Minimal clinically important difference for asthma endpoints: an expert consensus report

Multidisciplinary care in pediatric severe asthma: A comparative outcomes analysis

Background

There are limited data comparing the effectiveness of multidisciplinary severe asthma clinics (SACs) with that of conventional single-discipline clinics (SDCs) for pediatric severe asthma.

Objective

Our aim was to compare asthma outcomes between SACs and SDCs clinics and examine longitudinal health outcomes for patients with severe asthma who were followed in SACs.

Methods

We conducted a retrospective cohort study comparing pediatric asthma outcomes among patients with severe asthma between 2018 and 2022 who were treated at the multidisciplinary Arkansas Children's SAC with those of patients with severe asthma treated at SDCs. The primary outcome was acute health care utilization, including hospitalizations and emergency department visits. Secondary outcomes included systemic corticosteroid prescriptions and controller medications. For SAC enrollees, longitudinal outcomes including health care utilization, symptom control, and spirometry were evaluated 12 months before and after enrollment. Data sources included the electronic health record and SAC patient registry.

Results

The study population included 280 patients with severe asthma, aged 5 to 18 years, from the SAC (n = 56) and SDCs (n = 224). The SAC patients were more likely to be Black (79% vs 52% [P = .0002]), be non-Hispanic (100% vs 88% [P = .01]), have had at least 1 hospitalization (21% vs 10% [P = .04]), and have received at least 2 prescriptions for a systemic corticosteroid (34% vs 17% [P = .01]). Longitudinal outcomes among patients for the 12 months before SAC enrollment versus 12 months after SAC enrollment demonstrated significant reductions in acute exacerbations (from 35 to 8 [P < .001]), hospitalizations (from 21 to 1 [P < .001]), and intensive care unit admissions (from 8 to 1 [P = .02]).

Conclusions

The study highlights significant morbidity among predominately Black pediatric patients with severe asthma, particularly those followed in a SAC versus in SDCs at a tertiary care referral center. The findings demonstrate the value of targeted multidisciplinary approaches to reduce asthma utilization and improve outcomes among high-risk patients.

Impact of Smoking on Biological Treatment Response in Patients From the German Severe Asthma (GAN) Registry

BACKGROUND

Clinical studies of biologics in severe asthma exclude smokers or ex-smokers (ExS) with over 10 pack-years (py). Thus, the effectiveness of this therapy in ExS with severe asthma is not well understood.

OBJECTIVES

To assess the impact of smoking on clinical efficiency of biologics in patients with severe asthma from the German Asthma Net, a comprehensive international registry.

METHODS

This analysis included 1129 patients (55.8% female, mean age: 53.82 ± 14.67 years), of whom 56% were never-smokers (NS), whereas 44% were ExS (<10 py: 22.9%, 10-20 py: 10.3%, and >20 py: 10.6%). They received benralizumab (38.3%), dupilumab (28.9%), mepolizumab (18.3%), omalizumab (14%), or reslizumab (0.5%).

RESULTS

Biologic therapy significantly improved asthma control, measured by change in Asthma Control Test, Asthma Control Questionnaire-5, and Mini-Asthma Quality of Life Questionnaire, lung function, reduced exacerbations, and daily oral prednisolone dose in all patients at week 52. Of note, no significant differences in asthma control between NS and ExS at week 52 (P = .48, .09, and .15, respectively) were observed. Also, lung function improvement (forced expiratory volume in 1 second, forced vital capacity, total lung capacity, peak expiratory flow, mean expiratory flow at 50%, P > .05), and reduction in acute exacerbation (P = .8) and oral corticosteroid doses (P = .15) were comparable in NS and ExS. Markers of type 2 inflammation, such as fraction of exhaled nitric oxide and blood eosinophils, decreased in ExS similar to NS (P = .29 and P = .48, respectively).

CONCLUSION

ExS with severe asthma experienced similar improvements in asthma control, exacerbations, lung function, and biomarkers as NS after 1 year of biologics, suggesting that severe asthmatics even with a substantial smoking history can benefit from biologic therapy.

Treatable Traits in Patients with Obstructive Lung Diseases in a Well-Established Asthma/COPD Service for Primary Care

Purpose

The primary objective of this study was to assess the prevalence of treatable traits (TTs) in patients with obstructive lung diseases in a primary care setting and how these TTs co-occur. The secondary objective was to assess the stability of TTs and the effect of management advice on changes in traits and health outcomes.

Patients and Methods

Data from the Dutch asthma/COPD service (2007-2023) were studied retrospectively. Patients ≥18 years with asthma, COPD, or Asthma-COPD overlap (ACO) were included. The prevalence of eight TTs were assessed: 1) insufficient inhaler technique, 2) poor medication adherence, 3) blood eosinophilia, 4) smoking, 5) obesity, 6) physical inactivity, 7) reversible airflow limitation, and 8) anxiety and/or depression. The effect of management advice on TTs was evaluated for patients with a follow-up visit scheduled within 1-2 years.

Results

In total, 15246 patients (COPD n=4822; ACO n=1761, asthma n=8663) were included. The highest proportions of TTs were insufficient inhaler technique: 43.6% (95% CI: 42.9-44.4), followed by poor medication adherence: 40.3% (95% CI: 39.2-41.4) and blood eosinophilia: 36.9% (95% CI: 35.8-38.1). Overall, 83.3% of patients had ≥ 1 TTs, and 48.9% of patients ≥ 2 TTs. Among patients with blood eosinophilia, a significant reduction of the trait at follow-up (OR: 0.61, 95% CI: 0.39; 0.96) and improved health status were observed when the pulmonologist advised the general practitioner to initiate or increase the dose of ICS. No significant association was found between management advice and the exacerbation rate at follow-up.

Conclusion

The TTs assessed in this study are common in primary care patients, with nearly half of the patients showing a combination of at least two TTs. These TTs coexist in many different combinations. A personalized approach targeting these traits may be effective in achieving better control of these heterogeneous diseases.

The impact of dosage timing for inhaled corticosteroids in asthma: a randomised three-way crossover trial

BACKGROUND

Asthma demonstrates a robust daily rhythm, with airflow obstruction and airway inflammation peaking overnight. Aligning the timing of drug administration with rhythms in disease (chronotherapy) may improve therapeutic efficacy. We aimed to evaluate the impact of dosage timing for inhaled corticosteroids in asthma.

METHODS

This is a randomised three-way crossover trial. Participants with mild to moderate atopic asthma were randomised to beclometasone dipropionate: (1) 400 µg once daily between 08:00 and 09:00 (ODAM); (2) 400 µg once daily between 15:00 and 16:00 (ODPM); and (3) 200 µg twice daily between 08:00 and 09:00 and between 20:00 and 21:00 (BD) for 28 days, with a 2 week washout period in between treatment periods. Six-hourly spirometry and biomarkers were measured over 24 hours following the run-in period and at the end of each treatment period.

RESULTS

Of 25 participants, 21 completed all regimens. ODPM was superior in improving 22:00 FEV1 (median (IQR): +160 (+70, +270) ml) compared with ODAM (-20 (-80, +230) ml) and BD (+80 (-20, +200) ml). ODPM resulted in better overnight (22:00 and 04:00) suppression in blood eosinophil counts compared with BD and ODAM. All regimens improved asthma control and reduced fractional exhaled nitric oxide and serum cortisol levels with no difference among dosing regimens.

CONCLUSION

ODPM better suppresses the nocturnal dip in lung function and peak of blood eosinophil counts compared with BD and ODAM; this was without an increase in adverse events. Future trials are warranted to validate these findings in real-life settings and to determine which population may best benefit from chronotherapy.

Head-to-Head Effectiveness Comparison of Biological Therapies in Patients With Mixed Eosinophilic and Allergic Severe Asthma

BACKGROUND

Studies comparing biologic therapies for severe asthma usually have a selection bias considering that some of these therapies are indicated for allergic asthma and others for eosinophilic asthma. Severe mixed asthma (SMA) was considered in patients with both allergic and eosinophilic (mixed) severe asthma. In SMA, dupilumab, omalizumab, mepolizumab, and benralizumab can be used. Currently there are no head-to-head studies comparing the clinical response of biologic therapies in this group of patients.

OBJECTIVE

To compare the effectiveness of four biologic therapies in SMA.

METHODS

This was a prospective study with 1 year of follow-up. Patients with severe asthma with markers for allergic asthma (total IgE greater than 100 IU/L and specific IgE to aeroallergens) and eosinophilic asthma (eosinophils greater than 150 cells/mL) were recruited. Sociodemographic and clinical characteristics were evaluated at baseline to assess significant differences between groups. The primary outcome was the proportion of patients achieving greater than 20 points on the Asthma Control Test (ACT). As a secondary outcomes, we evaluated the number of severe exacerbations of asthma per year and changes in FEV1.

RESULTS

A total of 133 patients participated in the study (dupilumab, n = 43; omalizumab, n = 32; mepolizumab, n = 32; and benralizumab, n = 26). At baseline, the groups did not have significant differences in sociodemographic or clinical characteristics. After 1 year with biologic therapies, the four groups had significant improvement in clinical outcomes with few between-group differences. There was no difference for the main outcome (ACT) in the four groups. Dupilumab and mepolizumab demonstrated a higher interval improvement in FEV1 compared with omalizumab. Dupilumab users had the highest proportion of patients who achieved a 200-mL improvement in FEV1 over omalizumab and benralizumab. The greatest adherence was observed among benralizumab users.

CONCLUSIONS

In SMA the four biologic therapies offer similar symptom control according to the ACT, but there are some differences according to FEV1 and adherence. Therefore, the selection of these therapies in SMA must be based on the particular aspects of each patient.

Are leukotrienes really the world's best bronchoconstrictors and at least 100 to 1000 times more potent than histamine?

It has been stated numerous times that leukotrienes are 100 to 1000 times more potent compared with histamine, but is this statement correct? Can we really compare a charged mono-cation with lipoid amphiphiles in their ability to penetrate an epithelial cell layer after inhalation challenge? In this review we question the shift in clinical and drug development attention from histamine towards leukotriene receptor antagonists for the treatment of chronic asthma and acute asthma exacerbations. The presented data indicate that histamine very likely plays a much more important role than previously assumed. It is time to rethink mediator involvement during bronchospasm and shift attention back to histamine.

Real-life effectiveness of once-daily single-inhaler triple therapy (FF-UMEC-VI) after switching from dual therapy (ICS-LABA) in patients with symptomatic asthma: trelegy ellipta for real asthma control study

Introduction

A well-designed, protocol-driven randomized controlled trial (RCT) has demonstrated the efficacy of fluticasone furoate-umeclidinium-vilanterol (FF-UMEC-VI) in patients with asthma, but there is a lack of real-world data that can be used to translate the results of the RCT into clinical practice. This study evaluated the efficacy of switching the therapy from inhaled corticosteroid-long-acting β2-agonists (ICS-LABAs) to FF-UMEC-VI at the equivalent corticosteroid dose in a real-world setting.

Methods

A prospective, three-month, open-label, parallel-group, switching therapy trial was performed in patients with symptomatic asthma under routine management. Patients receiving low-to-medium doses of ICS-LABAs were switched to FF-UMEC-VI (100-62.5-25 µg, once daily) (T100 group), and patients receiving a high dose of ICS-LABAs were switched to FF-UMEC-VI (200-62.5-25 µg, once daily) (T200 group). The primary outcome was the change from baseline in forced expiratory volume in 1 s (ΔFEV1) at week 12, and the secondary outcomes were the improvement in fractional exhaled nitric oxide (FeNO), the asthma symptoms evaluated using the asthma control test (ACT), and the cough severity evaluated using the visual analog scale (VAS).

Results

Thirty-five patients were switched to T100, and thirty patients were switched to T200. The ΔFEV1 was improved by more than 100 ml at 8 weeks after switching in both groups (T100, 110.4 ± 39.8 ml; T200, 117.1 ± 39.8 ml) (p < 0.05) but slightly decreased at 12 weeks. ACT also improved by more than 3 points at 8 weeks after switching and was maintained to 12 weeks in both groups (p < 0.05). Patients with ACT scores of <20 (i.e., poor control) before switching showed a greater improvement in the symptoms during T100 therapy, and 92% had reached an ACT score of >20 (i.e., good control). FeNO in the T100 group was decreased at 4 weeks (p < 0.05). Cough VAS also significantly decreased but did not reach a minimal clinically important difference.

Conclusions

In patients with symptomatic asthma showing insufficient control, an improvement in the asthma symptoms was observed after switching to FF-UMEC-VI at the equivalent corticosteroid dose, accompanied by an improvement in FEV1.

A Consistent Lack of Consistency: Definitions, Evidentiary Expectations and Potential Use of Meaningful Change Data in Clinical Outcome Assessments Across Stakeholders. Results from a DIA Working Group Literature Review and Survey

BACKGROUND

Clinical outcome assessments (COAs) measure how patients feel or function and can be used to understand which patients experience benefits of treatment and which do not. Interpretation of COA data is influenced by how meaningful change is defined. We aimed to compare how different stakeholders define, assess, and use meaningful change for decisions that impact patients.

METHODS

A targeted literature review was undertaken in July 2021 using Medline, Embase, online grey literature search engines, and stakeholder organization websites. Additionally, a stakeholder survey on meaningful change was fielded between March and June 2023. Both quantitative and qualitative methods were used to analyze responses and identify key themes.

RESULTS

The literature review resulted in 86 references. These revealed different approaches to define, measure and validate meaningful change. There were 248 survey responses. Many respondents felt the terminology and methods for defining meaningful change are confusing. Respondents also emphasized the importance of distinguishing within-patient and between-group change, and defining meaningfulness from the patient perspective (most patients and caregivers do not share a similar definition of meaningfulness as their healthcare professionals).

CONCLUSION

Four key recommendations for defining, establishing, and interpreting meaningful change estimates for COAs are: (1) Be clear on the type of "meaningful change" that is discussed or needed for a COA, (2) Ensure the "patient voice" is informing meaningful change estimates/definitions, (3) Acknowledge that a meaningful change estimate for a COA may differ between populations, diseases, and disease states, and (4) Disseminate data in a way that reduces ambiguity.

Effectiveness of anti-IL-5/5Rα biologics in severe asthma in real-world studies: a systematic review and meta-analysis

Background

Three biologics targeting interleukin 5 (anti-IL-5) or its receptor-α (anti-IL-5Rα) are approved for patients with severe asthma.

Methods

We systematically searched the literature published in Medline and Embase up to 1 May 2023 to identify observational studies and nonrandomised trials that assess the response to anti-IL-5/5Rα in real-life patients with severe eosinophilic asthma. We also performed random-effects meta-analyses.

Results

We identified 6401 studies, of which 92 with 9546 patients were analysed. Biologics use was associated with a 62% reduction in severe exacerbations (risk ratio 0.38, 95% CI 0.29-0.50) and a 54% reduction in hospitalisations (risk ratio 0.46, 95% CI 0.35-0.61) at 12 months of treatment, compared to pre-treatment. Biologics improved asthma control (decrease in asthma control questionnaire score by 1.11 points (95% CI -1.29--0.94) and increase in asthma control test score by 6.41 points (95% CI 5.66-7.16)) and increased the asthma quality of life questionnaire score by 1.08 points (95% CI 0.88-1.28) and forced expiratory volume in 1 s by 0.21 L (95% CI 0.15-0.27) at 12 months. There was a significant reduction in oral corticosteroids use of 51% (risk ratio 0.49, 95% CI 0.42-0.56), with a mean dose reduction of 6.01 mg·day-1 (95% CI -7.55--4.48) at 12 months of treatment. Similar findings were observed at 3-4, 6 and 24 months. A biomarker-related response to treatment was also noted.

Conclusions

This comprehensive meta-analysis summarises the significant clinical response to anti-IL-5/5Rα biologics in real-life studies, providing important insights for their use in clinical practice.

Asthma control after recovery from mild to moderate COVID-19: from Omicron BA.2 to XBB- from a cohort in a university hospital in Hong Kong

BACKGROUND

At the time of Omicron BA.2 outbreak, it was shown that mild to moderate COVID-19 was associated with worsening of asthma control after recovery. Whether the same phenomenon was also observed at a later phase of COVID-19 pandemic by other variants have not been reported.

METHODS

We conducted a follow-up study on patients with asthma who received clinical care in Queen Mary Hospital. The patients were first recruited in the study entitled "Worsening of asthma control after recovery from mild to moderate COVID-19 in patients from Hong Kong". The primary outcome was the asthma control test (ACT) score difference among the patients who never had COVID-19 (no COVID-19 group), patients who had COVID-19 diagnosed in the initial study (past COVID-19 group) and patients who had COVID-19 diagnosed in the follow-up period (new COVID-19 group) of the current study.

RESULTS

189 patients were included. The change of ACT score from the last visit in the previous study to the last follow-up visit in current study was - 0.34 ± 3.7 in the no COVID-19 group, -0.0 ± 5.0 in the past COVID-19 group and - 0.17 ± 4.5 in the new COVID-19 group (p = 0.94). There were 10 (24.4%), 24 (25.5%) and 12 (22.2%) patients in the no COVID-19, past COVID-19 and new COVID-19 group who had worsening of asthma control by an increase in ACT score ≥ 3 from the last visit in the previous study to the last follow-up visit in current study (p = 0.90).

CONCLUSION

Patients who had COVID-19 in 2023 with Omicron XBB as the dominant strain did not have worsening of asthma control seen in previous study done in 2022 with Omicron BA.2 as the circulating strain. Patients who had worsening of asthma control after COVID-19 in 2022 had subsequent improvement of asthma control with longer follow-up interval.

Pharmacokinetic modeling of prenatal vitamin D exposure and the impact on offspring asthma and pulmonary function

Gestational 25-hydroxyvitamin D (25[OH]D) is important in fetal lung development and may influence offspring respiratory outcomes, making accurate exposure assessment essential to understand clinical associations. Therefore, we used the combined data from two large RCTs investigating prenatal vitamin D supplementation, which included early and late prenatal 25(OH)D measurements, to refine a population pharmacokinetic model of vitamin D-25(OH)D and estimate individual area under the curve (AUC) Z-scores. The primary outcome was physician-diagnosed offspring asthma/wheezing at ages 3 and 6 years, and lung function, as a secondary outcome, was evaluated by spirometry at the ages 6 and 8 years. In total, 1319 mother-child pairs were included. We found that clearance of 25(OH)D increased with gestational age and bodyweight, and decreased with higher baseline 25(OH)D levels. Prenatal 25(OH)D AUC Z-scores were negatively associated with asthma/wheezing at age 3 years (aOR = 0.75, 95 % CI = 0.64-0.88, p < 0.001) and 6 years (aOR = 0.83, 95 % CI = 0.72-0.95, p = 0.008). Longitudinal analysis of lung function from age 6-8 years showed that AUC Z-scores were positively associated with percent-predicted FEV1 (β = 1.21%, 95 % CI = 0.30-2.11; p = 0.009), FVC (β = 0.79 %, 95 % CI = 0.13-1.46; p = 0.021), FEV1/FVC ratio (β = 0.56 %, 95 % CI = 0.11-1.01; p = 0.015) and FEF25-75 % (β = 2.18 %, 95 % CI = 0.46-3.91; p = 0.009). These results together indicate an exposure-outcome relationship where higher gestational 25(OH)D exposure, estimated by AUC, is associated with reduced childhood asthma/recurrent wheeze and improved lung function.

Regional challenges to optimize the management of patients with severe asthma type 2 inflammation: a Delphi consensus in seven countries

Objective:Severe asthma burdens patients and presents clinical management challenges for healthcare professionals. Biologics are crucial interventions for severe type two (T2) patients with high eosinophil counts. We conducted a Delphi consensus in seven developing or typically underrepresented countries to understand expert agreement on managing severe asthma with type two (T2) inflammation.

Methods:The study comprised two online survey rounds and a participant meeting, involving 21 and 20 respiratory experts in the first and second survey, respectively. We developed a 70-statement questionnaire after literature review. Responses were recorded on a Likert scale (0-9) with 75% consensus threshold.

Results:Consensus was reached on 37/60 closed-ended questions, including subtypes, in survey-1 and 20/47 closed-ended questions in survey-2. 95% of participants agreed on biomarker use for biologic treatment selection. 100% agreed timely biologic treatment leads to improvement in patients with severe asthma and an eosinophilic phenotype. 90% agreed to avoid maintenance oral corticosteroids (OCS) and start biologic therapy directly. Experts defined clinical remission on treatment as no exacerbations, no OCS use, Asthma Control Questionnaire (ACQ)-5 score < 1.5, and lung function optimization (forced expiratory volume in one second [FEV1] ≥ 80% of predicted or pre-bronchodilator FEV1 increase ≥ 100 mL from baseline). In survey-1, 81% agreed these outcomes are achievable in practice. All referral statements achieved consensus.

Conclusions:This Delphi study focused on understanding patients with severe asthma and T2 inflammation in developing/underrepresented countries. Appropriately utilizing biomarkers, timely treatment interventions for best outcomes, expert consensus on clinical remission, and referral are crucial for improving patient management.

The Effect of Inhaled Beta-2 Agonists on Heart Rate in Patients With Asthma: Sensor-Based Observational Study

BACKGROUND

Beta-2 agonists play an important role in the management of asthma. Inhaled long-acting beta-2 agonists (LABAs) and short-acting beta-2 agonists (SABAs) cause bronchodilation by stimulating adrenoceptors. These receptors are also present in cardiac cells and, as a side effect, could also be stimulated by inhaled beta-2 agonists.

OBJECTIVE

This study aims to assess the effect of beta-2 agonists on heart rate (HR).

METHODS

The data were retrieved from an observational study, the myAirCoach Quantification Campaign. Beta-2 agonist use was registered by self-reported monthly questionnaires and by smart inhalers. HR was monitored continuously with the Fitbit Charge HR tracker (Fitbit Inc). Patients (aged 18 years and older) were recruited if they had uncontrolled asthma and used inhalation medication. Our primary outcome was the difference in HR between LABA and non-LABA users. Secondary outcomes were the difference in HR on days SABAs were used compared to days SABAs were not used and an assessment of the timing of inhaler use during the day.

RESULTS

Patients using LABA did not have a clinically relevant higher HR (average 0.8 beats per minute difference) during the day. Around the moment of SABA inhalation itself, the HR does increase steeply, and it takes 138 minutes before it returns to the normal range.

CONCLUSIONS

This study indicates that LABAs do not have a clinically relevant effect on HR. SABAs are instead associated with a short-term HR increase.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02774772; https://clinicaltrials.gov/study/NCT02774772.

Improvement in health-related quality of life questionnaires with biologic treatment in severe asthma and comorbid chronic rhinosinusitis with or without nasal polyposis: a real-life experience

BACKGROUND

Patients with severe asthma frequently have comorbid chronic rhinosinusitis (CRS) with or without nasal polyps, that can increase the symptom burden and complicate treatment. Real-life clinical data on the impact of biologic treatments on CRS-specific quality-of-life questionnaires are still lacking.

MATERIALS AND METHODS

In this retrospective real-life study, we collected data from patients with severe asthma with comorbid CRS with/without nasal polyposis at baseline, and after 3, 6 and 12 months of treatment with omalizumab, mepolizumab, benralizumab or dupilumab. In particular, we evaluated improvements in HRQoL as measured by SinoNasal Outcome Test-22 (SNOT-22, 0 - 110), Visual Analog Scale symptom scores (VAS, 0-10), and Asthma Control Test (ACT, 5-25) and the proportion of patients meeting the minimal clinically important difference (MCID).

RESULTS

Disease-specific HRQoL, as measured by SNOT 22 and VAS score improved in all patients at 3, 6, and 12 months of treatment compared with baseline (SNOT-22: 14, IQR: 0-52 vs 10, IQR:0-30 vs 0, IQR:0-15 vs 0, IQR:0-12, p < 0.001, VAS score: 1, IQR: 0-5 vs 0, IQR:0-3 vs 0, IQR:0-2 vs 0, IQR 0-1, p < 0.001). After 3 months of treatment >80% of patients reached the MCID for ACT, while only patients on dupilumab showed to reach a MCID in 100% of cases. The effect size depended upon the symptom burden at baseline.

CONCLUSIONS

The study confirms the efficacy of omalizumab, mepolizumab, benralizumab, and dupilumab in a real-life setting, with a rapid improvement in CRS-specific HRQoL and general health status. These data highlight the importance of targeting type 2 inflammation in asthmatic patients with co-existing upper and lower airways disease.The Authors disclose that preliminary data and analysis of the present study have been presented in abstract form during the "X International Workshop on Lung Health - Respiratory Disease and Immune Response", held in Nice on 19-21 January 2023.

Community Health Workers Linking Clinics and Schools and Asthma Control: A Randomized Clinical Trial

Importance

Childhood asthma is characterized by pervasive disparities, including 3-fold higher hospitalization rates and 7-fold higher death rates for Black children compared with White children. To address asthma disparities, one must intervene in all lived environments.

Objective

To determine if a community health worker (CHW) intervention to connect the primary care, home, and school for low-income minoritized school-aged children with asthma and their caregivers improves asthma control.

Design, Setting, and Participants

This study was a hybrid effectiveness/implementation trial using a 2 × 2 factorial, cluster randomized clinical trial design of 36 schools crossed with participant-level randomization into a clinic-based CHW intervention. The study was conducted from May 2018 to June 2022. The intervention took place in primary care offices, homes, and 36 West Philadelphia, Pennsylvania, public and charter schools. Children aged 5 to 13 years with uncontrolled asthma were recruited from local primary care practices.

Interventions

Asthma management, trigger remediation, and care coordination occurred in school, home, and primary care settings. Children were followed up for 12 months. The Yes We Can Children's Asthma Program, Open Airways For Schools Plus, and school-based asthma therapy were implemented.

Main Outcomes and Measures

Improvement in asthma control, as measured by the Asthma Control Questionnaire, comparing the mean difference between groups 1 year after randomization with their baseline (difference in differences). Both primary care and school interventions were dramatically disrupted by the COVID-19 pandemic; therefore, stratified analyses were performed to assess per-protocol intervention efficacy before the pandemic disruptions.

Results

A total of 1875 participants were approached, 1248 were excluded, and 1 was withdrawn. The 626 analyzed study participants (mean [SD] age, 8.7 [2.4] years; 363 male [58%]) self-identified as Black race (96%) and non-Hispanic ethnicity (98%). Although all groups had statistically significant improvements in asthma control from baseline to 12 months (P- group: -0.46; 95% CI, -0.58 to -0.33; P+ group: -0.57; 95% CI, -0.74 to -0.44; S- group: -0.47; 95% CI, -0.58 to -0.35; S+ group: -0.59; 95% CI, -0.74 to -0.44), none of the difference-in-differences estimates from the primary prespecified models showed a clinically meaningful improvement in asthma control. Analysis from the prepandemic interval, however, demonstrated that children in the combined clinic-school intervention had a statistically significant improvement in asthma control scores compared with control (-0.79; 95% CI, -1.40 to -0.18).

Conclusions and Relevance

This randomized clinical trial provides preliminary evidence that connecting all lived environments for care of children can be accomplished through linkages with CHWs.

Trial Registration

ClinicalTrials.gov Identifier: NCT03514485.

Glucagon-like Peptide 1 Receptor Agonists and Asthma Exacerbations: Which Patients Benefit Most?

Rationale: Although recent evidence suggested that glucagon-like peptide 1 receptor agonists (GLP1RAs) might reduce the risk of asthma exacerbations, it remains unclear which subpopulations might derive the most benefit from GLP1RA treatment. Objectives: To identify characteristics of patients with asthma that predict who might benefit the most from GLP1RA treatment using real-world data. Methods: We implemented an active-comparator, new-user design analysis using commercially ensured patients 18-65 years of age from MarketScan data for 2007-2019 and identified two cohorts: GLP1RAs versus thiazolidinediones and GLP1RAs versus sulfonylureas. The outcome was acute exacerbation of asthma (hospital admission or emergency department visit for asthma) within 180 days after initiation. We applied iterative causal forest, a novel causal machine learning subgrouping algorithm, to assess heterogeneous treatment effects. In identified subgroups, we predicted propensity score, conducted propensity score trimming, and then estimated adjusted risk differences for the effect of GLP1RAs relative to comparators on asthma exacerbation using inverse probability treatment weighting in the propensity score-trimmed subpopulation. Results: Among 10,989 patients initiating GLP1RAs or thiazolidinediones and 17,088 patients initiating GLP1RAs versus sulfonylurea, GLP1RA initiators had fewer exacerbations, with adjusted risk differences of -0.5% (95% confidence interval [CI], -1.1% to 0.1%) and -1.6% (95% CI, -2.2% to -1.1%), respectively. In the GLP1RA versus sulfonylurea cohort, in which we observed a beneficial effect, our iterative causal forest analysis identified five subgroups with different treatment effects, defined by the number of emergency department visits, the number of prescriptions for short-acting β2-agonists, the number of prescriptions for inhaled steroids and long-acting β-agonists (either combination therapy or concurrent use), and age ≥ 50 years. Among these, patients with two or more emergency department visits during the 12-month baseline period had the largest absolute exacerbation risk reduction, with a decrease of 2.8% for GLP1RAs (95% CI, -4.8% to -0.9%). Conclusions: GLP1RAs demonstrated a beneficial effect on reducing asthma exacerbation relative to sulfonylureas. Patients with asthma with two or more emergency department visits (a proxy for disease severity) benefit most from GLP1RAs. Emergency department visit frequency, the number of maintenance and reliever inhalers, and age might help individualize prediction of the short-term benefit of GLP1RAs on asthma exacerbation.

Tezepelumab for severe asthma: elevating current practice to recognize epithelial driven profiles

BACKGROUND

An increasing amount of evidence supports the relevance of epithelium across the wide spectrum of asthma pathobiology. On a clinical ground tezepelumab, selectively binding TSLP, a major epithelial cytokine, has demonstrated to be effective in asthma patients regardless their specific phenotype. In order to avoid the risk of considering tezepelumab as a not-specific option, the present perspective aims to sketch the tezepelumab best eligible patient profile and to propose some hallmarks of epithelial-driven disease by reviewing the published evidence on the drug mechanism of action and efficacy data.

MAIN BODY

Although it cannot rely on standardised or exclusive "markers", the relationship between environment and poor asthma control might suggest a major relevance of the epithelial barrier dysfunction. In that light, allergy and asthma exacerbations concomitant with specific exposures (pathogens, pollutants, chemicals), as well as increased susceptibility to infections can be considered as the hallmark of an impaired epithelial immune response. Tezepelumab is effective in allergic patients, being able to reduce asthma exacerbations precipitated by the exposure to seasonal or perennial aeroallergens, including fungi. In addition, tezepelumab reduced the incidence of co-occurring respiratory illness and asthma exacerbations. In terms of inflammation, epithelial immune response has been related to an impaired mucus hypersecretion and plugging. A placebo-controlled trial demonstrated a significant reduction of mucus plugging in treated patient. Airways hyperreactivity (AHR), airways obstruction and remodelling have been described as an expression of epithelial orchestrated immunological activation. Of note, a significantly higher incidence of mannitol negative test in patients treated with tezepelumab when compared to placebo group has been observed. In addition, A 130 mL improvement in pre-BD FEV1 has been described in patients assuming Tezepelumab. The above-mentioned data suggest that bronchial reversibility and AHR can be considered "functional biomarkers" supporting patients' phenotyping and the identification of tezepelumab best responders.

CONCLUSION

Integrating "functional biomarkers" to the inflammatory ones and a better characterization of asthma exacerbations might pave the way to a different and more transversal phenotyping, which overcomes the "restrictive" labels including T2 high, allergic/atopic or T2 low asthma. Precisely defining the disease characteristics and potential targets for a better control even in tezepelumab eligible subjects is essential to avoid the block buster temptation and optimize the personalized medicine approach according to each patient's individuality.

Multivariate Cluster Analyses to Characterize Asthma Heterogeneity and Benralizumab Responsiveness

BACKGROUND

An improved understanding of how severe asthma heterogeneity affects response could inform treatment decisions.

OBJECTIVES

Characterize heterogeneity and benralizumab responsiveness in patients grouped by predefined Severe Asthma Research Program clusters using a multivariate approach.

METHODS

In post-hoc analyses of the randomized, double-blind, placebo-controlled phase III SIROCCO (NCT01928771) and CALIMA (NCT01914757) studies, patients with severe asthma who received benralizumab or placebo were assigned to clusters using an established discriminant function to analyze 11 clinical characteristics simultaneously. The annualized asthma exacerbation rate, exacerbation incidence, and lung function were analyzed across clusters.

RESULTS

Patients (n = 2,281) met criteria for four of five clusters: cluster 2 (early-onset moderate asthma, n = 393), cluster 4 (early-onset severe asthma, n = 386), cluster 3 (late-onset severe asthma, n = 641), and cluster 5 (late-onset severe, obstructed asthma, n = 861); no patients met cluster 1 criteria. Exacerbation rate reductions were significant in late-onset severe asthma (-48% [95% CI, -61% to -31%]; P < .0001) and late-onset severe, obstructed asthma (-50% [95% CI, -59% to -38%]; P < .0001), with nonsignificant reductions in early-onset clusters. These differences could not be fully explained by blood eosinophil count differences. Values for improvements in FEV1 were significant in late-onset severe asthma (+133 mL [95% CI, 66-200]; P = .0001) and late-onset severe, obstructed asthma (+160 mL [95% CI, 85-235]; P < .0001) while maintaining acute bronchodilator responsiveness.

CONCLUSIONS

Benralizumab reduced exacerbations and improved lung function, primarily in late-onset asthma clusters. This multivariate approach to identify subphenotypes, potentially reflecting pathobiological mechanisms, can guide therapy beyond univariate approaches.

Clinical remission and control in severe asthma: agreements and disagreements

Over the last two decades, we have witnessed great advancements in our understanding of the immunological pathways of asthma, leading to the development of targeted therapies, such as biologic drugs, that have radically and definitively changed the clinical outcomes of severe asthma. Despite the numerous therapeutic options available, ~4-10% of all people with asthma have severe or uncontrolled asthma, associated with an increased risk of developing chronic oral corticosteroid use, fixed airflow limitation, exacerbations, hospitalization and, finally, increased healthcare costs. The new concept of disease modification in asthma comes from the evolution of asthma management, which encompasses phenotyping patients with different inflammatory endotypes characterizing the disease, followed by the advent of more effective therapies capable of targeting the proximal factors of airway inflammation. This treat-to-target approach aims to achieve remission of the disease. Because the novel treatment paradigm for severe asthma with the advent of biologic therapies is no longer clinical control but rather clinical remission - a step closer to the concept of cure - a deeper and more accurate understanding of the critical causal mechanisms and endotypes of asthma is necessary to achieve the goal of clinical remission, which has the potential to generate real life-changing benefits for patients. This review aims to frame the evolution of the debated concept of clinical remission and provide clinicians with insights that may be helpful in achieving remission in the greatest number of patients.

Sinonasal Outcomes Obtained after 2 Years of Treatment with Benralizumab in Patients with Severe Eosinophilic Asthma and CRSwNP: A "Real-Life" Observational Study

BACKGROUND/OBJECTIVES

Benralizumab is a monoclonal antibody that targets the interleukin-5 receptor (IL-5Rα), leading to the rapid depletion of blood eosinophils. RCTs have demonstrated efficacy in patients with severe eosinophilic asthma (SEA). The aim of this study was to assess the efficacy of benralizumab on sinonasal outcomes in a real-life setting in patients with SEA and concomitant chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

We included 25 patients (mean age: 57.47 years, range: 35-77, F/M = 12:13) who were prescribed 30 mg benralizumab every month for the first three administrations and then every 2 months. The primary endpoint was to evaluate changes in the SinoNasal Outcome Test-22 (SNOT-22) and nasal polyp score (NPS) over a 24-month treatment period. Secondary endpoints included measuring the effects on nasal obstruction and impaired sense of smell.

RESULTS

The mean NPS score decreased significantly from 5.11 ± 1.84 at baseline to 2.37 ± 1.96 at 24 months. The mean SNOT-22 decreased from 57 ± 15.30 at baseline to 26 ± 16.73 at 24 months. The SSIT-16 mean score improved with an increase in olfactory performance from 5.23 ± 2.58 at baseline to 7 ± 3.65 at 24 months. Moreover, 8/25 patients (32%) required rescue treatment with systemic steroids and 2 patients required endoscopic sinus surgery.

CONCLUSIONS

While the improvement may not seem optimal at 12 months, a progressive enhancement was noted during the second year of treatment. Despite our data showing an improvement in quality of life and a reduction in the size of nasal polyps, no significant improvement in olfactory sensitivity was observed. In addition, in several patients, rescue treatments were required to maintain control of nasal and sinus symptoms. A careful risk-benefit assessment is therefore needed when deciding to continue treatment, weighing the potential for further improvement against the risks of complications. Such decisions should always be made in the context of a multidisciplinary team.

Revealing the gap: fractional exhaled nitric oxide and clinical responsiveness to biological therapy in severe asthma - a retrospective study

A proportion of patients with severe asthma treated with biological drugs undergoes a significant decline in F ENO. However, variations in F ENO are largely independent of the clinical efficacy of the biological drug therapy. https://bit.ly/3xWszYJ.

Salbutamol Easyhaler provides non-inferior relief of methacholine induced bronchoconstriction in comparison to Ventoline Evohaler with spacer: A randomized trial

BACKGROUND

Salbutamol is a cornerstone for relieving acute asthma symptoms, typically administered through a pressurized metered-dose inhaler (pMDI). Dry powder inhalers (DPIs) offer an alternative, but concerns exist whether DPIs provide an effective relief during an obstructive event.

OBJECTIVE

We aimed to show non-inferiority of Salbutamol Easyhaler DPI compared to pMDI with spacer in treating methacholine-induced bronchoconstriction. Applicability of Budesonide-formoterol Easyhaler DPI as a reliever was also assessed.

METHODS

This was a randomized, parallel-group trial in subjects sent to methacholine challenge (MC) test for asthma diagnostics. Participants with at least 20 % decrease in forced expiratory volume in 1 s (FEV1) were randomized to receive Salbutamol Easyhaler (2 × 200 μg), Ventoline Evohaler with spacer (4 × 100 μg) or Budesonide-formoterol Easyhaler (2 × 160/4.5 μg) as a reliever. The treatment was repeated if FEV1 did not recover to at least -10 % of baseline.

RESULTS

180 participants (69 % females, mean age 46 yrs [range 18-80], FEV1%pred 89.5 [62-142] %) completed the trial. Salbutamol Easyhaler was non-inferior to pMDI with spacer in acute relief of bronchoconstriction showing a -0.083 (95 % LCL -0.146) L FEV1 difference after the first dose and -0.032 (-0.071) L after the last dose. The differences in FEV1 between Budesonide-formoterol Easyhaler and Salbutamol pMDI with spacer were -0.163 (-0.225) L after the first and -0.092 (-0.131) L after the last dose.

CONCLUSION

The study confirms non-inferiority of Salbutamol Easyhaler to Ventoline Evohaler with spacer in relieving acute bronchoconstriction, making Easyhaler a sustainable and safe reliever for MC test and supports its use during asthma attacks.

Assessing meaningful change in the Asthma Impairment and Risk Questionnaire

BACKGROUND

The Asthma Impairment and Risk Questionnaire (AIRQ) is a 10-item, yes/no, equally weighted control tool. Lower scores indicate better control. Moreover, 7 impairment items reflect previous 2-week symptoms, and 3 risk items assess previous 12-month exacerbations. The Follow-up AIRQ for use between annual assessments has a 3-month recall period for exacerbation items.

OBJECTIVE

To evaluate the responsiveness of the AIRQ over time and identify a minimal important difference (MID).

METHODS

The AIRQ longitudinal study data were analyzed from patients with asthma aged 12 years and older. Anchor-based methods assessed differences in AIRQ scores relative to Patient Global Impression of Change, the accepted MIDs for St. George's Respiratory Questionnaire and Asthma Control Test, and exacerbation occurrence over 12 months. Baseline and 12-month data reflected 12-month recall AIRQ scores; Follow-up AIRQ scores were used for 3-, 6-, and 9-month analyses.

RESULTS

A total of 1070 patients were included. The Patient Global Impression of Change rating of "much improved" was associated with AIRQ mean score changes from baseline to months 3, 6, 9, and 12 of -2.0, -1.9, -1.9, and -1.8, respectively. The mean AIRQ score change among patients who met the St. George's Respiratory Questionnaire MID (≥4-point decrease) was -1.8 at 6 and 12 months. The AIRQ mean scores decreased from baseline by -2.2 to -2.5 points at months 3, 6, 9, and 12 for patients who met the Asthma Control Test MID (≥ 3-point increase). A 2-point higher baseline AIRQ score was associated with a 1.7 odds ratio of 12-month exacerbation occurrence (95% CI, 1.53-1.89).

CONCLUSION

A change score of 2 is recommended as the AIRQ MID.

Preschool impulse oscillometry predicts active asthma and impaired lung function at school age

BACKGROUND

Asthmatic symptoms often start during early childhood. Impulse oscillometry (IOS) is feasible in preschool children who may be unable to reliably perform spirometry measurements.

OBJECTIVE

We sought to evaluate the use of IOS in a multicenter, multiethnic high-risk asthma cohort titled the Vitamin D Antenatal Asthma Reduction Trial.

METHODS

The trial recruited pregnant women whose children were followed from birth to age 8 years. Lung function was assessed with IOS at ages 4, 5, and 6 years and spirometry at ages 5, 6, 7, and 8 years. Asthma status, respiratory symptoms, and medication use were assessed with repeated questionnaires from birth to age 8 years.

RESULTS

In total, 220 children were included in this secondary analysis. Recent respiratory symptoms and short-acting β2-agonist use were associated with increased respiratory resistance at 5 Hz at age 4 years (β = 2.6; 95% CI, 1.0 to 4.4; P = .002 and β = 3.4; 95% CI, 0.7 to 6.2; P = .015, respectively). Increased respiratory resistance at 5 Hz at age 4 years was also associated with decreased lung function from ages 5 to 8 years (β = -0.3; 95% CI, -0.5 to -0.1; P < .001 for FEV1 at 8 years) and active asthma at age 8 years (β = 2.0; 95% CI, 0.2 to 3.8; P = .029).

CONCLUSIONS

Increased respiratory resistance in preschool IOS is associated with frequent respiratory symptoms as well as school-age asthma and lung function impairment. Our findings suggest that IOS may serve as a potential objective measure for early identification of children who are at high risk of respiratory morbidity.

House dust mite allergen avoidance strategies for the treatment of allergic asthma: A hypothesis-generating meta-analysis

Background

This study continues the review by Gøtzsche and Johansen (Cochrane Database of Systematic Reviews, 2008, Art. No: CD001187), aiming to systematically generate hypotheses on the effectiveness of (sub)strategies for house dust mite allergen avoidance in the treatment of allergic asthma.

Methods

We used the trials previously analysed by Gøtzsche and Johansen and searched recently published studies. Data on asthma symptom scores (ASS), ACQ, number of improved patients, AQLQ-scores, medication use, FEV1%, PC20, and FeNO levels were analysed. The effectiveness of strategies was assessed using Metafor in R.

Results

Thirty-five trials involving 2419 patients were included in the final study. The patient-reported outcome number of patients with improved condition following total bedroom control was RR = 3.39 (95% confidence interval: 1.04 to 11.04, P = 0.04). The mean differences in the ASS by nocturnal air purification was -0.7 (95% confidence interval: -1.08 to -0.32, P < 0.001). Other outcomes including partial bedroom control were non-significant or clinically not of importance.

Conclusions

Total bedroom control and nocturnal air purification of the breathing zone hypothetically provides clinical benefits in patients with house dust mite-induced allergic asthma. The number of patients with improvements in their condition respectively the asthma symptom score differences showed potential in small subgroups, consisting of single studies. Partial bedroom control is not recommended.

Systematic Review Registration

Prospero CRD42022323660.

Standard medical therapy with vs. without nebulised magnesium for children with asthma decompensation

Pediatric asthma is a common condition, and its exacerbations can be associated with significant morbidity and mortality. The role of nebulised magnesium as adjunct therapy for children with asthma exacerbations is still unclear. To compare clinical and functional outcomes for children with asthma exacerbation taking either nebulised magnesium sulfate added to standard medical therapy (SMT) versus SMT alone. PubMed, Embase, and Cochrane Library were systematically searched for randomised clinical trials (RCT) comparing the use of SMT with vs. without nebulised magnesium. The outcomes were respiratory rate, heart rate, % predicted peak expiratory flow rate (PEFR), % predicted forced expiratory volume (FEV1), peripheral O2 saturation, asthma severity scores, and need for intravenous (IV) bronchodilator use. Twelve RCTs and 2484 children were included. Mean age was 5.6 (range 2-17) years old, mean baseline % predicted FEV1 was 69.6%, and 28.66% patients were male. Children treated with magnesium had a significantly higher % predicted PEFR (mean difference [MD] 5.33%; 95% confidence interval [CI] 4.75 to 5.90%; p < 0.01). Respiratory rate was significantly lower in the magnesium group (MD -0.70 respirations per minute; 95% CI -1.24 to -0.15; p < 0.01). Need for IV bronchodilators, % predicted FEV1, heart rate, asthma severity scores, and O2 saturation were not significantly different between groups.

CONCLUSION

In children with asthma exacerbation, treatment with nebulised magnesium and SMT was associated with a statistically significant, but small improvement in predicted PEFR and respiratory rate, as compared with SMT alone.

WHAT IS KNOWN

• Magnesium sulfate has bronchodilating properties and aids in the treatment of asthma exacerbation when administered intravenously. • There is no significant evidence of benefit of nebulised magnesium as an adjunct therapy to the standard medical treatment for children with asthma exacerbations.

WHAT IS NEW

• Our study suggests nebulised magnesium sulfate may have a statistically significant, but small benefit in respiratory rate and peak expiratory flow rate. The addition of nebulised magnesium does not seem to increase adverse events.

Biologic agents licensed for severe asthma: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Six biologic agents are now approved for patients with severe asthma. This meta-analysis aimed to assess the efficacy and safety of licensed biologic agents in patients with severe asthma, including the recently approved tezepelumab.

METHODS

We searched MEDLINE, Embase and CENTRAL to identify randomised controlled trials involving licensed biologics until 31 January 2023. We used random-effects meta-analysis models for efficacy, including subgroup analyses by individual agents and markers of T2-high inflammation (blood eosinophils and fractional exhaled nitric oxide), and assessed safety.

RESULTS

48 studies with 16 350 patients were included in the meta-analysis. Biologics were associated with a 44% reduction in the annualised rate of asthma exacerbations (rate ratio 0.56, 95% CI 0.51-0.62) and 60% reduction of hospitalisations (rate ratio 0.40, 95% CI 0.27-0.60), a mean increase in the forced expiratory volume in 1 s of 0.11 L (95% CI 0.09-0.14), a reduction in asthma control questionnaire by 0.34 points (95% CI -0.46--0.23) and an increase in asthma quality of life questionnaire by 0.38 points (95% CI 0.26-0.49). There was heterogeneity between different classes of biologics in certain outcomes, with overall greater efficacy in patients with T2 inflammation. Overall, biologics exhibited a favourable safety profile.

CONCLUSIONS

This comprehensive meta-analysis demonstrated that licensed asthma biologics reduce exacerbations and hospitalisations, improve lung function, asthma control and quality of life, and limit the use of systemic corticosteroids, with a favourable safety profile. These effects are more prominent in patients with evidence of T2 inflammation.

Feasibility of Home-Based Pulmonary Rehabilitation of Pediatric Patients with Chronic Respiratory Diseases

BACKGROUND AND OBJECTIVE

Chronic respiratory diseases in children deteriorate their daily life due to dyspnea and reduced lung function. We aimed to evaluate the feasibility of home-based pulmonary rehabilitation in pediatric chronic respiratory diseases.

METHODS

This prospective, single-arm, cohort study included children with chronic lung disease. They were instructed to perform home-based pulmonary rehabilitation 30 min/session, three sessions/week for three months. Pulmonary function test (PFT) using spirometry, respiratory muscle strength (RMT), cardiopulmonary exercise test (CPET), 6 min walk test (6MWT), dyspnea questionnaires, speech evaluation, and pediatric quality of life inventory (PedsQL) were assessed pre- and post-pulmonary rehabilitation. Compliance and satisfaction of the program were also evaluated.

RESULTS

Twenty children (mean age: 11.2 ± 3.1 years) with chronic respiratory diseases without cardiopulmonary instability participated. The overall compliance was 71.1% with no related adverse events. After pulmonary rehabilitation, forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), RMT, 6MWT, dyspnea questionnaire, speech rate, and PedsQL (child) significantly improved (p < 0.05), particularly better in the FEV1 < 60% group than in the FEV1 ≥ 60% group and in the high-compliance group (compliance ≥ 50%) than in the low-compliance group (compliance < 50%).

CONCLUSIONS

Home-based pulmonary rehabilitation for children with chronic lung disease was feasible with high compliance and effective in terms of objective functions, subjective dyspnea symptom, and quality of life.

Efficacy and safety of macrolide therapy for adult asthma: A systematic review and meta-analysis

BACKGROUND

The evidence for macrolide therapy in adult asthma is not properly established and remains controversial. We conducted a systematic review and meta-analysis to examine the efficacy and safety of macrolide therapy for adult asthma.

METHODS

We searched randomized controlled trials from MEDLINE via the PubMed, CENTRAL, and Ichushi Web databases. The primary outcome was asthma exacerbation. The secondary outcomes were serious adverse events (including mortality), asthma-related quality of life (symptom scales, Asthma Control Questionnaire, and Asthma Quality of Life Questionnaire), rescue medication (puffs/day), respiratory function (morning peak expiratory flow, evening peak flow, and forced expiratory volume in 1 s), bronchial hyperresponsiveness, and minimum oral corticosteroid dose. Of the 805 studies, we selected seven studies for the meta-analysis, which was conducted using a random-effects model.

SYSTEMATIC REVIEW REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (UMIN000050824).

RESULTS

No significant difference between macrolide and placebo for asthma exacerbations was observed (risk ratio 0.71, 95 % confidence interval [CI] 0.46-1.09; p = 0.12). Macrolide therapy for adult asthma showed a significant improvement in rescue medication with short-acting beta-agonists (mean difference -0.41, 95 % CI -0.78 to -0.04; p = 0.03). Macrolide therapy did not show more serious adverse events (odd ratio 0.61, 95 % CI 0.34-1.10; p = 0.10) than those with placebo. The other secondary outcomes were not significantly different between the macrolide and placebo groups.

CONCLUSIONS

Macrolide therapy for adult asthma may be more effective than placebo and could be a treatment option.

Improving asthma control and quality of life via a smartphone self-management app: A randomized controlled trial

BACKGROUND

Mobile phone applications (apps) show promise for enhancing asthma self-management, but their effectiveness varies. This study examined the effect of a smartphone asthma app on asthma control and quality of life.

METHODS

Using block randomization, 60 patients with asthma were allocated to an intervention group (n = 30) or control group (n = 30) for this single-blind randomized controlled trial. At baseline, both groups completed the Asthma Control Test (ACT) and Asthma Quality of Life Questionnaire-Marks (AQLQ-M). The intervention group used a smartphone-based asthma self-management app plus their regular treatment, while the control group received only usual care. Follow-up ACT and AQLQ-M assessments occurred at 3 and 6 months. SPSS version 26 was used for analysis, including descriptive statistics, non-parametric tests (Wilcoxon and Mann-Whitney U), and analysis of variance with repeated measurements.

RESULTS

Both groups showed improved asthma control and quality of life at 3 and 6 months compared to baseline. However, after 6 months the intervention group had significantly greater improvement than controls (p < 0.05). Repeated measures ANOVA revealed divergent changes in ACT and AQLQ-M scores over time, with the intervention group demonstrating greater enhancement of asthma control and quality of life (p < 0.001).

CONCLUSION

This study demonstrated that use of a smartphone-based asthma self-management app improved asthma control and quality of life after 6 months compared to usual care alone. These findings indicate that guideline-based asthma apps can positively impact outcomes.

Long-Term Effectiveness of Benralizumab in Eosinophilic Granulomatosis With Polyangiitis

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystemic disease characterized by eosinophilic tissue inflammation. Benralizumab, an anti-IL-5 receptor (anti-IL-5R) monoclonal antibody, induces rapid depletion of eosinophils; its longer-term effect in EGPA is unknown.

OBJECTIVE

To assess the real-world effectiveness and clinical remission rates of anti-IL-5R therapy in EGPA.

METHODS

We performed a retrospective cohort analysis of patients with EGPA, who commenced treatment with benralizumab. Clinical remission, assessed at 1 year and 2 years after the initiation of benralizumab, was defined as an absence of active vasculitis (Birmingham Vasculitis Activity Score of 0) and an oral corticosteroid (OCS) dose of ≤4 mg/d of prednisolone. "Super-responders" were defined as patients in remission and free of any significant relapses (asthma or extrapulmonary) over the preceding 12 months. The corticosteroid-sparing capacity of benralizumab, patient-reported outcome measures, and characteristics associated with clinical remission and super-responder status were also analyzed.

RESULTS

A total of 70 patients completed at least 1 year of treatment with benralizumab, of whom 53 completed 2 years. Of 70 patients, 47 (67.1%) met the definition for clinical remission at 1 year, with a similar proportion in remission at 2 years. Excluding asthma-related relapses, 61 of 70 (87.1%) patients were relapse free at 1 year, and of the 53 who completed 2 years, 45 (84.9%) were relapse free. A total of 67.9% of patients no longer needed any OCS for disease control. No significant difference was seen between antineutrophilic cytoplasmic antibody (ANCA)-positive and ANCA-negative subgroups.

CONCLUSIONS

In this real-world setting of patients with EGPA, treatment with benralizumab was well tolerated and resulted in corticosteroid-free clinical remission for the majority of patients.

Cost-effectiveness and resource use analysis of patients with asthma before and after treatment with mepolizumab in a real-life setting

OBJECTIVE

To define the cost-effectiveness and health resource use of mepolizumab in a cohort of patients with severe eosinophilic asthma in real-life conditions in Spain.

METHODS

This was an observational, retrospective, single-center study. Patients included were diagnosed with severe eosinophilic asthma and treated with mepolizumab 100 mg subcutaneous (SC) 4-weekly for 12 months. Outcomes evaluated: incremental cost-effectiveness ratio (ICER), number of exacerbations, disease control with the Asthma Control Test (ACT), Asthma Quality of Life Questionnaire (AQLQ), and direct and indirect cost per patient.

RESULTS

12 months after mepolizumab initiation, a significant decrease in exacerbations was shown, from a mean (standard deviation [SD]) of 3.1 (2.6) to 0.7 (1.5), an increase from 4.9 (0.4) to 6.1 (0.5) in AQLQ, and from 14.9 (5.7) to 21.5 (3.9) in ACT scores. The number of cortico-dependent patients significantly decreased from 53.3% to 13.3% during this period. There was a significant decrease of 94% in the cost of hospitalization, from a mean (SD) of €4063.9 (5423.9) pretreatment to €238.6 (1306.9) post-treatment (p = 0.0003). Total costs decreased significantly from a median of €2,423.1 (1,512.8; 9,320.9) pretreatment to €1,177.5 (965.0; 1,737.8) post-treatment if mepolizumab was excluded. ICER per exacerbation avoided was €3606.9, per 3-point ACT score increase €3934.8, and per 0.5-point AQLQ score increase €3606.9.

CONCLUSIONS

Mepolizumab improves control of asthma and quality of life in patients with severe diseases in a cost-effectiveness range. The number of exacerbations decreased, and there was a clear reduction in primary care visits and hospitalizations. Further economic analyses of biological therapies for asthma are required.

How have we measured trial outcomes of asthma attack treatment? A systematic review

Background

Asthma attacks are a common problem for people with asthma and are responsible for significant healthcare costs. There is interest in a precision medicine approach to treatment. However, the choice of trial outcome measures for asthma attack treatment is hampered by the absence of a consensus on suitability. We carried out a systematic review to understand the characteristics of outcome measures used in randomised controlled trials of asthma attack treatment. Have randomised controlled trials of asthma attack treatment measured outcomes that are useful to patients and healthcare providers?

Methods

The protocol was registered on PROSPERO (CRD42022311479). We searched for randomised controlled trials comparing treatments for adults with asthma attacks, published in English between 1972 and 2022 on MEDLINE, Embase and Cochrane Library databases. We recorded the outcome measures and study characteristics.

Results

We identified 208 eligible randomised controlled trials from 35 countries. Trials ranged from 12 to 1109 participants, with a median of 60. The most common settings were the emergency department (n=165) and hospital admission (n=33). Only 128 studies had primary and secondary outcomes defined clearly. In those that did, 73% of primary outcomes measured change in lung function or other physiological parameters over a short period (usually <24 h). Patient-reported and healthcare utilisation outcomes were the primary outcome in 27%.

Conclusions

Outcomes in randomised controlled trials of asthma attack treatment focus on short-term changes in lung function and may not capture patient-centred and economically important longer-term measures. More work is needed to investigate patient and other stakeholder preferences on core outcome sets.

Benralizumab and mepolizumab treatment outcomes in two severe asthma clinics

BACKGROUND AND OBJECTIVE

This study compared the clinical outcomes of severe asthmatics treated with mepolizumab and benralizumab in a tertiary care severe asthma service setting.

METHODS

Patient data at baseline, six and 12 months were collected prospectively at two large tertiary hospital severe asthma clinics following treatment initiation. Two hundred and four patients received treatment with mepolizumab (117) or benralizumab (87). Baseline characteristics between groups were similar in regard to age, gender, body mass index, steroid dose and blood eosinophil count. However, the mepolizumab cohort had a higher Asthma Control Questionnaire Score (ACQ) at baseline (4.0 ± 1.1 vs. 3.6 ± 0.9, p = 0.018), accompanied by more frequent reliever medication usage and lower prebronchodilator FEV1 % (56.0 ± 20.1 vs. 63.8 ± 18.9, p = 0.008).

RESULTS

After 6 months treatment, both treatments induced significant improvements in (i) ACQ of 2.3 ± 0.1 (p < 0.001), (ii) oral steroid requiring exacerbations (incident rate ratio 0.26 (0.18-0.37), p < 0.001) and (iii) FEV1 . However, the improvement in FEV1 was 0.18 (0.05-0.30) litres greater with benralizumab than with mepolizumab (p = 0.002) even when adjusting statistically for baseline differences between groups. These differences were even more pronounced at 12 months post-treatment initiation, when the improvement in exacerbation frequency with benralizumab was 64% greater than with mepolizumab (p = 0.01). Whilst both treatments significantly reduced the blood eosinophil count at 6 and 12 months, this reduction was substantially greater with benralizumab than mepolizumab (-260 cells/μL [-400 to -110, p = 0.001]).

CONCLUSION

In this large group of severe eosinophilic asthmatics, mepolizumab and benralizumab both improved disease parameters. However, benralizumab treatment appeared significantly more effective than mepolizumab in reducing exacerbations, improving FEV1 and depleting blood eosinophils.

The effect of fine-particle size and extrafine particle size inhaled corticosteroid in reducing airway resistance in asthmatic patients

Background

Bronchial asthma is characterised by chronic inflammation of both large and small airways. Extra-fine formulation of inhaled corticosteroid (ICS) can achieve a higher peripheral lung deposition leading to improved asthma control. We investigated the effect of extra-fine and fine particle size inhaled ICS with airway resistance and severity of symptoms in asthmatic patients.

Methods

Prospective interventional study of outpatient asthmatics in Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Subjects were grouped based on pre-existing inhalers; extra-fine and fine inhaled corticosteroid (ICS)/long acting beta agonist (LABA). Crossover was at week 7 and treatment regime continued for 7 weeks. Subjects were assessed at week 0, 6 and 13 using asthma control test (ACT) score, forced expiratory volume in 1 s (FEV1) and impulse oscillometry (IOS) Inhaler technique was assessed periodically.

Results

Thirty-four subjects were recruited. Median asthma duration was 20 years. Twenty subjects (58%) in fine ICS/LABA and 14 (42%) in extra-fine ICS/LABA group. Thirty-one subjects were analysed before crossver. There was a significant improvement of FEV1 in the extra-fine ICS/LABA group (1.7 ± 0.47 to 1.88 ± 0.5; p = 0.01). ACT score reduced significantly in extra-fine ICS/LABA group (23 ± 5 to 21 ± 4; p = 0.04) at week 0–6. Week 7–13 showed a significant improvement of ACT score (16.5 ± 3 to 20 ± 3; p = 0.01) and FEV1 (1.71 ± 0.96 to 1.81 ± 1.02: p = 0.01) in extra-fine ICS/LABA. There was no significant difference in (IOS) parameters between the groups.

Conclusion

There was an improvement of FEV1 and ACT score with extra-fine ICS/LABA with no benefit in airway resistance.

Mepolizumab in Patients With Severe Asthma and Comorbidities: 1-Year REALITI-A Analysis

BACKGROUND

Severe asthma is complex; comorbidities may influence disease outcomes.

OBJECTIVE

To assess mepolizumab effectiveness in patients with severe asthma and comorbidities.

METHODS

REALITI-A was a 2-year international, prospective study enrolling adults with asthma newly prescribed mepolizumab (100 mg subcutaneously) at physician's discretion. This post hoc analysis assessed 1-year outcomes stratified by comorbidities at enrollment: chronic rhinosinusitis with nasal polyps (CRSwNP), gastroesophageal reflux disease (GERD), depression/anxiety, and chronic obstructive pulmonary disease (COPD). Outcomes included the rate of clinically significant asthma exacerbations (CSEs; requiring systemic corticosteroids and/or hospital/emergency room admission) between the 12 months pre- and post-mepolizumab treatment and changes from baseline in daily maintenance oral corticosteroid dose (mo 12), Asthma Control Questionnaire-5 score (mo 12) and forced expiratory volume in 1 second (FEV1; mo 9-12).

RESULTS

At enrollment (n = 822), 321 of 822 (39%), 309 of 801 (39%), 203 of 785 (26%), and 81 of 808 (10%) patients had comorbid CRSwNP, GERD, depression/anxiety, and COPD, respectively. Post- versus pre-treatment across all comorbidity subgroups: the rate of CSEs decreased by 63% or more; among 298 (39%) patients on maintenance oral corticosteroids at baseline, median dose decreased by 50% or more; Asthma Control Questionnaire-5 score decreased by 0.63 or more points; FEV1 increased by 74 mL or more. Patients with versus without CRSwNP had the greatest improvements (eg, rate of CSEs decreased by 75%). Patients without GERD, depression/anxiety, or COPD had greater improvements than those with the respective comorbidities, except for FEV1 in patients with COPD.

CONCLUSIONS

Mepolizumab improved disease outcomes in patients with severe asthma irrespective of comorbidities, with additional benefit for patients with CRSwNP.

Efficacy of Biologics in Patients with Allergic Severe Asthma, Overall and by Blood Eosinophil Count: A Literature Review

Patients with uncontrolled, allergic severe asthma may be prescribed biologic therapies to reduce exacerbations and improve disease control. Randomized controlled trials (RCTs) of these therapies have differed in design, with varying results overall and by baseline blood eosinophil count (BEC). This study describes published annualized asthma exacerbation rate (AAER) reductions from RCTs in patients with allergic severe asthma, overall and by baseline BEC category. A literature search was performed to identify published phase 3 RCT data of US Food and Drug Administration-approved biologics for severe asthma in patients with severe, uncontrolled asthma and confirmed sensitization to perennial aeroallergens. Analyses focused on AAER reduction versus placebo in the overall population and/or in those with an elevated or low BEC at baseline or screening. Baseline serum total immunoglobulin E levels varied between RCT populations. In patients with allergic severe asthma across all BEC categories, data were available for tezepelumab, dupilumab, benralizumab and omalizumab only; the greatest AAER reduction was observed with tezepelumab. In patients with allergic severe asthma and BECs of ≥ 260 cells/µL or ≥ 300 cells/μL, AAER reductions were observed with all biologics (tezepelumab, dupilumab, mepolizumab, benralizumab and omalizumab); the greatest AAER reduction was observed with tezepelumab and the smallest AAER reduction was observed with omalizumab. In patients with allergic severe asthma and BECs of < 260 cells/µL or < 300 cells/μL (regardless of historical BEC), an AAER reduction was observed with tezepelumab but not with benralizumab or omalizumab. Differential mechanisms of action may explain the differences in results observed between biologics. Among patients with allergic severe asthma, the efficacy of biologics in RCTs varied considerably overall and by BEC. Tezepelumab was the only biologic to demonstrate AAER reductions consistently across all subgroups. These differences can inform provider treatment decisions when selecting biologic treatments for patients with allergic severe asthma.

Phenotyping the Responses to Systemic Corticosteroids in the Management of Asthma Attacks (PRISMA): protocol for an observational and translational pilot study

INTRODUCTION

Asthma and its associated exacerbation are heterogeneous. Although severe asthma attacks are systematically prescribed corticosteroids and often antibiotics, little is known about the variability of response to these therapies. Blood eosinophils and fractional exhaled nitric oxide (FeNO) are type 2 inflammation biomarkers that have established mechanistic, prognostic and theragnostic values in chronic asthma, but their utility in acute asthma is unclear. We speculate that the clinical and biological response to those treatments varies according to inflammometry and microbiological test results.

METHODS AND ANALYSIS

An observational longitudinal pilot study with multimodal clinical and translational assessments will be performed on 50 physician-diagnosed ≥12-year-old asthmatics presenting with an asthma attack and 12 healthy controls, including blood eosinophil count (venous and point-of-care (POC) capillary blood), FeNO and testing for airway infection (sputum cultures and POC nasopharyngeal swabs). People with asthma will be assessed on day 0 and after a 7-day corticosteroid course, with home monitoring performed in between. The primary analysis will be the change in the forced expiratory volume in 1 s according to type 2 inflammatory status (blood eosinophils ≥0.15×109/L and/or FeNO ≥25 ppb) after treatment. Key secondary analyses will compare changes in symptom scores and the proportion of patients achieving a minimal clinically important difference. Exploratory analyses will assess the relationship between clinical, lung function, inflammatory and microbiome parameters; satisfaction plus reliability indices of POC tests; and sex-gender variability in treatment response. Ultimately, this pilot study will serve to plan a larger trial comparing the clinical and biological response to systemic corticosteroids according to inflammatory biomarkers, offering valuable guidance for more personalised therapeutic strategies in asthma attacks.

ETHICS AND DISSEMINATION

The protocol has been approved by the Research Ethics Committee of the CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada (#2023-4687). Results will be communicated in an international meeting and submitted to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05870215).

Bronchial thermoplasty attenuates bronchodilator responsiveness

INTRODUCTION

Bronchial thermoplasty is an effective intervention to improve respiratory symptoms and to reduce the rate of exacerbations in uncontrolled severe asthma. A reduction in airway smooth muscle is arguably the most widely discussed mechanisms accounting for these clinical benefits. Yet, this smooth muscle reduction should also translate into an impaired response to bronchodilator drugs. This study was designed to address this question.

METHODS

Eight patients with clinical indication for thermoplasty were studied. They were uncontrolled severe asthmatics despite optimal environmental control, treatment of comorbidities, and the use of high-dose inhaled corticosteroids and long-acting β2-agonists. Lung function measured by spirometry and respiratory mechanics measured by oscillometry were examined pre- and post-bronchodilator (salbutamol, 400 μg), both before and at least 1 year after thermoplasty.

RESULTS

Consistent with previous studies, thermoplasty yielded no benefits in terms of baseline lung function and respiratory mechanics, despite improving symptoms based on two asthma questionnaires (ACQ-5 and ACT-5). The response to salbutamol was also not affected by thermoplasty based on spirometric readouts, including forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio. However, a significant interaction was observed between thermoplasty and salbutamol for two oscillometric readouts, namely reactance at 5 Hz (Xrs5) and reactance area (Ax), showing an attenuated response to salbutamol after thermoplasty.

CONCLUSIONS

Thermoplasty attenuates the response to a bronchodilator. We argue that this result is a physiological proof of therapeutic efficacy, consistent with the well-described effect of thermoplasty in reducing the amount of airway smooth muscle.

Asthma improvement in patients treated with dupilumab for severe atopic dermatitis

Introduction

Atopic dermatitis (AD) is considered a systemic type 2 immune driven disease, and it is associated to many atopic comorbidities including asthma. The aim of our study was to prospectively evaluate the respiratory outcomes in patients with persistent allergic asthma treated with dupilumab due to severe AD (sAD).

Methods

We enrolled eligible patients with sAD for dupilumab treatment from September 2018 to December 2020. We then selected the subgroup of patients sensitized to perennial allergens. Dupilumab's efficacy and safety on AD and comorbid asthma were assessed at baseline, one month, four months, and then every 4 months up to one year.

Results

A total of 437 patients with sAD were enrolled for dupilumab treatment due to sAD, and 273 reached 48 weeks of therapy. Respiratory outcomes were evaluated in the 85 asthmatic patients with positivity only to perennial allergens. Our patients showed statistically and clinically significant improvement in asthma control (Asthma Control Test and Asthma Control Questionnaire) and airway obstruction parameters (FEV1), in addition to the expected AD-related skin outcomes. Specifically, a significant improvement was achieved at the fourth month of dupilumab therapy, and this trend was maintained up to twelve months, regardless of asthma severity.

Conclusions

Our results showed the overall improvement of the clinical picture that dupilumab offers for patients with severe AD and persistent allergic asthma of any severity, highlighting the importance of a global multidisciplinary approach of type 2 driven disease.

The Anti-Inflammatory Reliever (AIR) Algorithm Study: a protocol for a single-group study of an AIR stepwise approach to the treatment of adult asthma

Background

The stepwise approach to long-term asthma management, which traditionally incorporates short-acting β2-agonist reliever therapy, has been a core feature of asthma guidelines for over 30 years. There have been no studies, however, directly investigating the use of an entire guideline-recommended track. Recently, inhaled corticosteroid-formoterol has been recommended as the preferred reliever therapy in adult asthma, in accordance with a stepwise "Anti-Inflammatory Reliever" (AIR) treatment track.

Objective

The aim of this study was to evaluate the AIR stepwise approach recommended by the New Zealand adolescent and adult asthma guidelines, in combination with a novel algorithm for transitioning between treatment steps.

Methods

This 52-week, open-label, single-group study will recruit 100 adults aged 18 to 75 years with mild, moderate and moderate-severe asthma (ACTRN12620001010987). Participants will be allocated to budesonide-formoterol 200/6 µg, one actuation as needed (Step 1), one actuation twice daily and as needed (Step 2), or two actuations twice daily and one as needed (Step 3). Treatment steps will be adjusted throughout the study, in response to reliever use and asthma attacks, according to a stepwise AIR algorithm. Following a 26-week period of investigator-led transitions, participants will adjust their own treatment step. The primary outcome is participant satisfaction as measured by the Global Satisfaction score of the Treatment Satisfaction Questionnaire for Medication. Secondary outcomes will assess efficacy and safety, and describe patterns of medication use and participant flow through the treatment steps.

Conclusion

This is the first trial to assess the AIR treatment track and algorithm. The results will provide knowledge to guide the clinical use of this approach.

Long-Term Efficacy of Mepolizumab at 3 Years in Patients with Severe Asthma: Comparison with Clinical Trials and Super Responders

The efficacy mepolizumab in severe asthmatic patients is proven in the literature. Primarily to study the effect of mepolizumab on exacerbations, steroid dependence, and the continuation of efficacy in the long term. Secondarily to evaluate the effect of the drug on nasal polyps. Analyzing data from SANI (Severe Asthma Network Italy) clinics, we observed severe asthmatic patients treated with mepolizumab 100 mg/4 weeks, for a period of 3 years. 157 patients were observed. Exacerbations were reduced from the first year (-84.6%) and progressively to 90 and 95% in the second and third ones. Steroid-dependent patients decreased from 54% to 21% and subsequently to 11% in the second year and 6% in the third year. Patients with concomitant nasal polyps, assessed by SNOT-22, showed a 49% reduction in value from baseline to the third year. The study demonstrated the long-term efficacy of mepolizumab in a real-life setting.

Effectiveness of FeNO-guided treatment in adult asthma patients: A systematic review and meta-analysis

OBJECTIVE

Asthma control is generally monitored by assessing symptoms and lung function. However, optimal treatment is also dependent on the type and extent of airway inflammation. Fraction of exhaled Nitric Oxide (FeNO) is a noninvasive biomarker of type 2 airway inflammation, but its effectiveness in guiding asthma treatment remains disputed. We performed a systematic review and meta-analysis to obtain summary estimates of the effectiveness of FeNO-guided asthma treatment.

DESIGN

We updated a Cochrane systematic review from 2016. Cochrane Risk of Bias tool was used to assess risk of bias. Inverse-variance random-effects meta-analysis was performed. Certainty of evidence was assessed using GRADE. Subgroup analyses were performed based on asthma severity, asthma control, allergy/atopy, pregnancy and obesity.

DATA SOURCES

The Cochrane Airways Group Trials Register was searched on 9 May 2023.

ELIGIBILITY CRITERIA

We included randomized controlled trials (RCTs) comparing the effectiveness of a FeNO-guided treatment versus usual (symptom-guided) treatment in adult asthma patients.

RESULTS

We included 12 RCTs (2,116 patients), all showing high or unclear risk of bias in at least one domain. Five RCTs reported support from a FeNO manufacturer. FeNO-guided treatment probably reduces the number of patients having ≥1 exacerbation (OR = 0.61; 95%CI 0.44 to 0.83; six RCTs; GRADE moderate certainty) and exacerbation rate (RR = 0.67; 95%CI 0.54 to 0.82; six RCTs; moderate certainty), and may slightly improve Asthma Control Questionnaire score (MD = -0.10; 95%CI -0.18 to -0.02, six RCTs; low certainty), however, this change is unlikely to be clinically important. An effect on severe exacerbations, quality of life, FEV1, treatment dosage and FeNO values could not be demonstrated. There were no indications that effectiveness is different in subgroups of patients, although evidence for subgroup analysis was limited.

CONCLUSIONS

FeNO-guided asthma treatment probably results in fewer exacerbations but may not have clinically important effects on other asthma outcomes.

Efficacy of Biologics in Severe, Uncontrolled Asthma Stratified by Blood Eosinophil Count: A Systematic Review

INTRODUCTION

Randomized controlled trials (RCTs) of biologics in patients with severe, uncontrolled asthma have shown differential results by baseline blood eosinophil count (BEC). In the absence of head-to-head trials, we describe the effects of biologics on annualized asthma exacerbation rate (AAER) by baseline BEC in placebo-controlled RCTs. Exacerbations associated with hospitalization or an emergency room visit, pre-bronchodilator forced expiratory volume in 1 s, Asthma Control Questionnaire score, and Asthma Quality of Life Questionnaire score were also summarized.

METHODS

MEDLINE (via PubMed) was searched for RCTs of biologics in patients with severe, uncontrolled asthma and with AAER reduction as a primary or secondary endpoint. AAER ratios and change from baseline in other outcomes versus placebo were compared across baseline BEC subgroups. Analysis was limited to US Food and Drug Administration-approved biologics.

RESULTS

In patients with baseline BEC ≥ 300 cells/μL, AAER reduction was demonstrated with all biologics, and other outcomes were generally improved. In patients with BEC 0 to < 300 cells/μL, consistent AAER reduction was demonstrated only with tezepelumab; improvements in other outcomes were inconsistent across biologics. In patients with BEC 150 to < 300 cells/μL, consistent AAER reduction was demonstrated with tezepelumab and dupilumab (300 mg dose only), and in those with BEC 0 to < 150 cells/μL, AAER reduction was demonstrated only with tezepelumab.

CONCLUSION

The efficacy of all biologics in reducing AAER in patients with severe asthma increases with higher baseline BEC, with varying profiles across individual biologics likely due to differing mechanisms of action.

Benralizumab in Patients with Severe Eosinophilic Asthma: A Multicentre Real-Life Experience

BACKGROUND

Mepolizumab and benralizumab are monoclonal antibodies directed against anti-IL-5 and anti-IL5R, respectively, and their use reduces the exacerbation rate and maintains oral corticosteroid requirements in severe eosinophilic asthma. Previous studies have tested the therapeutic switch between two biologics with excellent results, further demonstrating the heterogeneity of asthmatic disease and the complexity of the therapeutic choice. It remains unclear if such patients may improve following a switch from mepolizumab to benralizumab.

AIMS

Within a multicentre real-life setting, we decided to evaluate the potential effectiveness of a therapeutic switch to benralizumab in patients with severe eosinophilic asthma initially treated with mepolizumab, who experienced sub-optimal responses. The secondary aim was to identify the clinical factors associated with a better response to benralizumab.

METHODS

We retrospectively assessed patients with severe eosinophilic asthma treated at six Italian specialist centres, who were switched from mepolizumab to benralizumab following a sub-optimal response, defined as a partial or total lack of clinical remission (i.e., frequent severe exacerbations and/or poorly controlled symptoms and/or higher OCS daily use in patients with a poor or moderate response in the global evaluation of treatment effectiveness scale), after at least 12 months of treatment.

RESULTS

Twenty-five patients were included in the analysis (mean age 56.76 ± 11.97 years, 65% female). At 6 months of treatment with benralizumab, the ACT score was significantly higher than the ACT score with mepolizumab (20.24 ± 3.38 vs. 16.77 ± 3.48, p < 0.0001); the mean number of daily SABA inhalations was significantly lower after 6 months and 12 months of treatment with benralizumab than that after treatment with mepolizumab; OCS intake and the prednisone median dosage at 6 months of treatment with benralizumab were significantly lower than those with mepolizumab. Benralizumab treatment resulted in a marked improvement in asthma control, suppressed blood eosinophil levels and reduction in the number of exacerbations in the subgroup of patients with severe eosinophilic asthma and nasal polyposis.

CONCLUSIONS

Patients diagnosed with severe eosinophilic asthma who experience a partial response to mepolizumab could benefit from switching to benralizumab, and even more those who have nasal polyposis.

Effect of Hydration on Pulmonary Function and Development of Exercise-Induced Bronchoconstriction among Professional Male Cyclists

BACKGROUND

Exercise-induced bronchoconstriction (EIB) is a common problem in elite athletes. Classical pathways in the development of EIB include the osmotic and thermal theory as well as the presence of epithelial injury in the airway, with local water loss being the main trigger of EIB. This study aimed to investigate the effects of systemic hydration on pulmonary function and to establish whether it can reverse dehydration-induced alterations in pulmonary function.

MATERIALS AND METHODS

This follow-up study was performed among professional cyclists, without a history of asthma and/or atopy. Anthropometric characteristics were recorded for all participants, and the training age was determined. In addition, pulmonary function tests and specific markers such as fractional exhaled nitric oxide (FeNO) and immunoglobulin E (IgE) were measured. All the athletes underwent body composition analysis and cardiopulmonary exercise testing (CPET). After CPET, spirometry was followed at the 3rd, 5th, 10th, 15th, and 30th min. This study was divided into two phases: before and after hydration. Cyclists, who experienced a decrease in Forced Expiratory Volume in one second (FEV₁) ≥ 10% and/or Maximal Mild-Expiratory Flow Rate (MEF_25-75) ≥ 20% after CPET in relation to the results of the spirometry before CPET, repeated the test in 15-20 days, following instructions for hydration.

RESULTS

One hundred male cyclists (n = 100) participated in Phase A. After exercise, there was a decrease in all spirometric parameters (p < 0.001). In Phase B, after hydration, in all comparisons, the changes in spirometric values were significantly lower than those in Phase A (p < 0.001).

CONCLUSIONS

The findings of this study suggest that professional cyclists have non-beneficial effects on respiratory function. Additionally, we found that systemic hydration has a positive effect on spirometry in cyclists. Of particular interest are small airways, which appear to be affected independently or in combination with the decrease in FEV₁. Our data suggest that pulmonary function improves systemic after hydration.

Air Quality Index and Childhood Asthma: A Pilot Randomized Clinical Trial Intervention

INTRODUCTION

To reduce air pollution exposure, the U.S. asthma guidelines recommend that children check the Air Quality Index before outdoor activity. Whether adding the Air Quality Index and recommendations to asthma action plans reduces exacerbations and improves control and quality of life in children with asthma is unknown.

METHODS

A pilot, unblinded, randomized clinical trial of 40 children with persistent asthma, stratified by age and randomized 1:1, recruited from the University of Pittsburgh Medical Center Children's Hospital of Pittsburgh (Pittsburgh, PA) was conducted. All participants received asthma action plans and Air Quality Index education. The intervention group received printed Air Quality Index information and showed the ability to use AirNow. Asthma exacerbations were assessed through a questionnaire, asthma control was assessed with the Asthma Control Test and Childhood Asthma Control Test, and quality of life was assessed with the Pediatric Asthma Quality of Life Questionnaire. After randomization (July-October 2020), participants were followed monthly for 6 months (exit January-March 2021). Outcome differences between groups were evaluated at the exit visit and over time (analysis was in 2021).

RESULTS

At randomization, there were no significant differences in age, sex, race, or asthma severity. At exit, more intervention participants checked the Air Quality Index (63% vs 15%) with no differences in the proportion of asthma exacerbations or mean Childhood Asthma Control Test or Pediatric Asthma Quality of Life Questionnaire scores. The mean change in Asthma Control Test score was higher in the intervention group (change in Asthma Control Test=2.00 vs 0.15 for the control), which was modified by time (β=1.85, CI=0.09, 3.61). Physical activity was decreased overall and showed modification by treatment and time.

CONCLUSIONS

Addition of the Air Quality Index to asthma action plans led to improved asthma control by Asthma Control Test scores but may decrease outdoor activity.

Effects of Tezepelumab on Quality of Life of Patients with Moderate-to-Severe, Uncontrolled Asthma: Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

To assess the effects of tezepelumab on quality of life (QoL) in patients with moderate-to-severe, uncontrolled asthma.

RECENT FINDINGS

Tezepelumab improves pulmonary function tests (PFTs) and reduces the annualized asthma exacerbation rate (AAER) in patients with moderate-to-severe, uncontrolled asthma. We searched MEDLINE, Embase, and Cochrane Library from inception to September 2022. We included randomized controlled trials comparing tezepelumab versus placebo in patients aged ≥ 12 years with asthma on medium- or high-dose inhaled corticosteroids with ≥ 1 additional controller medication for ≥ 6 months and who had ≥ 1 asthma exacerbation in the 12 months before enrollment. We estimated effects measures with a random-effects model. Of 239 records identified, three studies were included, with a total of 1,484 patients. Tezepelumab significantly decreased biomarkers of T helper 2-driven inflammation, including blood eosinophil count (MD -135.8 [95% CI -164.37, -107.23]) and fractional exhaled nitric oxide (MD -9.64 [95% CI -13.75, -5.53]); improved PFTs, including pre-bronchodilator forced expiratory volume in 1 s (MD 0.18 [95% CI 0.08-0.27]); reduced the AAER (MD 0.47 [95% CI 0.39-0.56]); improved asthma-specific health-related QoL in the Asthma Control Questionnaire-6 (MD -0.33 [95% CI -0.34, -0.32]), Asthma Quality of Life Questionnaire for 12 Years and Older (MD 0.34 [95% CI 0.33, -0.35]), Asthma Symptom Diary (MD -0.11 [95% CI -0.18, -0.04]), and European Quality of Life 5 Dimensions 5 Levels Questionnaire (SMD 3.29 [95% CI 2.03, 4.55]) scores, although not clinically important; and did not change key safety outcomes, including any adverse event (OR 0.78 [95% CI 0.56-1.09]).