Weekly low-dose methotrexate for reduction of Global Initiative for Asthma Step 5 treatment in severe refractory asthma: study protocol for a randomized controlled trial

Rheumatoid arthritis and changes on spirometry by smoking status in two prospective longitudinal cohorts

OBJECTIVE

To compare longitudinal changes in spirometric measures between patients with rheumatoid arthritis (RA) and non-RA comparators.

METHODS

We analysed longitudinal data from two prospective cohorts: the UK Biobank and COPDGene. Spirometry was conducted at baseline and a second visit after 5-7 years. RA was identified based on self-report and disease-modifying antirheumatic drug use; non-RA comparators reported neither. The primary outcomes were annual changes in the per cent-predicted forced expiratory volume in 1 s (FEV1%) and per cent predicted forced vital capacity (FVC%). Statistical comparisons were performed using multivariable linear regression. The analysis was stratified based on baseline smoking status and the presence of obstructive pattern (FEV1/FVC <0.7).

RESULTS

Among participants who underwent baseline and follow-up spirometry, we identified 233 patients with RA and 37 735 non-RA comparators. Among never-smoking participants without an obstructive pattern, RA was significantly associated with more FEV1% decline (β=-0.49, p=0.04). However, in ever smokers with ≥10 pack-years, those with RA exhibited significantly less FEV1% decline than non-RA comparators (β=0.50, p=0.02). This difference was more pronounced among those with an obstructive pattern at baseline (β=1.12, p=0.01). Results were similar for FEV1/FVC decline. No difference was observed in the annual FVC% change in RA versus non-RA.

CONCLUSIONS

Smokers with RA, especially those with baseline obstructive spirometric patterns, experienced lower FEV1% and FEV1/FVC decline than non-RA comparators. Conversely, never smokers with RA had more FEV1% decline than non-RA comparators. Future studies should investigate potential treatments and the pathogenesis of obstructive lung diseases in smokers with RA.

Sodium houttuynia alleviates airway inflammation in asthmatic mice by regulating FoxP3/RORγT expression and reversing Treg/Th17 cell imbalance

Synthetized from a natural oil of Houttuynia cordata, sodium houttuynia was reported to have anti-inflammatory effects. The present study aimed to investigate whether sodium houttuynia could alleviate the characteristic airway inflammation and Treg/Th17 cell imbalance of asthma in vivo. Experimental mice with neutrophilic asthma were injected with sodium houttuynia or dexamethasone (alone or in combination) intraperitoneally. The airway reactivity was measured, and bronchoalveolar lavage fluid was collected for cell count. Hematoxylin/eosin and periodic acid-Schiff staining were performed to assess pulmonary inflammation and mucus hypersecretion. Immunohistochemical analysis was conducted to determine the expression of IL-10, IL-17A, FoxP3, and RORγT in the lung tissue, and the serum levels of IL-10 and IL-17A were analyzed by ELISA. The proportion of CD4⁺CD25⁺FoxP3⁺ Treg and Th17 cells within the CD4⁺ T cell subset of splenocytes was analyzed by flow cytometry. FoxP3 and RORγT mRNA and protein expressions in the lung were analyzed by real-time PCR and western blot, respectively. Overall, sodium houttuynia was found to ameliorate the Treg/Th17 cell imbalance and reduce the airway inflammation, hyperresponsiveness, and mucus hypersecretion by increasing the frequency of CD4⁺CD25⁺FoxP3⁺ Treg cells and the secretion of IL-10, while decreasing the proportion of Th17 cells and IL-17A production. Although the regulatory effect of sodium houttuynia was not as good as that achieved with dexamethasone, combination of the two compounds showed improved inhibitory effects on airway hyperresponsiveness, inflammation, and mucus hypersecretion. Hence, sodium houttuynia may be beneficial for the treatment of asthma.

Approach to Patients with Severe Asthma: a Consensus Statement from the Respiratory Care Experts' Input Forum (RC-EIF), Iran

Challenges in the assessment, diagnosis and management of severe, difficult-to-control asthma are increasingly regarded as clinical needs yet unmet. The assessments required to determine asthma severity, comorbidities and confounding factors, disease phenotypes and optimal treatment are among the controversial issues in the field. The respiratory care experts' input forum (RC-EIF), comprised of an Iranian panel of experts, reviewed the definition, appraised the available guidelines and provided a consensus for evaluation and treatment of severe asthma in adults. A systematic literature review followed by discussions during and after the forum, yielded the present consensus. The expert panel used the appraisal of guidelines for research and evaluation-II (AGREE-II) protocol to define an initial locally-adapted strategy for the management of severe asthma. Severe asthma is considered a heterogeneous condition with various phenotypes. Issues such as assessment of difficult-to-control asthma, phenotyping, the use of blood and sputum eosinophil count, exhaled nitric oxide to guide therapy, the position of anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty as well as the use of established, recently-developed and evolving treatment approaches were discussed and unanimously agreed upon in the panel. A systematic approach is required to ensure proper diagnosis, evaluate compliance, and to identify comorbidities and triggering factors in severe asthma. Phenotyping helps select optimized treatment. The treatment approach laid down by the Global Initiative for Asthma (GINA) needs to be followed, while the benefit of using biological therapies should be weighed against the cost and safety concerns.

Methotrexate as a steroid sparing agent for asthma in adults

BACKGROUND

Sustained oral corticosteroid use can lead to complications, so there is interest in identifying agents that can reduce oral steroid use in people with asthma. Methotrexate has attracted attention as a possible steroid sparing agent in patients with chronic oral steroid dependent asthma.

OBJECTIVES

The objective of this review was to assess the effects of adding methotrexate to oral corticosteroids in adults with stable asthma who are dependent on oral corticosteroids.

SEARCH STRATEGY

The Cochrane Airways Group trials register and reference lists of identified articles were searched.

SELECTION CRITERIA

Randomised trials of the addition of methotrexate compared with placebo in adult steroid dependent asthmatics. Duration of therapy needed to be at least 12 weeks.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data extraction was carried out by two reviewers independently. Study authors were contacted for missing information.

MAIN RESULTS

Ten trials involving a total of 185 people were included. Study design and quality, corticosteroid dosages and outcomes varied widely. There was a reduction in oral corticosteroid dose favouring methotrexate in parallel trials (weighted mean difference -4.1 mg per day, 95% confidence interval -6.8 to -1.3) and also in cross-over trials (weighted mean difference -2.9 mg per day, 95% confidence interval -5.9 to -0.2). There was no difference between methotrexate and placebo for forced expiratory volume in one minute (weighted mean difference 0.12 litre, 95% confidence interval -0.21 to 0.45). Hepatotoxicity was a common adverse effect with methotrexate compared to placebo (odds ratio 6.9, 95% confidence interval 3.1 to 15.5).

REVIEWER'S CONCLUSIONS

Methotrexate may have a small steroid sparing effect in adults with asthma who are dependent on oral corticosteroids. However, the overall reduction in daily steroid use is probably not large enough to reduce steroid-induced adverse effects. This small potential to reduce the impact of steroid side-effects is probably insufficient to offset the adverse effects of methotrexate.