1
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Abou Taam R, Labouret G, Michelet M, Schweitzer C, Lejeune S, Giovannini-Chami L. [Initial severity before treatment and control: Definitions and associated factors]. Rev Mal Respir 2024; 41 Suppl 1:e28-e34. [PMID: 39181755 DOI: 10.1016/j.rmr.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Affiliation(s)
- R Abou Taam
- Service de pneumologie et d'allergologie pédiatrique, AP-HP, hôpital Necker, Paris, France
| | - G Labouret
- Service de pneumologie et d'allergologie pédiatrique, CHU de Toulouse, Toulouse, France
| | - M Michelet
- Service de pneumologie et d'allergologie pédiatrique, CHU de Toulouse, Toulouse, France
| | - C Schweitzer
- Service de médecine infantile et explorations fonctionnelles pédiatriques, hôpital d'enfants, université de Lorraine, faculté de médecine de Nancy, DeVAH EA 3450; CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - S Lejeune
- Service de pneumologie et d'allergologie pédiatrique, hôpital Jeanne de Flandre, université Lille, CHU de Lille, 59000 Lille, France.
| | - L Giovannini-Chami
- Service de pneumologie et d'allergologie pédiatrique, université Côte d'Azur; hôpitaux pédiatriques de Nice CHU-Lenval, Nice, France
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2
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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3
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Ko FWS, Chan KP, Ng JKC, Ngai JCL, Yip WH, Lo RLP, Chan TO, Hui DSC. 1-Year Prospective Study of the Relationship of Serial Exhaled Nitric Oxide Level and Asthma Control. J Asthma Allergy 2023; 16:725-734. [PMID: 37469451 PMCID: PMC10353557 DOI: 10.2147/jaa.s417117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023] Open
Abstract
Background and Objective Previous studies found that the fractional nitric oxide concentration in exhaled breath (FeNO) levels in healthy Chinese adults was higher than in White adults. More understanding of serial changes of FeNO levels with asthma control in a real-life clinical setting would be important to explore the utility of this biomarker in routine asthma management. This study assessed the FeNO levels of Chinese asthma subjects with different levels of asthma control and the serial changes with respect to the changes in asthma control over 1 year. Methods A 12-month prospective study (subjects recruited between November 2019 and January 2021) with serial measurement of FeNO levels at baseline, 4, 8 and 12 months. Asthma control was assessed by the Global Initiative for Asthma classification, Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ). Results Altogether, 136 subjects (mean age 51.51±15.09 years, 46[33.8%] male) had successful baseline FeNO measurements. At baseline, the FeNO levels did not show a statistically significant difference for controlled, partly controlled and uncontrolled asthma according to GINA classification, ACT and ACQ. FeNO levels decreased with improving asthma control and stayed at similar levels with unchanged or worsening asthma control for all subjects. For subjects with baseline blood eosinophil levels ≥300 cells/µL(n=59), FeNO levels decreased with improving asthma control, stayed similar without change for asthma control and increased with worsening asthma control. Receiver operating characteristic (ROC) analysis with the highest area under curve (AUC) for changes in FeNO levels for improving asthma control was between ≤ -10 to -25 ppb at various time points in the 12-month study. Conclusion Changes in FeNO levels over time were associated with changes in clinical asthma control, particularly in those with higher blood eosinophil count and are likely more useful than a single time point measurement in managing asthma.
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Affiliation(s)
- Fanny Wai San Ko
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Ka Pang Chan
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Joyce Ka Ching Ng
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Jenny C L Ngai
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Wing Ho Yip
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Rachel Lai Ping Lo
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Tat On Chan
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - David Shu Cheong Hui
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
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4
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Guida G, Bagnasco D, Carriero V, Bertolini F, Ricciardolo FLM, Nicola S, Brussino L, Nappi E, Paoletti G, Canonica GW, Heffler E. Critical evaluation of asthma biomarkers in clinical practice. Front Med (Lausanne) 2022; 9:969243. [PMID: 36300189 PMCID: PMC9588982 DOI: 10.3389/fmed.2022.969243] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
The advent of personalized medicine has revolutionized the whole approach to the management of asthma, representing the essential basis for future developments. The cornerstones of personalized medicine are the highest precision in diagnosis, individualized prediction of disease evolution, and patient-tailored treatment. To this aim, enormous efforts have been established to discover biomarkers able to predict patients' phenotypes according to clinical, functional, and bio-humoral traits. Biomarkers are objectively measured characteristics used as indicators of biological or pathogenic processes or clinical responses to specific therapeutic interventions. The diagnosis of type-2 asthma, prediction of response to type-2 targeted treatments, and evaluation of the risk of exacerbation and lung function impairment have been associated with biomarkers detectable either in peripheral blood or in airway samples. The surrogate nature of serum biomarkers, set up to be less invasive than sputum analysis or bronchial biopsies, has shown several limits concerning their clinical applicability. Routinely used biomarkers, like peripheral eosinophilia, total IgE, or exhaled nitric oxide, result, even when combined, to be not completely satisfactory in segregating different type-2 asthma phenotypes, particularly in the context of severe asthma where the choice among different biologics is compelling. Moreover, the type-2 low fraction of patients is not only an orphan of biological treatments but is at risk of being misdiagnosed due to the low negative predictive value of type-2 high biomarkers. Sputum inflammatory cell analysis, considered the highest specific biomarker in discriminating eosinophilic inflammation in asthma, and therefore elected as the gold standard in clinical trials and research models, demonstrated many limits in clinical applicability. Many factors may influence the measure of these biomarkers, such as corticosteroid intake, comorbidities, and environmental exposures or habits. Not least, biomarkers variability over time is a confounding factor leading to wrong clinical choices. In this narrative review, we try to explore many aspects concerning the role of routinely used biomarkers in asthma, applying a critical view over the "state of the art" and contemporarily offering an overview of the most recent evidence in this field.
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Affiliation(s)
- Giuseppe Guida
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Diego Bagnasco
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Vitina Carriero
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Francesca Bertolini
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Fabio Luigi Massimo Ricciardolo
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Stefania Nicola
- Allergy and Immunology, AO Mauriziano Hospital, University of Turin, Turin, Italy
| | - Luisa Brussino
- Allergy and Immunology, AO Mauriziano Hospital, University of Turin, Turin, Italy
| | - Emanuele Nappi
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giovanni Paoletti
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giorgio Walter Canonica
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Heffler
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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5
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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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6
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Abdelwahab H, Hamad A, Ali R, Abumossalam A, Algharabawy M. Combined assessment of bronchial asthma control using forced expiratory volume in first second and exhaled nitric oxide. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2022. [DOI: 10.4103/ecdt.ecdt_21_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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7
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Tsolakis N, Jacinto T, Janson C, Borres M, Malinovschi A, Alving K. Relationship between longitudinal changes in type-2 inflammation, immunoglobulin E sensitization, and clinical outcomes in young asthmatics. Clin Transl Allergy 2021; 11:e12066. [PMID: 34582101 PMCID: PMC9083004 DOI: 10.1002/clt2.12066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/25/2021] [Accepted: 09/16/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Asthma is a heterogeneous condition where biomarkers may be of considerable advantage in diagnosis and therapy monitoring. However, the changes in asthma biomarkers and immunoglobulin E (IgE) over the course of life has not been extensively investigated. OBJECTIVE To study longitudinal changes in type-2 inflammatory biomarkers, IgE, and clinical outcomes, and the association between these changes, in young asthmatics. METHODS Asthmatics (age 10-35 years, n = 253) were examined at baseline and at a follow-up visit, 43 [23-65] (median [range]) months later. Subjects were analyzed using the multi-allergen tests Phadiatop and fx5 (ImmunoCAP) and grouped based on the baseline allergen-specific IgE antibody (sIgE) concentration: <0.10, 0.10-0.34, and ≥0.35 kUA /L. The relationship between changes (Δ values) in type-2 biomarkers (individualized fraction of exhaled nitric oxide [FeNO%], blood eosinophil [B-Eos] count, total IgE [tIgE] and sIgE, lung function [% predicted forced expiratory volume in 1 second (FEV1 ) and FEV1 /forced vital capacity (FVC)], and Asthma Control Test [ACT]) score were determined. RESULTS At follow up, FEV1 and FEV1 /FVC had decreased (93.6% vs. 95.8%, and 93.4% vs. 94.7% of predicted, respectively [p < 0.001 both]), whereas ACT score had increased (21.6 vs. 20.6, p = 0.001). A significant decline in lung function was seen in subjects with sIgE ≥ 0.10 kUA/L, but not in those with undetectable sIgE (<0.10 kUA /L). Furthermore, tIgE and sIgE declined over time (p < 0.001 all) whereas FeNO% and B-Eos count were not significantly changed. In univariate analysis, significant negative correlations between ∆B-Eos count and ∆FeNO%, on one hand, and changes in lung function, on the other hand, were seen, and multivariate analysis showed an independent relationship between ΔFeNO%, and ΔFEV1 (p < 0.05) and ΔFEV1 /FVC% (p < 0.01). Sex-specific analysis showed that the independent association between ΔFeNO%, and ΔFEV1 remained only in females (p = 0.005), and there was a significant interaction with sex (p = 0.02). CONCLUSION In young asthmatics, IgE levels declined over 43 months, whereas FeNO and B-Eos remained unchanged. In spite of improved asthma control, an accelerated lung function decline was seen in patients with detectable sIgE at baseline, and the decline correlated with changes in type-2 biomarkers. Particularly, the increase in individualized FeNO associated independently with decline in FEV1 in females.
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Affiliation(s)
- Nikolaos Tsolakis
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | - Magnus Borres
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,ImmunoDiagnostics, Thermo Fisher Scientific, Uppsala, Sweden
| | | | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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8
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Ulrik CS, Lange P, Hilberg O. Fractional exhaled nitric oxide as a determinant for the clinical course of asthma: a systematic review. Eur Clin Respir J 2021; 8:1891725. [PMID: 33708363 PMCID: PMC7919904 DOI: 10.1080/20018525.2021.1891725] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Precision medicine means linking the right patient to the right management strategy including best possible pharmacological therapy, considering the individual variability of the disease characteristics, type of inflammation, genes, environment, and lifestyle. For heterogenous diseases such as asthma, reliable biomarkers are needed to facilitate the best possible disease control and reduce the risk of side effects. The present review examines fractional exhaled nitric oxide (FeNO) as a guide for the management strategy of asthma and predictor of its clinical course. Method: The literature included was identified by searching the PubMed database using specific key words and MeSH terms. Studies were not excluded based on their design alone. The search resulted in 212 hits, of which 35 articles were included in this review. Results: Several studies support a potential role for high FeNO levels as a prognostic biomarker for accelerated lung function decline in adults with newly diagnosed asthma. Furthermore, studies report an association between high FeNO levels and excess decline in FEV1 in adults with long-standing moderate to severe asthma despite optimised therapy, whereas the findings for patients with less severe disease are conflicting. Applying a FeNO-based management algorithm reduces the exacerbation rate in adults with asthma. Similar observations are seen in children, though based on fewer studies. The available studies provide evidence that the level of FeNO may be useful as a predictor of subsequent loss of asthma control in adults, though the evidence is somewhat conflicting in children and young adults. Conclusion: The present review provides evidence of the prognostic value of FeNO as a surrogate biomarker for type 2 inflammation in the airways. FeNO is likely to emerge as an important biomarker in monitoring and tailoring modern asthma treatment, either alone or in combination with other biomarkers.
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Affiliation(s)
- Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark and Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lange
- Section of Epidemiology, Department of Public Health, Medical Department, Herlev-Gentofte Hospital, University of Copenhagen, DK-1014 Copenhagen K, Denmark, Herlev, Denmark
| | - Ole Hilberg
- Department of Medicine, Vejle Hospital, Southern Denmark University Hospital, Denmark
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9
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Kouri A, Gupta S, Yadollahi A, Ryan CM, Gershon AS, To T, Tarlo SM, Goldstein RS, Chapman KR, Chow CW. Addressing Reduced Laboratory-Based Pulmonary Function Testing During a Pandemic. Chest 2020; 158:2502-2510. [PMID: 32652095 PMCID: PMC7345485 DOI: 10.1016/j.chest.2020.06.065] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/23/2020] [Accepted: 06/27/2020] [Indexed: 01/04/2023] Open
Abstract
To reduce the spread of the severe acute respiratory syndrome coronavirus 2, many pulmonary function testing (PFT) laboratories have been closed or have significantly reduced their testing capacity. Because these mitigation strategies may be necessary for the next 6 to 18 months to prevent recurrent peaks in disease prevalence, fewer objective measurements of lung function will alter the diagnosis and care of patients with chronic respiratory diseases. PFT, which includes spirometry, lung volume, and diffusion capacity measurement, is essential to the diagnosis and management of patients with asthma, COPD, and other chronic lung conditions. Both traditional and innovative alternatives to conventional testing must now be explored. These may include peak expiratory flow devices, electronic portable spirometers, portable exhaled nitric oxide measurement, airwave oscillometry devices, and novel digital health tools such as smartphone microphone spirometers and mobile health technologies along with integration of machine learning approaches. The adoption of some novel approaches may not merely replace but could improve existing management strategies and alter common diagnostic paradigms. With these options comes important technical, privacy, ethical, financial, and medicolegal barriers that must be addressed. However, the coronavirus disease 19 pandemic also presents a unique opportunity to augment conventional testing by including innovative and emerging approaches to measuring lung function remotely in patients with respiratory disease. The benefits of such an approach have the potential to enhance respiratory care and empower patient self-management well beyond the current global pandemic.
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Affiliation(s)
- Andrew Kouri
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON.
| | - Samir Gupta
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON,Department of Medicine, University of Toronto, Toronto, ON
| | - Azadeh Yadollahi
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON,KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON
| | - Clodagh M. Ryan
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto General Hospital, University Health Network, Toronto, ON
| | - Andrea S. Gershon
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Sunnybrook Health Sciences Center, Toronto, ON
| | - Teresa To
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON,Dalla Lana Graduate School of Public Health, University of Toronto, Toronto, ON
| | - Susan M. Tarlo
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto Western Hospital, University Health Network, Toronto, ON
| | - Roger S. Goldstein
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respiratory Medicine, West Part Healthcare Centre, Toronto, ON, Canada
| | - Kenneth R. Chapman
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto Western Hospital, University Health Network, Toronto, ON
| | - Chung-Wai Chow
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto General Hospital, University Health Network, Toronto, ON
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10
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Duong-Quy S, Le-Thi-Minh H, Nguyen-Thi-Bich H, Pham-Thu H, Thom VT, Pham-Thi-Hong N, Duong-Thi-Ly H, Nguyen-Huy B, Ngo-Minh X, Nguyen-Thi-Dieu T, Craig TJ. Correlations between exhaled nitric oxide, rs28364072 polymorphism of FCER2 gene, asthma control, and inhaled corticosteroid responsiveness in children with asthma. J Breath Res 2020; 15:016012. [PMID: 33108776 DOI: 10.1088/1752-7163/abc4ec] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In children with asthma, the responsiveness of inhaled corticosteroids (ICS) is depended on asthma endotype and phenotype. This study aimed to describe the clinical and biological characteristics, and its correlation with polymorphism of rs28364072 in FCER2 of asthmatic children. This work aimed to study the correlation between fractional concentration of exhaled nitric oxide (FENO) level and rs28364072 polymorphism of FCER2 gene with ICS responsiveness and disease control in children with asthma. This study was a prospective and descriptive study. All clinical characteristics, FENO, blood eosinophil counts (BEC), skin prick test (SPT), total IgE, asthma control test, and FCER2 gene polymorphism were performed for each patient. One hundred and seven asthmatic children who were over 5 years old (9.2 ± 2.6), were included. Patients with FENO > 20 ppb had higher percentage of positive SPT, total IgE level, and BEC (89.2 vs 80.0%, 851.1 vs 656.9 UI ml-1, and 785 ± 576 G L-1 vs 425 ± 364 G L-1; respectively). Among them, there were 54.2% of homozygous TT, 36.4% of heterozygous TC, and 9.4% of homozygous CC of rs28364072 polymorphism in FCER2. The percentage of patients with controlled asthma was increasing after 1 month and 3 months (47.1% and 58.8%; respectively). During the study, the ICS was decreasing as indicated by asthma control (348 ± 118 mcg at 1st month vs 329 ± 119 mcg at 3rd month; p < 0.05). CC genotype had the lowest level of increasing FEV1 compared to that in genotype TC and TT (8.4% vs 8.7% and 27.1%; p > 0.05 and p < 0.05; respectively). The percentage of polymorphism in rs28364072 of FCER2 was significant higher in patients with controlled asthma compared to uncontrolled asthma. Asthmatic children with high FENO and rs28364072 polymorphism in FCER2 gene are good responders to ICS; however, asthmatic children with homozygous variant CC of rs28364072 are poorly responsive to ICS.
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Affiliation(s)
- S Duong-Quy
- Department of Respiratory Immuno-Allergology, Bio-Medical Research Centre, Lam Dong Medical College, Dalat, Vietnam. Medical Department, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam. These authors are co-first authors
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11
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Exhaled nitric oxide and its predictive power related to lung function and bronchial inflammation. Biochem Pharmacol 2020; 179:114101. [DOI: 10.1016/j.bcp.2020.114101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 11/22/2022]
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12
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Bonini M, Di Paolo M, Bagnasco D, Baiardini I, Braido F, Caminati M, Carpagnano E, Contoli M, Corsico A, Del Giacco S, Heffler E, Lombardi C, Menichini I, Milanese M, Scichilone N, Senna G, Canonica GW. Minimal clinically important difference for asthma endpoints: an expert consensus report. Eur Respir Rev 2020; 29:29/156/190137. [PMID: 32499305 PMCID: PMC9488652 DOI: 10.1183/16000617.0137-2019] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/09/2020] [Indexed: 02/02/2023] Open
Abstract
Minimal clinically important difference (MCID) can be defined as the smallest change or difference in an outcome measure that is perceived as beneficial and would lead to a change in the patient's medical management. The aim of the current expert consensus report is to provide a “state-of-the-art” review of the currently available literature evidence about MCID for end-points to monitor asthma control, in order to facilitate optimal disease management and identify unmet needs in the field to guide future research. A series of MCID cut-offs are currently available in literature and validated among populations of asthmatic patients, with most of the evidence focusing on outcomes as patient reported outcomes, lung function and exercise tolerance. On the contrary, only scant and partial data are available for inflammatory biomarkers. These clearly represent the most interesting target for future development in diagnosis and clinical management of asthma, particularly in view of the several biologic drugs in the pipeline, for which regulatory agencies will soon require personalised proof of efficacy and treatment response predictors. Minimal clinically important difference (MCID) cut-offs in asthma are validated for patient reported outcomes and lung function, but not for inflammatory biomarkers. MCID represents a key target for future development in asthma management. http://bit.ly/33hcWIe
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Affiliation(s)
- Matteo Bonini
- National Heart and Lung Institute, Royal Brompton Hospital & Imperial College London, London, UK.,UOC Pneumologia, Istituto di Medicina Interna, F. Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marcello Di Paolo
- National Heart and Lung Institute, Royal Brompton Hospital & Imperial College London, London, UK
| | - Diego Bagnasco
- Allergy and Respiratory diseases, University of Genoa, Dept of Internal Medicine (DiMI), Ospedale Policlinico San Martino, Genoa, Italy
| | - Ilaria Baiardini
- Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Fulvio Braido
- Allergy and Respiratory diseases, University of Genoa, Dept of Internal Medicine (DiMI), Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Caminati
- Dept of Medicine, University of Verona, Verona, Italy.,Asthma Center and Allergy Unit, Verona University Hospital, Verona, Italy
| | - Elisiana Carpagnano
- Division of Respiratory Diseases, Dept of Medical and Surgical Sciences, University of Foggia, Italy
| | - Marco Contoli
- Section of Internal and Cardiorespiratory Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Angelo Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation - Dept of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Stefano Del Giacco
- Dept of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy - Humanitas Research Hospital, Rozzano, Italy
| | - Carlo Lombardi
- Departmental Unit of Pneumology & Allergology, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ilaria Menichini
- Dept of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Science, "Sapienza" University, Rome, Italy
| | | | - Nicola Scichilone
- AOUP Policlinico Universitario, DIBIMIS, Università di Palermo, Palermo, Italy
| | - Gianenrico Senna
- Dept of Medicine, University of Verona, Verona, Italy.,Asthma Center and Allergy Unit, Verona University Hospital, Verona, Italy
| | - Giorgio W Canonica
- Personalized Medicine, Asthma and Allergy - Humanitas Research Hospital, Rozzano, Italy
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13
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Ciprandi G, Marseglia GL, Ricciardolo FLM, Tosca MA. Pragmatic Markers in the Management of Asthma: A Real-World-Based Approach. CHILDREN-BASEL 2020; 7:children7050048. [PMID: 32443418 PMCID: PMC7278574 DOI: 10.3390/children7050048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022]
Abstract
Bronchial hyperreactivity, reversible airflow limitation and chronic airway inflammation characterize asthma pathophysiology. Personalized medicine, i.e., a tailored management approach, is appropriate for asthma management and is based on the identification of peculiar phenotypes and endotypes. Biomarkers are necessary for defining phenotypes and endotypes. Several biomarkers have been described in asthma, but most of them are experimental and/or not commonly available. The current paper will, therefore, present pragmatic biomarkers useful for asthma management that are available in daily clinical practice. In this regard, eosinophil assessment and serum allergen-specific IgE assay are the most reliable biomarkers. Lung function, mainly concerning forced expiratory flow at 25-755 of vital capacity (FEF25-75), and nasal cytology may be envisaged as ancillary biomarkers in asthma management. In conclusion, biomarkers have clinical relevance in asthma concerning both the endotype definition and the personalization of the therapy.
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Affiliation(s)
- Giorgio Ciprandi
- Allergy Clinic, Casa di Cura Villa Montallegro, Via P. Boselli 5, 16146 Genoa, Italy
- Correspondence:
| | - Gian Luigi Marseglia
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy;
| | - Fabio Luigi Massimo Ricciardolo
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy;
| | - Maria Angela Tosca
- Pediatric Allergy Center, Istituto Giannina Gaslini, 16100 Genoa, Italy;
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14
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Ngo-Minh X, Tang-Thi-Thao T, Doan-Thi-Quynh N, Craig TJ, Duong-Quy S. Study of the role of exhaled nitric oxide (NO) in predicting controlled or uncontrolled asthma in asthmatic children. Multidiscip Respir Med 2020; 15:656. [PMID: 32431811 PMCID: PMC7232017 DOI: 10.4081/mrm.2020.656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/04/2020] [Indexed: 12/15/2022] Open
Abstract
Background Exhaled nitric oxide (NO), especially fractional concentration of exhaled NO (FENO) has been used to predict the responsiveness to inhaled corticosteroid (ICS) in children with asthma. However, the use of exhaled NO for predicting asthma control in children is still controversial. Methods This was a perspective observational study. Asthmatic children who were naïve to inhaled corticosteroid (ICS) were included in the present study. The measurements of FENO and CANO (concentration of NO in the gas phase of the alveolar), spirometry, blood eosinophil counts (BEC), and total IgE levels were done for each asthmatic child. All study subjects started proper asthma treatment after the enrollment. Results Ninety three asthmatic children (9±3 years) with moderate (63.4%) to severe (36.6%) asthma were included and finished the 3-month study. The levels of FENO and CANO at inclusion were 37±11 ppb and 5.8±1.4 ppb, respectively; the mean of BEC was 617±258 cells/μL; the level of total IgE was 1563±576 UI/mL; 89% of subjects were positive for at least one respiratory allergen. The percentage of severe asthma was reduced significantly after 3 months (P<0.001). Well controlled asthma subjects at 3 months had higher levels of FENO and lower levels of CANO at inclusion (P<0.05 and P<0.05). FENO<20 ppb or CANO>5ppb had a risk of uncontrolled asthma at 3 months (OR: 1.7, CI 95% [(0.8) - (3.3)], P<0.05; OR: 1.9, CI 95% [(0.9) - (2.7)], P<0.05; respectively). FENO>35 ppb at inclusion had a positive predictive value for asthma control at 3 months (OR: 3.5, CI 95% [2.2-5.9], P<0.01). Conclusions Exhaled NO is a biomarker of asthma which may have a potential role to predict the control of asthma in short-term follow up in asthmatic children.
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Affiliation(s)
- Xuan Ngo-Minh
- Department of Medicine, Pham Ngoc Thach University, Ho Chi Minh city, Vietnam
| | | | | | - Timothy J Craig
- Division of Immuno-Allergology, Hershey Medical Center, Penn State Medical College, Hershey, PA, USA
| | - Sy Duong-Quy
- Department of Medicine, Pham Ngoc Thach University, Ho Chi Minh city, Vietnam.,Clinical Research Center, Lam Dong Medical College, Dalat city, Vietnam.,Division of Immuno-Allergology, Hershey Medical Center, Penn State Medical College, Hershey, PA, USA
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15
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Combination of Fractional Exhaled Nitric Oxide (FeNO) Level and Asthma Control Test (ATC) in Detecting GINA-Defined Asthma Control in Treated Asthmatic Patients in Vietnam. Can Respir J 2020; 2020:5735128. [PMID: 32377282 PMCID: PMC7196968 DOI: 10.1155/2020/5735128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 11/25/2022] Open
Abstract
Background FeNO has been used as a marker for Th2-mediated airway inflammation in asthma. There is evidence which recommends the use of this biomarker in asthma management. Little is known about whether the FeNO test alone or in combination with the ACT score can reflect asthma control in Vietnamese patients. Materials and Methods A cross-sectional study was conducted in asthmatic patients (≥18 years old) recruited at the University Medical Center, Ho Chi Minh City, Vietnam from March 2016 to March 2017. Asthma control levels were assessed following the GINA 2017 guidelines, and FeNO was measured by a Niox Mino device. FeNO cut-offs predicting asthma control status were determined using the ROC curve analysis. The combination of FeNO and ACT was investigated in detecting well-controlled and uncontrolled asthma. The results of the study are as follows: 278 patients with 68% females, mean age of 44 years, and mean asthma duration of 10 years were analyzed. All patients were treated following step 2 to 4 of GINA guidelines. Mean (SD) FeNO was 30.6 (24) ppb. Patients with uncontrolled (16%), partly controlled (29%), and well-controlled asthma (55%) had a median (IQR) FeNO of 50.0 (74), 25.0 (23), and 21.0 (22.3) ppb, respectively, and the mean of FeNO in the uncontrolled group was significantly higher than that in other groups (p < 0.001). The area under the ROC curve (AUC) for FeNO detecting uncontrolled asthma was 0.730 with an optimal cut-off point of FeNO > 50 ppb, and this AUC increased to 0.89 when combining FeNO and ACT. The AUC for FeNO detecting well-controlled asthma was 0.601 with an optimal cut-off point of FeNO <25 ppb and this AUC increased to 0.78 if combining FeNO and ACT. Conclusions FeNO can predict asthma control status with an estimated cut-off point of <25 ppb for well-controlled and >50 ppb for uncontrolled asthma. The combination of FeNO and ACT provides better information regarding asthma control than FeNO alone, and this combination is useful to predict asthma control statuses in asthmatic patients in Viet Nam.
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16
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Malinovschi A. Limited use of biomarker-guided therapy in mild asthma. THE LANCET RESPIRATORY MEDICINE 2020; 8:648-649. [PMID: 32171066 DOI: 10.1016/s2213-2600(20)30074-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 02/10/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala 75185, Sweden.
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17
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Heffler E, Carpagnano GE, Favero E, Guida G, Maniscalco M, Motta A, Paoletti G, Rolla G, Baraldi E, Pezzella V, Piacentini G, Nardini S. Fractional Exhaled Nitric Oxide (FENO) in the management of asthma: a position paper of the Italian Respiratory Society (SIP/IRS) and Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC). Multidiscip Respir Med 2020; 15:36. [PMID: 32269772 PMCID: PMC7137762 DOI: 10.4081/mrm.2020.36] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023] Open
Abstract
Asthma prevalence in Italy is on the rise and is estimated to be over 6% of the general population. The diagnosis of asthma can be challenging and elusive, especially in children and the last two decades has brought evidences that asthma is not a single disease but consists of various phenotypes. Symptoms can be underestimated by the patient or underreported to the clinician and physical signs can be scanty. Usual objective measures, like spirometry, are necessary but sometimes not significant. Despite proper treatment, asthma can be a very severe condition (even leading to death), however new drugs have recently become available which can be very effective in its control. Since asthma is currently thought to be caused by inflammation, a direct measure of the latter can be of paramount importance. For this purpose, the measurement of Fractional Exhaled Nitric Oxide (FENO) has been used since the early years of the current century as a non-invasive, easy-to-assess tool useful for diagnosing and managing asthma. This SIP-IRS/SIAAIC Position Paper is a narrative review which summarizes the evidence behind the usefulness of FENO in the diagnosis, management and phenotypization of asthma.
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Affiliation(s)
- Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanna Elisiana Carpagnano
- Department of Medical and Surgical Sciences, University of Foggia; Section of Respiratory Diseases, Hospital d'Avanzo, Foggia
| | - Elisabetta Favero
- Department of Medicine-DIMED, Immunological and Respiratory Rare Disease, Allergologic Clinic Ca' Foncello Hospital, Treviso
| | - Giuseppe Guida
- Allergy and Pneumology Unit, A.O. S. Croce e Carle, Cuneo
| | - Mauro Maniscalco
- Respiratory Rehabilitation Unit, ICS Maugeri, Institute of Telese Terme IRCCS
| | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, Pozzuoli (NA)
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanni Rolla
- Allergy and Clinical Immunology, University of Turin and A.O. Mauriziano, Turin
| | - Eugenio Baraldi
- Department of Woman's and Child's Health, University Hospital of Padua
| | - Vincenza Pezzella
- Department of Woman, Child and of General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples
| | - Giorgio Piacentini
- Paediatric Section, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona
| | - Stefano Nardini
- Italian Respiratory Society-Società Italiana di Pneumologia, Milan, Italy
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18
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Asano K, Sagara H, Ichinose M, Hirata M, Nakajima A, Ortega H, Tohda Y. A Phase 2a Study of DP 2 Antagonist GB001 for Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:1275-1283.e1. [PMID: 31778823 DOI: 10.1016/j.jaip.2019.11.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/30/2019] [Accepted: 11/02/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND GB001, a DP2 antagonist, may inhibit recruitment and activation of inflammatory cells in patients with asthma, consequently reducing airway inflammation. OBJECTIVE Explore the efficacy and safety of GB001 in adults with mild to moderate asthma. METHODS During a 4-week run-in period, adult patients with asthma (N = 158) received medium-dose inhaled corticosteroid and placebo and were then randomized to treatment once daily with GB001 5 mg, 20 mg, or placebo for 16 weeks or until asthma worsening/exacerbation. Patients were tapered to and then discontinued from low-dose inhaled corticosteroid at randomization and at 4 weeks postrandomization, respectively. Primary end point was change in morning peak expiratory flow (AM PEF); secondary end points included measures of asthma control. Safety was also assessed. RESULTS Baseline characteristics were similar among GB001 5 mg, 20 mg, and placebo groups. Changes in AM PEF in 5 mg and 20 mg groups versus placebo showed mean differences (95% CI) of 15.2 (3.1-27.4) L/min (P = .02) and 13.7 (1.5-25.8) L/min (P = .03), respectively. The changes in forced expiratory volume in 1 second of 55 mL and 32 mL, respectively, were not significant. There was a significant difference between GB001 20 mg and placebo for the secondary end points of time to asthma worsening/exacerbation (hazard ratio, 0.29), 5-item Asthma Control Questionnaire score (-0.60 point), the percentage of days without asthma symptoms (26%), and the percentage of rescue-free days (22%). Patients with baseline eosinophil levels greater than or equal to 300/μL had larger differences between GB001 20 mg and placebo for changes in AM PEF. Similar effects were seen in a post hoc analysis for time to worsening/exacerbations and 5-item Asthma Control Questionnaire score. The most common nonserious adverse event in the GB001 groups compared with the placebo group was nasopharyngitis. CONCLUSIONS GB001 was well tolerated and although not associated with clinically meaningful changes in lung function, improvements in asthma worsening/exacerbations and markers of asthma control were demonstrated. In addition, greater treatment effects were observed in patients with high baseline blood eosinophils. Further studies are needed to confirm these findings in the context of standard of care treatment.
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Affiliation(s)
- Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Hironori Sagara
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | | | - Hector Ortega
- Clinical Development, Gossamer Bio, Inc, San Diego, Calif
| | - Yuji Tohda
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
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19
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Garcia-Marcos L, Edwards J, Kennington E, Aurora P, Baraldi E, Carraro S, Gappa M, Louis R, Moreno-Galdo A, Peroni DG, Pijnenburg M, Priftis KN, Sanchez-Solis M, Schuster A, Walker S. Priorities for future research into asthma diagnostic tools: A PAN-EU consensus exercise from the European asthma research innovation partnership (EARIP). Clin Exp Allergy 2019; 48:104-120. [PMID: 29290104 DOI: 10.1111/cea.13080] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The diagnosis of asthma is currently based on clinical history, physical examination and lung function, and to date, there are no accurate objective tests either to confirm the diagnosis or to discriminate between different types of asthma. This consensus exercise reviews the state of the art in asthma diagnosis to identify opportunities for future investment based on the likelihood of their successful development, potential for widespread adoption and their perceived impact on asthma patients. Using a two-stage e-Delphi process and a summarizing workshop, a group of European asthma experts including health professionals, researchers, people with asthma and industry representatives ranked the potential impact of research investment in each technique or tool for asthma diagnosis and monitoring. After a systematic review of the literature, 21 statements were extracted and were subject of the two-stage Delphi process. Eleven statements were scored 3 or more and were further discussed and ranked in a face-to-face workshop. The three most important diagnostic/predictive tools ranked were as follows: "New biological markers of asthma (eg genomics, proteomics and metabolomics) as a tool for diagnosis and/or monitoring," "Prediction of future asthma in preschool children with reasonable accuracy" and "Tools to measure volatile organic compounds (VOCs) in exhaled breath."
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Affiliation(s)
- L Garcia-Marcos
- Respiratory and Allergy Units, Arrixaca University Children's Hospital, University of Murcia & IMIB Research Institute, Murcia, Spain
| | | | | | - P Aurora
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital for Children, London, UK.,Department of Respiratory, Critical Care and Anaesthesia Unit, University College London (UCL) Great Ormond Street Institute of Child Health, London, UK
| | - E Baraldi
- Women's and Children's Health Department, University of Padua, Padova, Italy
| | - S Carraro
- Women's and Children's Health Department, University of Padua, Padova, Italy
| | - M Gappa
- Children's Hospital & Research Institute, Marienhospital Wesel, Wesel, Germany
| | - R Louis
- Department of Respiratory Medicine, University of Liege, Liege, Belgium
| | - A Moreno-Galdo
- Paediatric Pulmonology Unit, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - D G Peroni
- Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Pisa, Italy
| | - M Pijnenburg
- Paediatrics/Paediatric Respiratory Medicine, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K N Priftis
- Department of Paediatrics, Athens University Medical School, Attikon General Hospital, Athens, Greece
| | - M Sanchez-Solis
- Respiratory and Allergy Units, Arrixaca University Children's Hospital, University of Murcia & IMIB Research Institute, Murcia, Spain
| | - A Schuster
- Department of Paediatrics, University Hospital, Düsseldorf, Germany
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20
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Rachel M, Biesiadecki M, Aebisher D, Galiniak S. Exhaled nitric oxide in pediatric patients with respiratory disease. J Breath Res 2019; 13:046007. [PMID: 31234165 DOI: 10.1088/1752-7163/ab2c3d] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Measurement of nitric oxide (NO) levels in exhaled air from the upper and lower airways is currently used as a non-invasive marker of inflammation in respiratory diseases. Assessment of NO exhaled from the lower air respiratory tract is considered to be a quick method for confirmation and control of asthma in patients as well as an estimation of treatment efficiency. The main aim of this study was to determine differences between levels of exhaled nitric oxide (fractional exhaled NO; FeNO) in patients with respiratory disease as measured by an electrochemical analyzer. Measurements were taken in 352 pediatric patients aged 4-17 with cystic fibrosis (CF) (n = 43), asthma (n = 69), allergic rhinitis (AR) (n = 70), asthma and AR (n = 128) and non-diseased children (n = 42) recruited from the Allergology Outpatient Department, Provincial Hospital No 2, Rzeszów. The second objective of this study was to assess any correlations between FeNO and clinical parameters of patients. The level of FeNO in patients with CF was normal when compared with control subjects (10.8 ± 2.9 versus 11.4 ± 6 ppb). We found significantly higher FeNO in patients with asthma (26.6 ± 15.3 ppb, p < 0.001), AR (18.4 ± 9.6 ppb, p < 0.01) as well as in patients with both asthma and AR (43.3 ± 31.1 ppb, p < 0.001) when compared to healthy children. Statistical analysis revealed a positive correlation between FeNO and age, height and weight of control subjects, and height in children with AR. FeNO was independent of sex, BMI, spirometry and blood results as well as the type of residence in control children and subjects with CF, asthma, AR and combined asthma and AR. In conclusion, we found normal levels of FeNO in children with CF and elevated levels in patients with asthma, AR and combined asthma and AR as compared to control subjects. Due to conflicting data, there is still a need for additional research, especially related to regarding factors that affect FeNO levels in respiratory disease.
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Affiliation(s)
- Marta Rachel
- Faculty of Medicine, University of Rzeszów, Warzywna 1, 35-315 Rzeszów, Poland. Allergology Outpatient Department, Provincial Hospital No 2, Lwowska 60, 35-301 Rzeszów, Poland
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21
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Chang DV, Teper A, Balinotti J, Castro Simonelli C, Garcia-Bournissen F, Kofman C. Exhaled nitric oxide predicts loss of asthma control in children after inhaled corticosteroids withdrawal. Pediatr Pulmonol 2019; 54:537-543. [PMID: 30688035 DOI: 10.1002/ppul.24268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 01/02/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Exhaled nitric oxide (eNO) has been proposed for monitoring airway inflammation, diagnosis, and prediction of steroid responsiveness in asthma. However, its utility after elective suspension of asthma medication is still unclear. We aimed to determine the association between eNO values and the subsequent loss of asthma control (LAC) in asymptomatic asthmatic children after inhaled corticosteroids (ICS) withdrawal. METHODS We conducted a prospective observational cohort study. Forty-two children (23 boys), mean age 11 years, with clinically controlled asthma, according to GINA guidelines, and receiving low-dose of ICS (budesonide 200 μg/day or equivalent) were included immediately after the withdrawal of ICS. eNO, Asthma Control Test (ACT) and spirometry were monthly assessed, during 54 weeks or until the presence of at least one of the following criteria of LAC: 1) asthma exacerbation, 2) obstructive spirometric pattern, 3) ACT ≤ 19. RESULTS eNO baseline geometric mean (eNOb ), measured 4 weeks after discontinuation of ICS, was 23.7 ppb (SD: 1.16). An eNOb cutoff point of 21.8 ppb was determined to better discriminate between high and low eNO groups. Twenty-five subjects (71.4%) had LAC. High eNOb was associated to LAC (OR: 9.01; 95CI: 1.10-74.26). In addition, LAC occurred earlier in high eNOb than in low eNOb patients (8 vs 28 weeks, respectively; P = 0.017). CONCLUSIONS Our findings suggest that eNO predicts loss of asthma control and may contribute for clinical follow up decisions during childhood asthma after ICS withdrawal.
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Affiliation(s)
- Daniel V Chang
- Centro Respiratorio Dr. Alberto Álvarez, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Alejandro Teper
- Centro Respiratorio Dr. Alberto Álvarez, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Juan Balinotti
- Centro Respiratorio Dr. Alberto Álvarez, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | | | | | - Carlos Kofman
- Centro Respiratorio Dr. Alberto Álvarez, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
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22
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Azaldegi G, Korta J, Sardón O, Corcuera P, Pérez-Yarza EG. Small Airway Dysfunction in Children With Controlled Asthma. Arch Bronconeumol 2019; 55:208-213. [PMID: 30770124 DOI: 10.1016/j.arbres.2018.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/02/2018] [Accepted: 08/29/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Asthma is characterized by chronic inflammation of the central and distal airways. The aim of this study was to assess the small airway (SA) of children with moderate-severe asthma with normal FEV1. METHODS This was an open-label, prospective, observational, cross-sectional study with consecutive inclusion of patients with moderate-severe asthma, receiving standard clinical treatment, with normal baseline FEV1. We determined multiflow FEno (CAno), oscillatory resistance and reactance (R5-R20, X5), forced spirometry (FEV1, FEF25-75), total body plethysmography (RV/TLC) and bronchodilation test. SA involvement was defined as: CAno>4.5 ppb, R5-R20>0.147kPa/L/s, X5<-0.18kPa/L, FEF25-75<-1.65 z-score, RV/TLC>33%. Poor asthma control was defined as ≤ 19 points on the ACT questionnaire or ≤ 20 on the c-ACT. RESULTS In a cohort of 100 cases, 76 had moderate asthma and 24 had severe asthma; 71 children were classified as poorly controlled and 29 were well-controlled. In total, 77.78% of the group with all the correct determinations (n=72) showed ≥ 1 altered SA parameter and 48.61% ≥ 2 parameters. There were no differences between well-controlled or poorly controlled cases. CONCLUSIONS Children with moderate-severe asthma, with normal FEV1, show a phenotype of dysfunctional SA. In our series, the evaluation of SA using the techniques described above did not provide information on disease control.
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Affiliation(s)
- Garazi Azaldegi
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, España
| | - Javier Korta
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, España; Departamento de Pediatría, Universidad del País Vasco (UPV/EHU), San Sebastián, España
| | - Olaia Sardón
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, España; Departamento de Pediatría, Universidad del País Vasco (UPV/EHU), San Sebastián, España
| | - Paula Corcuera
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, España
| | - Eduardo G Pérez-Yarza
- Sección de Neumología Infantil, Hospital Universitario Donostia, San Sebastián, España; Departamento de Pediatría, Universidad del País Vasco (UPV/EHU), San Sebastián, España; Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), San Sebastián, España.
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Duong-Quy S, Tran Van H, Vo Thi Kim A, Pham Huy Q, Craig TJ. Clinical and Functional Characteristics of Subjects with Asthma, COPD, and Asthma-COPD Overlap: A Multicentre Study in Vietnam. Can Respir J 2018; 2018:1732946. [PMID: 29808101 PMCID: PMC5901814 DOI: 10.1155/2018/1732946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 02/17/2018] [Accepted: 02/22/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Subjects with asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) share common features of patients with asthma and COPD. Our study was planned to describe the clinical and functional features of subjects with ACO compared to asthma and COPD patients. Subjects and Methods Study subjects who met the inclusion criteria were classified into three different groups: asthma, COPD, and ACO groups. All study subjects underwent clinical examination and biological and functional testing. They were then followed for 6 months to evaluate the response to conventional treatment. Results From March 2015 to March 2017, 76 asthmatic (mean age: 41 ± 22 years), 74 COPD (59 ± 13 years), and 59 ACO (52 ± 14 years) subjects were included. The percentage of subjects with dyspnea on excretion in the ACO group was higher than that in asthma and COPD groups (P < 0.001 and P < 0.05, resp.). Subjects with COPD and ACO had significant airflow limitation (FEV1) compared to asthma (64 ± 17% and 54 ± 14% versus 80 ± 22%; P < 0.01 and P < 0.01, resp.). The levels of FENO in subjects with asthma and ACO were significantly higher than those in subjects with COPD (46 ± 28 ppb and 34 ± 12 ppb versus 15 ± 8 ppb; P < 0.001 and P < 0.001, resp.). VO2 max and 6MWD were improved in study subjects after 6 months of treatment. Increased CANO and AHI > 15/hour had a significant probability of risk for ACO (OR = 33.2, P < 0.001, and OR = 3.4, P < 0.05, resp.). Conclusion Subjects with ACO share the common clinical and functional characteristics of asthma and COPD but are more likely to have sleep apnea. The majority of patients with ACO have a favourable response to combined treatment.
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Affiliation(s)
- Sy Duong-Quy
- Bio-Medical Research Center, Lam Dong Medical College, Dalat, Vietnam
- Division of Pulmonary, Allergy and Critical Care Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Huong Tran Van
- Department of Health Science, Thang Long University, Hanoi, Vietnam
| | | | - Quyen Pham Huy
- Department of Clinical Immuno-Allergology, Hai Phong University, Haiphong, Vietnam
| | - Timothy J. Craig
- Division of Pulmonary, Allergy and Critical Care Medicine, Penn State College of Medicine, Hershey, PA, USA
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Abstract
The history of nitric oxide (NO) in the respiratory field dates back to the beginning of the 1990s with the pioneering study by Lars Gustafsson et al describing the presence of endogenous NO in the exhaled breath of human beings. Soon after, independent studies showed that exhaled NO concentrations (FENO) is higher in asthmatics than in normal subjects. Not all asthmatics demonstrate a high FENO, reflecting the heterogeneity of asthma. High values of FENO are associated with over-expression of corticosteroid-sensitive iNOS isoform and allergic/eosinophilic inflammation. A major feature of elevated FENO in asthma is the prediction of inhaled corticosteroid (ICS) response, and FENO more than 50 ppb in adults is a strong indicator of likely ICS sensitivity. In addition, FENO values are elevated in asthma when asthma control deteriorates, identifying patients at risk of exacerbations, and, on the other hand, FENO reductions during ICS therapy precede improvement in respiratory symptoms and lung function, suggesting that FENO is a sensitive predictor of loss of asthma control. FENO also predicts the response to biological therapy (anti-IgE, -IL-5 and -IL-13 antibodies) in severe asthma but, interestingly, FENO values fall only after treatment with anti-IL-13 and -IL-4/IL-13 receptor antibodies. The use of FENO as a Type-2 inflammatory biomarker, in constellation with other Type-2 markers, could help to determine who might benefit from ICS and biological treatment. It remains to find out more precise cut-off values of FENO to identify potential ICS responders in specific phenotypes.
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Michils A, Haccuria A, Michiels S, Van Muylem A. Airway calibre variation is a major determinant of exhaled nitric oxide's ability to capture asthma control. Eur Respir J 2017; 50:50/2/1700392. [PMID: 28818874 DOI: 10.1183/13993003.00392-2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 05/17/2017] [Indexed: 11/05/2022]
Abstract
Changes in airway calibre have the potential to modify exhaled nitric oxide fraction (FENO) values and could hamper how FENO captures changes in asthma control. Here, our objective was to assess whether forced expiratory volume in 1 s (FEV1) variations alter the ability of FENO to reflect asthma control.FENO, asthma control (Asthma Control Questionnaire (ACQ)) and FEV1 were measured at least two times in 527 patients during 1819 pairs of visits. Determinants of FENO-ACQ discordance probability were evaluated through a logistic regression analysis. The effectiveness of FENO at capturing either asthma control worsening or improvement between two visits was then assessed by undertaking a stratified receiver operating characteristic curves analysis.When FEV1 and FENO change in the same direction, the odds of FENO-ACQ being discordant are multiplied by 3 (p<0.001). The area under the curve values were 0.765 (95% CI 0.713-0.805) (improvement; p<0.001) and 0.769 (95% 0.706-0.810) (worsening; p<0.001) or 0.590 (95% 0.531-0.653) (improvement; p=0.001) and 0.498 (95% 0.416-0.567) (worsening; p=0.482) when FEV1 and FENO changed in the opposite or same direction, respectively.The manner in which FENO and FEV1 vary concomitantly when asthma control changes determines the ability of FENO to capture this change: parallel or opposite changes in FEV1 and FENO either decrease or increase this ability to capture asthma control changes.
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Affiliation(s)
- Alain Michils
- Chest Dept, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Amaryllis Haccuria
- Chest Dept, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Sebastien Michiels
- Chest Dept, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Alain Van Muylem
- Chest Dept, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
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Lugogo N, Green CL, Agada N, Zhang S, Meghdadpour S, Zhou R, Yang S, Anstrom KJ, Israel E, Martin R, Lemanske RF, Boushey H, Lazarus SC, Wasserman SI, Castro M, Calhoun W, Peters SP, DiMango E, Chinchilli V, Kunselman S, King TS, Icitovic N, Kraft M. Obesity's effect on asthma extends to diagnostic criteria. J Allergy Clin Immunol 2017. [PMID: 28624608 DOI: 10.1016/j.jaci.2017.04.047] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The use of inflammatory biomarkers to delineate the type of lung inflammation present in asthmatic subjects is increasingly common. However, the effect of obesity on these markers is unknown. OBJECTIVES We aimed to determine the effect of obesity on conventional markers of inflammation in asthmatic subjects. METHODS We performed secondary analysis of data from 652 subjects previously enrolled in 2 Asthma Clinical Research Network trials. We performed linear correlations between biomarkers and logistic regression analysis to determine the predictive value of IgE levels, blood eosinophil counts, and fraction of exhaled nitric oxide values in relationship to sputum eosinophil counts (>2%), as well as to determine whether cut points existed that would maximize the sensitivity and specificity for predicting sputum eosinophilia in the 3 weight groups. RESULTS Overall, statistically significant but relatively weak correlations were observed among all 4 markers of inflammation. Within obese subjects, the only significant correlation found was between IgE levels and blood eosinophil counts (r = 0.33, P < .001); furthermore, all other correlations between inflammatory markers were approximately 0, including correlations with sputum eosinophil counts. In addition, the predictive value of each biomarker alone or in combination was poor in obese subjects. In fact, in obese subjects none of the biomarkers of inflammation significantly predicted the presence of high sputum eosinophil counts. Obese asthmatic subjects have lower cut points for IgE levels (268 IU), fraction of exhaled nitric oxide values (14.5 ppb), and blood eosinophil counts (96 cells/μL) than all other groups. CONCLUSIONS In obese asthmatic subjects conventional biomarkers of inflammation are poorly predictive of eosinophilic airway inflammation. As such, biomarkers currently used to delineate eosinophilic inflammation in asthmatic subjects should be approached with caution in these subjects.
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Affiliation(s)
- Njira Lugogo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Mich.
| | - Cynthia L Green
- Department of Biostatistics and BioInformatics, Duke University, Durham, NC
| | - Noah Agada
- Division of Pediatric Allergy and Immunology, Department of Pediatric Pulmonology, Riley Children's Hospital, and Eli Lilly and Company, Indianapolis, Ind
| | - Siyi Zhang
- Department of Biostatistics and BioInformatics, Duke University, Durham, NC
| | - Susanne Meghdadpour
- Department of Pediatrics, Division of Allergy, Immunology, Pulmonary and Sleep Medicine, Duke University, Durham, NC
| | - Run Zhou
- Department of Biostatistics and BioInformatics, Duke University, Durham, NC
| | - Siyun Yang
- Department of Biostatistics and BioInformatics, Duke University, Durham, NC
| | - Kevin J Anstrom
- Department of Biostatistics and BioInformatics, Duke University, Durham, NC
| | - Elliot Israel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Richard Martin
- Department of Medicine, National Jewish Health and University of Colorado Denver, Denver, Colo
| | - Robert F Lemanske
- Department of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Homer Boushey
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Calif
| | - Stephen C Lazarus
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Calif
| | - Stephen I Wasserman
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of California, San Diego, Calif
| | - Mario Castro
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, Saint Louis, Mo
| | - William Calhoun
- Division of Pulmonary, Critical Care, and Sleep and Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Tex
| | - Stephen P Peters
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University, Winston-Salem, NC
| | - Emily DiMango
- Department of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Columbia University, New York, NY
| | - Vernon Chinchilli
- Department of Public Health Services, Penn State College of Medicine, Division of Biostatistics, Hershey, Pa
| | - Susan Kunselman
- Department of Public Health Services, Penn State College of Medicine, Division of Biostatistics, Hershey, Pa
| | - Tonya S King
- Department of Public Health Services, Penn State College of Medicine, Division of Biostatistics, Hershey, Pa
| | - Nikolina Icitovic
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Monica Kraft
- Department of Medicine, University of Arizona, Tucson, Ariz
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Demarche SF, Schleich FN, Paulus VA, Henket MA, Van Hees TJ, Louis RE. Asthma Control and Sputum Eosinophils: A Longitudinal Study in Daily Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1335-1343.e5. [PMID: 28389300 DOI: 10.1016/j.jaip.2017.01.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/16/2016] [Accepted: 01/31/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Longitudinal trials have suggested that asthma control may be influenced by fluctuations in eosinophilic inflammation. This association has however never been confirmed in daily practice. OBJECTIVE To investigate the relationship between asthma control and sputum eosinophils in clinical practice. METHODS A retrospective longitudinal study was conducted on 187 patients with asthma with at least 2 successful sputum inductions at our Asthma Clinic. Linear mixed models were used to assess the relationship between asthma control and individual changes in sputum eosinophils. Receiver-operating characteristic curves were constructed to define minimal important differences (MIDs) of sputum eosinophils associated with a change of at least 0.5 in Asthma Control Questionnaire (ACQ) score. Then, a validation cohort of 79 patients with asthma was recruited to reassess this relationship and the accuracy of the MID values. RESULTS A multivariate analysis showed that asthma control was independently associated with individual fluctuations in sputum eosinophil count (P < .001). In patients with intermittent/persistently eosinophilic asthma, we calculated a minimal important decrease of 4.3% in the percentage of sputum eosinophils (area under the curve [AUC], 0.69; P < .001) or 3.4-fold (AUC, 0.65; P = .003) for a significant improvement in asthma control and a minimal important increase of 3.5% (AUC, 0.67; P = .004) or 1.8-fold (AUC, 0.63; P = .02) for a significant worsening in asthma control. The association between asthma control and sputum eosinophils and the accuracy of the MIDs of sputum eosinophils were confirmed in the validation cohort. CONCLUSIONS At the individual level, asthma control was associated with fluctuations in sputum eosinophil count over time.
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Affiliation(s)
- Sophie F Demarche
- Department of Respiratory Medicine, GIGA I(3) Research Group, University of Liege, Liege, Belgium; Department of Clinical Pharmacy, Center for Interdisciplinary Research on Medicines, University of Liege, Liege, Belgium.
| | - Florence N Schleich
- Department of Respiratory Medicine, GIGA I(3) Research Group, University of Liege, Liege, Belgium
| | - Virginie A Paulus
- Department of Respiratory Medicine, GIGA I(3) Research Group, University of Liege, Liege, Belgium
| | - Monique A Henket
- Department of Respiratory Medicine, GIGA I(3) Research Group, University of Liege, Liege, Belgium
| | - Thierry J Van Hees
- Department of Clinical Pharmacy, Center for Interdisciplinary Research on Medicines, University of Liege, Liege, Belgium
| | - Renaud E Louis
- Department of Respiratory Medicine, GIGA I(3) Research Group, University of Liege, Liege, Belgium
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Fractional Exhaled Nitric Oxide for Identification of Uncontrolled Asthma in Children. Indian Pediatr 2017; 53:307-10. [PMID: 27156543 DOI: 10.1007/s13312-016-0842-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine the utility of Fractional Exhaled Nitric Oxide (FENO) in the identification of uncontrolled asthma in children on therapy, and to identify its cut-off value for determining asthma control. METHODS 207 children (age 5-15 y) with physician-diagnosed asthma on therapy with at least 12 months follow up were enrolled. Spirometry and FENO measurements were performed. Asthma control was assessed as per GINA guidelines. Sensitivity and specificity of various cut-off values of FENO (15 ppb, 20 ppb, 25 ppb, 30 ppb) for identification of status of control of asthma were calculated. RESULTS 156 (75%) children had uncontrolled or partly controlled asthma and 51 children were assessed to have controlled asthma. Median (IQR) FENO in children with controlled and uncontrolled asthma was 16 (11-23) ppb and 13 (11-25) ppb, respectively (P=0.26). No FENO cut-off had a reasonable combination of sensitivity and specificity to discriminate between controlled and uncontrolled asthma. CONCLUSIONS FENO, in itself, does not have good discriminatory value in assessment of controlled and uncontrolled asthma in children on asthma therapy.
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Högman M, Lehtimäki L, Dinh-Xuan AT. Utilising exhaled nitric oxide information to enhance diagnosis and therapy of respiratory disease - current evidence for clinical practice and proposals to improve the methodology. Expert Rev Respir Med 2017; 11:101-109. [PMID: 28076986 DOI: 10.1080/17476348.2017.1281746] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION A non-invasive tool to diagnose respiratory diseases and to follow treatment has long been looked-for. Exhaled nitric oxide (NO) is a promising marker of inflammation in asthma but nearly 25-years of research has shown that it works in only certain endotypes of asthma. The modelling of NO dynamics of the lung can give more information than a single FENO value. Areas covered: The estimation of the NO production in the conducting airways and in the gas exchange area has given new insight of the NO production in diseases beyond asthma. In this article, we discuss the importance of methodology for NO measurement in the exhaled breath and the indication of applying this technique to detect respiratory disorders. This narrative review is an attempt to examine and discuss the physiological basis underlying exhaled NO measurements and the clinical evidence of the usefulness of this method in asthma and various other respiratory disorders. Expert commentary: Estimation of the NO parameters would aid in our understanding of the NO dynamics of the lung and thereby give more knowledge how to interpret the measured FENO value in clinical practice.
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Affiliation(s)
- Marieann Högman
- a Department of Medical Sciences, Lung- Allergy- and Sleep Research , Uppsala University , Uppsala , Sweden
| | - Lauri Lehtimäki
- b Allergy Centre , Tampere University Hospital , Tampere , Finland.,c Medical School , University of Tampere , Tampere , Finland
| | - Anh Tuan Dinh-Xuan
- d Department of Respiratory Physiology , Cochin Hospital & Paris Descartes University , Paris , France
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Silkoff PE, Laviolette M, Singh D, FitzGerald JM, Kelsen S, Backer V, Porsbjerg CM, Girodet PO, Berger P, Kline JN, Chupp G, Susulic VS, Barnathan ES, Baribaud F, Loza MJ, Lam S, Eich A, Ludwig-Sengpiel A, Leigh R, Dransfield M, Calhoun W, Hussaini A, Chanez P. Identification of airway mucosal type 2 inflammation by using clinical biomarkers in asthmatic patients. J Allergy Clin Immunol 2017; 140:710-719. [PMID: 28089872 DOI: 10.1016/j.jaci.2016.11.038] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 11/06/2016] [Accepted: 11/21/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Airways Disease Endotyping for Personalized Therapeutics (ADEPT) study profiled patients with mild, moderate, and severe asthma and nonatopic healthy control subjects. OBJECTIVE We explored this data set to define type 2 inflammation based on airway mucosal IL-13-driven gene expression and how this related to clinically accessible biomarkers. METHODS IL-13-driven gene expression was evaluated in several human cell lines. We then defined type 2 status in 25 healthy subjects, 28 patients with mild asthma, 29 patients with moderate asthma, and 26 patients with severe asthma based on airway mucosal expression of (1) CCL26 (the most differentially expressed gene), (2) periostin, or (3) a multigene IL-13 in vitro signature (IVS). Clinically accessible biomarkers included fraction of exhaled nitric oxide (Feno) values, blood eosinophil (bEOS) counts, serum CCL26 expression, and serum CCL17 expression. RESULTS Expression of airway mucosal CCL26, periostin, and IL-13-IVS all facilitated segregation of subjects into type 2-high and type 2-low asthmatic groups, but in the ADEPT study population CCL26 expression was optimal. All subjects with high airway mucosal CCL26 expression and moderate-to-severe asthma had Feno values (≥35 ppb) and/or high bEOS counts (≥300 cells/mm3) compared with a minority (36%) of subjects with low airway mucosal CCL26 expression. A combination of Feno values, bEOS counts, and serum CCL17 and CCL26 expression had 100% positive predictive value and 87% negative predictive value for airway mucosal CCL26-high status. Clinical variables did not differ between subjects with type 2-high and type 2-low status. Eosinophilic inflammation was associated with but not limited to airway mucosal type 2 gene expression. CONCLUSION A panel of clinical biomarkers accurately classified type 2 status based on airway mucosal CCL26, periostin, or IL-13-IVS gene expression. Use of Feno values, bEOS counts, and serum marker levels (eg, CCL26 and CCL17) in combination might allow patient selection for novel type 2 therapeutics.
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Affiliation(s)
| | - Michel Laviolette
- Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ), Quebec City, Quebec, Canada
| | - Dave Singh
- Centre for Respiratory Medicine and Allergy, University of Manchester, and the Medicines Evaluation Unit, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - J Mark FitzGerald
- Institute for Heart and Lung Health, Lung Centre, Gordon and Leslie Diamond Health Care Centre, Vancouver, British Columbia, Canada
| | - Steven Kelsen
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine, Philadelphia, Pa
| | - Vibeke Backer
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Celeste M Porsbjerg
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Pierre-Olivier Girodet
- Université Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Patrick Berger
- Université Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Joel N Kline
- Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, Iowa
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Kavitha V, Mohan A, Madan K, Hadda V, Khilnani GC, Guleria R. Fractional exhaled nitric oxide is a useful adjunctive modality for monitoring bronchial asthma. Lung India 2017; 34:132-137. [PMID: 28360460 PMCID: PMC5351354 DOI: 10.4103/0970-2113.201322] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Objective: To evaluate the utility of fractional exhaled nitric oxide (FeNO) in monitoring asthma control. Materials and Methods: Steroid naïve nonsmoking asthmatics were recruited and followed for 6–8 weeks on standard treatment. Serial measurements of FeNO, peak expiratory flow rate (PEFR) variability, forced expiratory volume in 1 s (FEV1), bronchodilator reversibility (BDR), and asthma control test (ACT) score were measured at baseline and after 6–8 weeks of treatment. Results: One hundred and fifty-one patients were recruited over an 18-month period. These comprised 79 males (52.3%) with mean (standard deviation) age of 34.2 (11.6). Mean (SD) FeNO levels at baseline and after therapy were 45.4 (35.9) and 38.4 (23.7) ppb, respectively (P = 0.01). Baseline FeNO correlated strongly with FEV1 (r = −0.78, P < 0.001), ACT score (r = −0.76, P < 0.001), PEFR variability (r = −0.74, P < 0.001), and moderately with BDR (r = 0.50, P < 0.001). After treatment with inhaled steroids, the correlation remained strong with ACT score (r = −0.68, P < 0.001) but weakened with PEFR variability (r = −0.34, P = 0.01) and FEV1 (r = −0.36, P = 0.01). Conclusions: FeNO may be useful as an adjunctive noninvasive modality to assess asthma control in both steroid naïve asthmatics and asthmatics on treatment. However, the suboptimal sensitivity and specificity may limit its utility as a point-of-care single monitoring tool.
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Affiliation(s)
- Venkatnarayan Kavitha
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - G C Khilnani
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
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Schleich F, Demarche S, Louis R. Biomarkers in the Management of Difficult Asthma. Curr Top Med Chem 2016; 16:1561-73. [PMID: 26467509 PMCID: PMC4997932 DOI: 10.2174/1568026616666151015093406] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/16/2015] [Accepted: 08/21/2015] [Indexed: 01/06/2023]
Abstract
Difficult asthma is a heterogeneous disease of the airways including various types of bronchial inflammation and various degrees of airway remodeling. Therapeutic response of severe asthmatics can be predicted by the use of biomarkers of Type2-high or Type2-low inflammation. Based on sputum cell analysis, four inflammatory phenotypes have been described. As induced sputum is time-consuming and expensive technique, surrogate biomarkers are useful in clinical practice. Eosinophilic phenotype is likely to reflect ongoing adaptive immunity in response to allergen. Several biomarkers of eosinophilic asthma are easily available in clinical practice (blood eosinophils, serum IgE, exhaled nitric oxyde, serum periostin). Neutrophilic asthma is thought to reflect innate immune system activation in response to pollutants or infectious agents while paucigranulocytic asthma is thought to be not inflammatory and characterized by smooth muscle dysfunction. We currently lack of user-friendly biomarkers of neutrophilic asthma and airway remodeling. In this review, we summarize the biomarkers available for the management of difficult asthma.
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Kobayashi S, Hanagama M, Yamanda S, Ishida M, Yanai M. Inflammatory biomarkers in asthma-COPD overlap syndrome. Int J Chron Obstruct Pulmon Dis 2016; 11:2117-2123. [PMID: 27660429 PMCID: PMC5021052 DOI: 10.2147/copd.s113647] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The clinical phenotypes and underlying mechanisms of asthma-COPD overlap syndrome (ACOS) remain elusive. This study aimed to investigate a comparison of COPD patients with and without ACOS, focusing on inflammatory biomarkers, in an outpatient COPD cohort. Methods We conducted a cross-sectional study analyzing prospectively collected data from the Ishinomaki COPD Network registry. All participants were diagnosed with COPD, confirmed by using spirometry, and were aged 40–90 years and former smokers. Patients with features of asthma including both variable respiratory symptoms and variable expiratory airflow limitation were identified and defined as having ACOS. Then, the inflammatory biomarkers such as fractional exhaled nitric oxide level, blood eosinophil count and percentage, total immunoglobulin E (IgE) level, and presence of antigen-specific IgE were evaluated. Results A total of 257 patients with COPD were identified, including 37 (14.4%) with ACOS. Patients with ACOS tended to be younger, have a shorter smoking history, and use more respiratory medications, especially inhaled corticosteroids and theophylline. Mean fractional exhaled nitric oxide level was significantly higher in those with ACOS than in those without ACOS (38.5 parts per billion [ppb] vs 20.3 ppb, P<0.001). Blood eosinophil count and percentage were significantly increased in those with ACOS (295/mm3 vs 212/mm3, P=0.032; 4.7% vs 3.2%, P=0.003, respectively). Total IgE level was also significantly higher, and presence of antigen-specific IgE was observed more frequently in patients with ACOS. Receiver operating characteristic curve analysis indicated that the sensitivity and specificity of these biomarkers were relatively low, but combinations of these biomarkers showed high specificity for ACOS diagnosis. Conclusion These results provide evidence that these inflammatory biomarkers can be used to support the diagnosis of ACOS.
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Affiliation(s)
- Seiichi Kobayashi
- Department of Respiratory Medicine, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
| | - Masakazu Hanagama
- Department of Respiratory Medicine, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
| | - Shinsuke Yamanda
- Department of Respiratory Medicine, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
| | - Masatsugu Ishida
- Department of Respiratory Medicine, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
| | - Masaru Yanai
- Department of Respiratory Medicine, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
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Korevaar DA, Westerhof GA, Bel EH. Biomarkers for diagnosing asthma: a smoking gun? Clin Exp Allergy 2016; 46:516-8. [PMID: 27021117 DOI: 10.1111/cea.12707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- D A Korevaar
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - G A Westerhof
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - E H Bel
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Lehtimäki L, Csonka P, Mäkinen E, Isojärvi J, Hovi SL, Ahovuo-Saloranta A. Predictive value of exhaled nitric oxide in the management of asthma: a systematic review. Eur Respir J 2016; 48:706-14. [DOI: 10.1183/13993003.00699-2016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/03/2016] [Indexed: 01/25/2023]
Abstract
The clinical value of measuring fractional exhaled nitric oxide (FeNO) in asthma is not clear. We aimed to assess whether FeNO can reliably predict clinical outcomes in asthma treated with inhaled corticosteroids (ICS). We also evaluated whether its predictive role is influenced by different inflammatory phenotypes of asthma.We conducted a systematic review focusing on five clinically relevant questions. Two authors independently screened search results, extracted data and assessed quality of the included studies. Data were synthesised by qualitative methods.12 prospective studies were included, answering partly three of the five questions. In steroid-naïve asthma, a high FeNO level probably predicts good response to ICS. In ICS-treated asthmatics, a low FeNO level probably predicts low risk of exacerbation, and the patient is unlikely to benefit from increasing ICS dose. There were scarce data to conclude whether FeNO predicts exacerbations when ICS treatment is stopped in well-controlled asthma. Only one study reported results separately in different asthma phenotypes.The current evidence on the predictive value of FeNO and its role in the management of asthma is incomplete. Future studies should focus on clinically meaningful questions and probably target only eosinophilic phenotypes where FeNO is best associated with the activity of airway inflammation.
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Biomarkers Guided Treatment Strategies in Adult Patients with Asthma: Ready for the Clinical Field? Arch Immunol Ther Exp (Warsz) 2016; 65:1-9. [PMID: 27271573 DOI: 10.1007/s00005-016-0407-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
Abstract
Asthma is a chronic inflammatory airways disorder mainly characterized by heterogeneity. In the more severe forms, a discordance often exists between symptoms and inflammation. Difficulty in managing asthma derives partly from the multiple phenotypes existing and our inability to recognize them. The use of non-invasive, with main representative the fraction of exhaled nitric oxide, or semi-invasive techniques such as induced sputum are effective tools that can help us to guide asthma treatment. In the latest years, several serum biomarkers related to asthmatic inflammation have been used for the better recognition of asthma sub-phenotypes to achieve optimization of therapy and disease outcome. In patients with mild-moderate asthma, as well as patients with more severe asthma, the use of blood eosinophils revealed an acceptable accuracy for the prediction of airway eosinophilia indicating that in future studies may facilitate both individualized treatment and management of asthma. None of the above techniques have been incorporated in clinical practice although sputum eosinophils can be used in patients with severe asthma particularly in specialized centers with great experience. Of great interest are blood eosinophils since current data support their role either as tool for treatment selections or/and as a biomarker of airway eosinophilia.
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Tsilogianni Z, Hillas G, Bakakos P, Aggelakis L, Konstantellou E, Papaioannou AI, Papaporfyriou A, Papiris S, Koulouris N, Loukides S, Kostikas K. Sputum interleukin-13 as a biomarker for the evaluation of asthma control. Clin Exp Allergy 2016; 46:923-31. [PMID: 26990030 DOI: 10.1111/cea.12729] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 02/27/2016] [Accepted: 03/05/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Asthma control refers to the extent to which the manifestations of asthma have been reduced or eradicated by treatment. Interleukin-13 (IL-13) has a central role in Th2 response and serves as a possible therapeutic target in uncontrolled asthma. Fraction of exhaled nitric oxide (FeNO) and sputum eosinophils have modest performance in the evaluation of asthma control. OBJECTIVE To assess the diagnostic performance of sputum IL-13 for the evaluation of asthma control and furthermore to investigate the performance of sputum eosinophils and FeNO. METHODS One hundred and seventy patients with asthma were studied. All subjects underwent assessment of asthma control by asthma control test (ACT), lung function tests, FeNO measurement and sputum induction for cell count identification and IL-13 measurement in supernatants. RESULTS IL-13 (pg/mL) levels in sputum supernatant differed significantly among patients with well-controlled asthma and those with not well-controlled asthma [median IQR 78 (66-102) vs. 213 (180-265), P < 0.001]. Receiver operating characteristic (ROC) analysis showed that, for the whole study population, the diagnostic performance of IL-13 was superior to both sputum eosinophils and FeNO levels [area under the curve (AUC) 0.92, 95% CI 0.87 to 0.95 vs. AUC 0.65, 95% CI 0.58 to 0.72 vs. AUC 0.65, 95% CI 0.55 to 0.72, respectively]. CONCLUSION The diagnostic performance of sputum IL-13 was superior to both sputum eosinophils and FeNO levels for the identification of well-controlled asthma. Sputum IL-13 levels could serve as a useful biomarker for asthma control assessment.
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Affiliation(s)
- Z Tsilogianni
- 2nd Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - G Hillas
- 1st Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - P Bakakos
- 1st Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - L Aggelakis
- 1st Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - E Konstantellou
- 1st Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - A I Papaioannou
- 2nd Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - A Papaporfyriou
- 1st Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - S Papiris
- 2nd Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - N Koulouris
- 1st Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - S Loukides
- 2nd Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
| | - K Kostikas
- 2nd Respiratory Medicine Department, University of Athens Medical School, Athens, Greece
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Ricciardolo F, Sorbello V, Bellezza Fontana R, Schiavetti I, Ciprandi G. Exhaled nitric oxide in relation to asthma control: A real-life survey. Allergol Immunopathol (Madr) 2016; 44:197-205. [PMID: 26589339 DOI: 10.1016/j.aller.2015.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 05/16/2015] [Accepted: 05/26/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asthma is characterised by chronic airway inflammation, a complex cascade of events, mostly sustained by eosinophil recruitment and activation. Fractional exhaled nitric oxide (FeNO) is a surrogate marker of airway inflammation closely associated with bronchial eosinophilia. FeNO is used to define asthma phenotype, to assess eosinophilic inflammatory severity and to predict corticosteroid responsiveness. OBJECTIVE The aim of this study was to investigate whether FeNO may be associated with some clinical and functional factors in asthmatics evaluated in a real life setting. METHODS Globally 363 patients (150 males, mean age 46.3 years) with asthma were consecutively evaluated. The following parameters were assessed: history, including comorbidities, physical examination, body mass index (BMI), lung function, asthma control grade, asthma control test (ACT), and FeNO. RESULTS FeNO values were significantly higher in patients with poorly controlled asthma (p<0.01), asthma symptoms (p=0.015), wheezing (p<0.001), rhinitis diagnosis, (p=0.049) and rhinitis symptoms (p=0.019), but lower in patients with GERD (p=0.024) and pneumonia history (p=0.048). FeNO values increased in patients with the lowest corticosteroid dose (p=0.031). FeNO values>25ppb were associated with poorly controlled asthma (OR 3.71), asthma signs (OR 3.5) and symptoms (OR 1.79). A FeNO value cut-off of 29.9ppb was fairly predictive of (AUC 0.7) poorly controlled asthma. CONCLUSIONS FeNO assessment in clinical practice may be a useful tool for monitoring asthmatics as it is associated with several clinical factors, including asthma control.
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Papaioannou AI, Kostikas K, Zervas E, Kolilekas L, Papiris S, Gaga M. Control of asthma in real life: still a valuable goal? Eur Respir Rev 2016; 24:361-9. [PMID: 26028647 PMCID: PMC9487814 DOI: 10.1183/16000617.00001615] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Although studies show that control of asthma can be achieved in the majority of patients, surveys repeatedly show that this is not the case in real life. Important measures to implement in order to achieve asthma control are trained healthcare professionals, a good patient–doctor relationship, patient education, avoidance of exposure to triggers, personalised management and adherence to treatment. These measures help the majority of asthma patients but have not yet been widely implemented and there should be a concerted action for their implementation. Moreover, further and focused research is needed in severe/refractory asthma. Achieving asthma control requires implementation of evidence-based guidelines and further research into severe asthmahttp://ow.ly/KzrOp
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Affiliation(s)
- Andriana I Papaioannou
- 2nd Respiratory Medicine Dept, University of Athens Medical School, Attikon Hospital, Athens, Greece
| | - Konstantinos Kostikas
- 2nd Respiratory Medicine Dept, University of Athens Medical School, Attikon Hospital, Athens, Greece
| | - Eleftherios Zervas
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Lykourgos Kolilekas
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Spiridon Papiris
- 2nd Respiratory Medicine Dept, University of Athens Medical School, Attikon Hospital, Athens, Greece
| | - Mina Gaga
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
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Abstract
PURPOSE OF REVIEW Severe asthma is a heterogeneous syndrome. Classification of asthma into phenotypes and endotypes can improve understanding and treatment of the disease. Identification and utilization of biomarkers, particularly those linked to T2 inflammation, can help group patients into phenotypes, predict those who will respond to a specific therapy, and assess the response to treatment. RECENT FINDINGS Biomarkers are present in sputum, exhaled breath, and blood of patients with asthma. These include sputum eosinophils and neutrophils, fractional excretion of nitric oxide, blood eosinophilia, IgE, and periostin. Many of these biomarkers are associated with eosinophilic inflammation propagated mainly by T2 cytokines such as IL-5 and IL-13, which are released from Th2 cells and Type 2 innate lymphoid cells. Biomarkers have been utilized in recent trials of novel biologic agents targeted at T2 inflammation and may contribute to the defining population who would respond to these therapies. SUMMARY Despite advances in the identification and utilization of asthma biomarkers, further studies are needed to better clarify the role of biomarkers, individually or in combination, in the diagnosis and treatment of severe asthma. Future therapeutic trials should include the use of biomarkers in their design, which may lead to a more personalized approach to therapy and improved outcomes.
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Different patterns of exhaled nitric oxide response to β2-agonists in asthmatic patients according to the site of bronchodilation. J Allergy Clin Immunol 2015; 137:806-12. [PMID: 26688519 DOI: 10.1016/j.jaci.2015.09.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 09/18/2015] [Accepted: 09/24/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND In asthmatic patients undergoing airway challenge, fraction of exhaled nitric oxide (FENO) levels decrease after bronchoconstriction. In contrast, model simulations have predicted both decreased and increased FENO levels after bronchodilation, depending on the site of airway obstruction relief. OBJECTIVE We sought to investigate whether β2-agonists might induce divergent effects on FENO values in asthmatic patients as a result of airway obstruction relief occurring at different lung depths. METHODS FENO, FEV1, and the slope of phase III of the single-breath washout test (S) of He (S(He)) and sulfur hexafluoride (S(SF6)) were measured in 68 asthmatic patients before and after salbutamol inhalation. S(He) and S(SF6) decreases reflected preacinar and intra-acinar obstruction relief, respectively. Changes (Δ) were expressed as a percentage from the baseline. RESULTS No FENO change (|ΔFENO| ≤ 10%) was found in 16 patients (mean [SD]: 2.5% [5.2%]; ie, FENO= group); a ΔFENO value of greater than 10% was found in 23 patients (31.7% [20.3%]; ie, the FENO+ group); and a ΔFENO value of less than -10% was found in 29 patients (-31.5% [17.3%]; ie, the FENO- group). All groups had similar ΔFEV1 values. In the FENO= group neither S(He) nor S(SF6) changed, in the FENO+ group only S(He) decreased significantly (-21.8% [SD 28.5%], P = .03), and in the FENO- group both S(He) (-29.8% [24.0%], P < .001) and S(SF6) (-27.2% [23.3%], P < .001) decreased. DISCUSSION Three FENO behaviors were observed in response to β2-agonists: a decrease likely caused by relief of an intra-acinar airway obstruction that we propose reflects amplification of nitric oxide back-diffusion, an increase likely associated with a predominant dilation up to the preacinar airways, and FENO stability when obstruction relief involved predominantly the central airways. In combination, these results suggest a new role for FENO in identifying the site of airway obstruction in asthmatic patients.
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Ricciardolo FL, Sorbello V, Ciprandi G. A pathophysiological approach for FeNO: A biomarker for asthma. Allergol Immunopathol (Madr) 2015; 43:609-16. [PMID: 25796309 DOI: 10.1016/j.aller.2014.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 11/19/2014] [Accepted: 11/25/2014] [Indexed: 10/23/2022]
Abstract
The present review is focused on literature concerning the relevance of fractional exhaled nitric oxide (FeNO) in clinical practice from a pathophysiological point of view. There is increasing evidence that asthma is a heterogeneous pathological condition characterised by different phenotypes/endotypes related to specific biomarkers, including FeNO, helpful to predict therapeutic response in selected asthmatic populations. Nowadays FeNO, a non-invasive biomarker, appears to be useful to foresee asthma developing, to recognise specific asthma phenotypes, like the eosinophilic, to ameliorate asthma diagnosis and management in selected populations and to predict standard corticosteroid and biologic therapy efficacy. In addition, FeNO assessment may also be useful in patients with allergic rhinitis in order to detect the potential involvement of eosinophilic bronchial inflammation in "case finding" subjects at risk of asthma diagnosis. Therefore, it is possible to hypothesise a future with an appropriate use of FeNO by physicians dealing with worrisome clinical issues in specific asthma phenotypes.
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Lin J, Yin K, Su N, Huang M, Qiu C, Liu C, Cai S, Hao C. Chinese expert consensus on clinical use of non-invasive airway inflammation assessment in bronchial asthma. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:302. [PMID: 26697462 PMCID: PMC4669313 DOI: 10.3978/j.issn.2305-5839.2015.11.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | - on behalf of the Chinese Society of Chest Physicians
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
| | - Chinese Medical Doctor Association
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
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Lin J, Yin K, Su N, Huang M, Qiu C, Liu C, Cai S, Hao C. Chinese expert consensus on clinical use of non-invasive airway inflammation assessment in bronchial asthma. J Thorac Dis 2015; 7:2061-78. [PMID: 26716047 PMCID: PMC4669291 DOI: 10.3978/j.issn.2072-1439.2015.11.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | - on behalf of the Chinese Society of Chest Physicians
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
| | - Chinese Medical Doctor Association
- China-Japan Friendship Hospital, Beijing 100029, China; The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China; Shenzhen People’s Hospital, Shenzhen 518020, China; West China Hospital, Sichuan University, Chengdu 610041, China; Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Soochow University Affiliated Children’s Hospital, Suzhou 215003, China
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Tamada T, Sugiura H, Takahashi T, Matsunaga K, Kimura K, Katsumata U, Takekoshi D, Kikuchi T, Ohta K, Ichinose M. Biomarker-based detection of asthma-COPD overlap syndrome in COPD populations. Int J Chron Obstruct Pulmon Dis 2015; 10:2169-76. [PMID: 26491283 PMCID: PMC4608617 DOI: 10.2147/copd.s88274] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) was proposed by the science committees of both Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD). However, the definition of ACOS has remained unclear all over the world, and the prevalence rate of ACOS is basically dependent on the patient's symptoms or the physician's opinion, based on questionnaire testing. In the current case report, we investigated the prevalence rate of COPD patients with high levels of fractional exhaled nitric oxide (FENO) or immunoglobulin E (IgE) as candidate markers of ACOS in COPD, as a multicenter, cross-sectional study. Outpatients with COPD were enrolled from Tohoku University Hospital, Sendai, Japan, and five hospitals (Tohoku University Hospital, Sendai, Japan; NTT East Tohoku Hospital, Sendai, Japan; Wakayama Medical University Hospital, Kimiidera, Japan; Hiraka General Hospital, Yokote, Japan; Iwate Prefectural Isawa Hospital, Oshu, Japan) with pulmonary physicians from March 1, 2013 to February 28, 2014. When they were estimated using 35 ppb as the cutoff value of FENO, the prevalence rate of ACOS was 16.3% in COPD. When estimated by both FENO and IgE, the high-FENO/high-IgE group was 7.8% in COPD. To the best of our knowledge, this study is the first to detect the prevalence rate of ACOS in COPD populations by using objective biomarkers. The results from the current study should be useful to identify the subgroup requiring early intervention by inhaled corticosteroids/long-acting beta agonist combination in COPD in order to improve the long-term management for ACOS.
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Affiliation(s)
- Tsutomu Tamada
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hisatoshi Sugiura
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tsuneyuki Takahashi
- Nippon Telegraph and Telephone East Corporation Tohoku Hospital, Sendai, Japan
| | - Kazuto Matsunaga
- Division of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | | | | | - Daisuke Takekoshi
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshiaki Kikuchi
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ken Ohta
- National Hospital Organization, Tokyo National Hospital, Kiyose, Tokyo, Japan
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Peiman S, Abtahi H, Akhondzadeh S, Safavi E, Moin M, Rahimi Foroushani A. Fluticasone propionate in clinically suspected asthma patients with negative methacholine challenge test. CLINICAL RESPIRATORY JOURNAL 2015; 11:433-439. [PMID: 26256808 DOI: 10.1111/crj.12353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 05/17/2015] [Accepted: 08/03/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite reports of response to steroid inhaler in some clinically suspected asthma patients with negative methacholine challenge test (CSA/MCT-), treatment in these patients has not been prospectively studied. OBJECTIVE We studied the role of a 12 week high dose inhaled fluticasone trial in CSA/MCT- patients. METHODS After a 2 week run-in period, CSA/MCT-patients were treated with 12 weeks of Fluticasone propionate 1000 µg/day. The Asthma Control Test (ACT), numeric cough score (NCS) and bronchodilator use were compared with their pretreatment values. RESULTS Thirty-four of 42 CSA/MCT-patients completed the study. Mean pretreatment ACT score (pACT) was significantly increased after treatment (14.7 ± 3.37 to 20.9 ± 3.1, P < 0.001). Posttreatment values of daytime (1.0 ± 1.0) and night-time (0.6 ± 0.9) NCS decreased compared to their pretreatment values (2.8 ± 1.1 and 1.9 ± 1.3, respectively; P < 0.001). ACT score change (ΔACT) were significantly greater in those with pACT < 15 than in those ≥15 (P < 0.001) . Fifteen of 21 patients with ΔACT > 5 did not need to use bronchodilator for their symptom relief. Wheeze disappeared in all six patients with ΔACT > 5 after the trial. Six months after the study, steroid inhaler continued to be used by 72.2% of patients. CONCLUSION A significant portion of CSA/MCT- (especially those with pretreatment ACT score <15) respond to high dose fluticasone inhaler in terms of symptoms relief, disappearance of wheeze and need to bronchodilator use. ΔACT could not be predicted with any individual symptoms or signs before MCT, % FEV1 decline or symptoms during MCT and exhaled nitric oxide.
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Affiliation(s)
- Soheil Peiman
- Department of Pulmonary and Critical Care, Advanced Thoracic Research Center, Imamkhomeini Medical center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Abtahi
- Department of Pulmonary and Critical Care, Advanced Thoracic Research Center, Imamkhomeini Medical center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Akhondzadeh
- Department of Psychiatry, Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Enayat Safavi
- Department of Pulmonary and Critical Care, Advanced Thoracic Research Center, Imamkhomeini Medical center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Moin
- Department of Pediatrics, Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Rahimi Foroushani
- Department of Epidemiology and Biostatistics, School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran, Iran
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Sfaxi I, Ben Saad H, Rouatbi S. Fraction of exhaled nitric oxide in healthy elderly Tunisian subjects. Nitric Oxide 2015; 50:88-97. [PMID: 26344327 DOI: 10.1016/j.niox.2015.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/29/2015] [Accepted: 08/31/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Exhaled-fraction-of-nitric-oxide (FeNO) norms are absent in healthy elderly North-African subjects. OBJECTIVES i) to identify FeNO influencing factors of elderly Tunisians older 50 years and more; ii) to assess the applicability of some published FeNO norms for elderly in local population; iii) to set-up FeNO norms and to prospectively evaluate their validity in two elderly validation-groups (healthy and asthmatic subjects). METHODS A convenience sample of healthy and asthmatic elderly Tunisians was recruited. Subjects responded to a medical questionnaire and then FeNO levels were measured by an online method (Medisoft, Sorinnes (Dinant), Belgium). Clinical, anthropometric and spirometric data were collected. Three groups of subjects were identified: group I (healthy-elderly; n = 100, 57 females); group II (healthy-validation; n = 17, 4 females) and group III (asthmatic-validation; n = 10, 9 females). ANOVA was performed to compare the three groups' data. RESULTS No significant factor, among those evaluated, influenced Tunisian elderly FeNO values. The available published FeNO norms did not reliably predict FeNO in Tunisian elderly population. The mean ± SD (minimum-maximum) of FeNO (ppb) for group I was 14 ± 6 (3-34). For Tunisian people, each elderly FeNO value higher than 34 ppb will be considered as abnormal. There was no statistical significant difference between FeNO (ppb) mean values of group I and groups II (15 ± 8) or III (18 ± 13). No subject of group II had a FeNO value higher than 34 ppb. Thirty percent of group III subjects had a FeNO value higher than 34 ppb. CONCLUSION In practice, FeNO value of more than 34 ppb is considered abnormal in elderly Tunisian population.
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Affiliation(s)
- Ines Sfaxi
- Laboratory of Physiology, Faculty of Medicine of Sousse, University of Sousse, 4000 Sousse, Tunisia; Department of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia.
| | - Helmi Ben Saad
- Laboratory of Physiology, Faculty of Medicine of Sousse, University of Sousse, 4000 Sousse, Tunisia; Department of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia; Research Laboratory N° LR14ES05: Interactions of the Cardiopulmonary System, Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Sonia Rouatbi
- Laboratory of Physiology, Faculty of Medicine of Sousse, University of Sousse, 4000 Sousse, Tunisia; Department of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia
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Comhair SAA, McDunn J, Bennett C, Fettig J, Erzurum SC, Kalhan SC. Metabolomic Endotype of Asthma. THE JOURNAL OF IMMUNOLOGY 2015; 195:643-50. [PMID: 26048149 DOI: 10.4049/jimmunol.1500736] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/13/2015] [Indexed: 11/19/2022]
Abstract
Metabolomics, the quantification of small biochemicals in plasma and tissues, can provide insight into complex biochemical processes and enable the identification of biomarkers that may serve as therapeutic targets. We hypothesized that the plasma metabolome of asthma would reveal metabolic consequences of the specific immune and inflammatory responses unique to endotypes of asthma. The plasma metabolomic profiles of 20 asthmatic subjects and 10 healthy controls were examined using an untargeted global and focused metabolomic analysis. Individuals were classified based on clinical definitions of asthma severity or by levels of fraction of exhaled NO (FENO), a biomarker of airway inflammation. Of the 293 biochemicals identified in the plasma, 25 were significantly different among asthma and healthy controls (p < 0.05). Plasma levels of taurine, lathosterol, bile acids (taurocholate and glycodeoxycholate), nicotinamide, and adenosine-5-phosphate were significantly higher in asthmatics compared with healthy controls. Severe asthmatics had biochemical changes related to steroid and amino acid/protein metabolism. Asthmatics with high FENO, compared with those with low FENO, had higher levels of plasma branched-chain amino acids and bile acids. Asthmatics have a unique plasma metabolome that distinguishes them from healthy controls and points to activation of inflammatory and immune pathways. The severe asthmatic and high FENO asthmatic have unique endotypes that suggest changes in NO-associated taurine transport and bile acid metabolism.
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Affiliation(s)
- Suzy A A Comhair
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195; Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195
| | | | - Carole Bennett
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Jade Fettig
- Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195
| | - Serpil C Erzurum
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195; Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195; Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Satish C Kalhan
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195; Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195;
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49
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Cowan DC, Taylor DR, Peterson LE, Cowan JO, Palmay R, Williamson A, Hammel J, Erzurum SC, Hazen SL, Comhair SAA. Biomarker-based asthma phenotypes of corticosteroid response. J Allergy Clin Immunol 2014; 135:877-883.e1. [PMID: 25488689 DOI: 10.1016/j.jaci.2014.10.026] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/29/2014] [Accepted: 10/06/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Asthma is a heterogeneous disease with different phenotypes. Inhaled corticosteroid (ICS) therapy is a mainstay of treatment for asthma, but the clinical response to ICSs is variable. OBJECTIVE We hypothesized that a panel of inflammatory biomarkers (ie, fraction of exhaled nitric oxide [Feno], sputum eosinophil count, and urinary bromotyrosine [BrTyr] level) might predict steroid responsiveness. METHODS The original study from which this analysis originates comprised 2 phases: a steroid-naive phase 1 and a 28-day trial of ICSs (phase 2) during which Feno values, sputum eosinophil counts, and urinary BrTyr levels were measured. The response to ICSs was based on clinical improvements, including a 12% or greater increase in FEV1, a 0.5-point or greater decrease in Asthma Control Questionnaire score, and 2 doubling dose or greater increase in provocative concentration of adenosine 5'-monophosphate causing a 20% decrease in FEV1 (PC20AMP). Healthy control subjects were also evaluated in this study for comparison of biomarkers with those seen in asthmatic patients. RESULTS Asthmatic patients had higher than normal Feno values, sputum eosinophil counts, and urinary BrTyr levels during the steroid-naive phase and after ICS therapy. After 28-day trial of ICSs, Feno values decreased in 82% of asthmatic patients, sputum eosinophil counts decreased in 60%, and urinary BrTyr levels decreased in 58%. Each of the biomarkers at the steroid-naive phase had utility for predicting steroid responsiveness, but the combination of high Feno values and high urinary BrTyr levels had the best power (13.3-fold, P < .01) to predict a favorable response to ICS therapy. However, the magnitude of the decrease in biomarker levels was unrelated to the magnitude of clinical response to ICS therapy. CONCLUSION A noninvasive panel of biomarkers in steroid-naive asthmatic patients predicts clinical responsiveness to ICS therapy.
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Affiliation(s)
- Douglas C Cowan
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - D Robin Taylor
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Laura E Peterson
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jan O Cowan
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Rochelle Palmay
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Avis Williamson
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jef Hammel
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serpil C Erzurum
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stanley L Hazen
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Suzy A A Comhair
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
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50
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Dinh-Xuan AT, Annesi-Maesano I, Berger P, Chambellan A, Chanez P, Chinet T, Degano B, Delclaux C, Demange V, Didier A, Garcia G, Magnan A, Mahut B, Roche N. Contribution of exhaled nitric oxide measurement in airway inflammation assessment in asthma. A position paper from the French Speaking Respiratory Society. Rev Mal Respir 2014; 32:193-215. [PMID: 25704902 DOI: 10.1016/j.rmr.2014.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 08/27/2014] [Indexed: 01/06/2023]
Abstract
Nitric oxide (NO) is both a gas and a ubiquitous inter- and intracellular messenger with numerous physiological functions. As its synthesis is markedly increased during inflammatory processes, NO can be used as a surrogate marker of acute and/or chronic inflammation. It is possible to quantify fractional concentration of NO in exhaled breath (FENO) to detect airway inflammation, and thus improve the diagnosis of asthma by better characterizing asthmatic patients with eosinophilic bronchial inflammation, and eventually improve the management of targeted asthmatic patients. FENO measurement can therefore be viewed as a new, reproducible and easy to perform pulmonary function test. Measuring FENO is the only non-invasive pulmonary function test allowing (1) detecting, (2) quantifying and (3) monitoring changes in inflammatory processes during the course of various respiratory disorders, including corticosensitive asthma.
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Affiliation(s)
- A T Dinh-Xuan
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de physiologie-explorations fonctionnelles, université Paris-Descartes, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| | - I Annesi-Maesano
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Inserm et université de médecine Pierre-et-Marie-Curie, 75571 Paris cedex 12, France
| | - P Berger
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Centre de recherche cardio-thoracique Inserm U1045, université de Bordeaux, 33076 Bordeaux cedex, France
| | - A Chambellan
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Inserm UMR 1087, institut du thorax, 44007 Nantes cedex, France
| | - P Chanez
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de pneumologie, hôpital Nord, chemin des Bourrelly, 13015 Marseille, France
| | - T Chinet
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de pneumologie, CHU Ambroise-Paré, 92104 Boulogne, France
| | - B Degano
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Explorations fonctionnelles, hôpital Jean-Minjoz, centre hospitalier régional universitaire, 25000 Besançon, France
| | - C Delclaux
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France
| | - V Demange
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Département épidémiologie en entreprise, INRS, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France
| | - A Didier
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de pneumologie, CHU de Toulouse, 24, chemin de Pouvourville - TSA, 31059 Toulouse cedex 9, France
| | - G Garcia
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de physiologie, hôpital Bicêtre, Assistance publique-Hôpitaux de Paris, 94275 Le Kremlin-Bicêtre, France
| | - A Magnan
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Inserm UMR 915, institut du thorax, CHU de Nantes, 44007 Nantes cedex, France
| | - B Mahut
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Cabinet de pédiatrie, 4, avenue de la Providence, 92160 Antony, France
| | - N Roche
- Groupe d'experts de la société de pneumologie de langue française sur la mesure du NO expiré dans l'asthme, société de pneumologie de langue française, 66, boulevard Saint-Michel, 75006 Paris, France; Service de pneumologie et soins intensifs respiratoires, Hôtel Dieu, groupe hospitalier Cochin-Broca, 75014 Paris, France
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