DOI: 10.2147/jir.s295038] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/17/2021] [Indexed: 12/11/2022] Open
Abstract
The present prevailing inflammatory paradigm in asthma is of T2-high inflammation orchestrated by key inflammatory cells like Type 2 helper lymphocytes, innate lymphoid cells group 2 and associated cytokines. Eosinophils are key components of this T2 inflammatory pathway and have become key therapeutic targets. Real-world evidence on the predominant T2-high nature of severe asthma is emerging. Various inflammatory biomarkers have been adopted in clinical practice to aid asthma characterization including airway measures such as bronchoscopic biopsy and lavage, induced sputum analysis, and fractional exhaled nitric oxide. Blood measures like eosinophil counts have also gained widespread usage and multicomponent algorithms combining different parameters are now appearing. There is also growing interest in potential future biomarkers including exhaled volatile organic compounds, micro RNAs and urinary biomarkers. Additionally, there is a growing realisation that asthma is a heterogeneous state with numerous phenotypes and associated treatable traits. These may show particular inflammatory patterns and merit-specific management approaches that could improve asthma patient outcomes. Inhaled corticosteroids (ICS) remain the mainstay of asthma management but their use earlier in the course of disease is being advocated. Recent evidence suggests potential roles for ICS in combination with long-acting beta-agonists (LABA) for as needed use in mild asthma whilst maintenance and reliever therapy regimes have gained widespread acceptance. Other anti-inflammatory strategies including ultra-fine particle ICS, leukotriene receptor antagonists and macrolide antibiotics may show efficacy in particular phenotypes too. Monoclonal antibody biologic therapies have recently entered clinical practice with significant impacts on asthma outcomes. Understanding of the efficacy and use of those agents is becoming clearer with a growing body of real-world evidence as is their potential applicability to other treatable comorbid traits. In conclusion, the evolving understanding of T2 driven inflammation alongside a treatable traits disease model is enhancing therapeutic approaches to address inflammation in asthma.
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Affiliation(s)
- Hitasha Rupani
- Department of Respiratory Medicine, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Wei Chern Gavin Fong
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
- David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK
| | - Aref Kyyaly
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
- David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK
| | - Ramesh J Kurukulaaratchy
- Department of Respiratory Medicine, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
- David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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50
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Li JH, Han R, Wang YB, Cheng M, Chen HY, Lei WH, Li L, Gao C, Zhao NN, Nie NF, Li ZY, Yin GQ, Huang S, He Y. Diagnostic possibility of the combination of exhaled nitric oxide and blood eosinophil count for eosinophilic asthma. BMC Pulm Med 2021; 21:259. [PMID: 34372824 PMCID: PMC8351446 DOI: 10.1186/s12890-021-01626-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 08/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tests to identify reversible airflow limitation are important in asthma diagnosis, but they are time-consuming and it may be difficult for patients to cooperate. We aimed to evaluate whether the combination of fractional exhaled nitric oxide (FeNO) and blood eosinophil (B-Eos) can be used to distinguish some asthma patients who could avoid objective tests. METHODS We conducted a retrospective cohort study on 7463 suspected asthma cases between January 2014 and December 2019 in Chongqing, China, and identified 2349 patients with complete FeNO, B-Eos count, and spirometry data. Asthma was diagnosed by clinicians by the criteria of recurrent respiratory symptoms and a positive bronchial-provocation or bronchodilation test (BPT, BPD). We evaluated the diagnostic accuracy of FeNO or B-Eos alone or both in combination for asthma using receiver operating characteristic (ROC) curve analysis. RESULTS In this study, 824 patients were diagnosed with asthma. When FeNO and B-Eos counts were used in combination, the area under the ROC curve (AUC) for diagnosing asthma increased slightly (0.768 vs. 0.745 [FeNO] or 0.728 [B-Eos]; both P < 0.001). The odds ratio for having asthma increased progressively with a gradual increase in FeNO or B-Eos count (both P < 0.001; assessed using the Cochran-Armitage trend test). Further analysis of in-series combinations of different threshold values for these biomarkers indicated that moderately elevated biomarker levels (FeNO > 40 ppb and B-Eos > 300 cells/μl) support a diagnosis of asthma because diagnostic specificity was > 95% and the positive likelihood ratio (PLR) was > 10. This conclusion was verified when selecting the 2017-2019 data as the internal validation dataset. CONCLUSION FeNO or B-Eos count alone is insufficient to accurately diagnose asthma. Patients with moderately elevated biomarkers (FeNO > 40 ppb and B-Eos > 300 cells/μl) could be diagnosed with asthma and avoid objective tests when such tests are not feasible.
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Affiliation(s)
| | - Rui Han
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Yu-Bo Wang
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Min Cheng
- Department of Cardiology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Heng-Yi Chen
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Wen-Hui Lei
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Li Li
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Chen Gao
- Department of Clinical Laboratory Medicine, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Na-Na Zhao
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Nai-Fu Nie
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Zhong-Yan Li
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Guo-Qing Yin
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Shuai Huang
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China
| | - Yong He
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, 10# Changjiang Branch Road, Chongqing, 400042, China.
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