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Thomas M, Beasley R. The treatable traits approach to adults with obstructive airways disease in primary and secondary care. Respirology 2023; 28:1101-1116. [PMID: 37877554 DOI: 10.1111/resp.14610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.
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Affiliation(s)
- Mike Thomas
- Primary Care Research, School of Primary Care, Population Sciences and Medical Education (PPM), Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Richard Beasley
- Medicine, Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
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2
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Jiang Y, Deng S, Hu X, Luo L, Zhang Y, Zhang D, Li X, Feng J. Identification of potential biomarkers and immune infiltration characteristics in severe asthma. Int J Immunopathol Pharmacol 2022; 36:3946320221114194. [PMID: 35817495 PMCID: PMC9280849 DOI: 10.1177/03946320221114194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES We hope to identify key molecules that can be used as markers of asthma severity and investigate their correlation with immune cell infiltration in severe asthma. METHODS An asthma dataset was downloaded from the Gene Expression Omnibus database and then processed by R software to obtain differentially expressed genes (DEGs). First, multiple enrichment platforms were applied to analyze crucial biological processes and pathways and protein-protein interaction networks related to the DEGs. We next combined least absolute shrinkage and selection operator logistic regression and the support vector machine-recursive feature elimination algorithms to screen diagnostic markers of severe asthma. Then, a local cohort consisting of 40 asthmatic subjects (24 with moderate asthma and 16 with severe asthma) was used for biomarker validation. Finally, infiltration of immune cells in asthma bronchoalveolar lavage fluid and their correlation with the screened markers was evaluated by CIBERSORT. RESULTS A total of 97 DEGs were identified in this study. Most of these genes are enriched in T cell activation and immune response in the asthma biological process. CC-chemokine receptor 7 (CCR7) and natural killer cell protein 7(NKG7) were identified as markers of severe asthma. The highest area under the ROC curve (AUC) was from a new indicator combining CCR7 and NKG7 (AUC = 0.851, adj. p < 0.05). Resting and activated memory CD4 T cells, activated NK cells, and CD8 T cells were found to be significantly higher in the severe asthma group (adj. p < 0.01). CCR7 and NKG7 were significantly correlated with these infiltrated cells that showed differences between the two groups. In addition, CCR7 was found to be significantly positively correlated with eosinophils (r = 0.38, adj. p < 0.05) infiltrated in bronchoalveolar lavage fluid. CONCLUSION CCR7 and NKG7 might be used as potential markers for asthma severity, and their expression may be associated with differences in immune cell infiltration in the moderate and severe asthma groups.
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Affiliation(s)
- Yuanyuan Jiang
- Center of Respiratory Medicine, Xiangya Hospital, 12570Central South University, Changsha, Hunan, China
| | - Shuanglinzi Deng
- Center of Respiratory Medicine, Xiangya Hospital, 12570Central South University, Changsha, Hunan, China
| | - Xinyue Hu
- Center of Respiratory Medicine, Xiangya Hospital, 12570Central South University, Changsha, Hunan, China
| | - Lisha Luo
- Center of Respiratory Medicine, Xiangya Hospital, 12570Central South University, Changsha, Hunan, China
| | - Yingyu Zhang
- Center of Respiratory Medicine, Xiangya Hospital, 12570Central South University, Changsha, Hunan, China
| | - Daimo Zhang
- Center of Respiratory Medicine, Xiangya Hospital, 12570Central South University, Changsha, Hunan, China
| | - Xiaozhao Li
- Department of Nephrology, Xiangya Hospital, 12570Central South University, Changsha, Hunan, China
| | - Juntao Feng
- Center of Respiratory Medicine, Xiangya Hospital, 12570Central South University, Changsha, Hunan, China
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3
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Kilmukhametova YH, Batig VM, Ostafiichuk MA, Tokar OM, Glushchenko TA, Batih IV, Sheremet MI. Indicators of antioxidant protection of blood in necrotizing ulcerative gingivitis in experimental animals. J Med Life 2021; 14:68-74. [PMID: 33767788 PMCID: PMC7982257 DOI: 10.25122/jml-2020-0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This article highlights the results of a study of blood parameters in animals with simulated necrotizing ulcerative gingivitis and compares them, under the same conditions, with animals that received local treatment with a developed complex of antioxidant drugs. Following the work tasks, the nature of changes in the state of the antioxidant - prooxidant system and their influence on quantitative and functional indicators of markers of inflammatory intensity was analyzed and investigated during the pathological process in the background and without treatment with a developed complex. This work shows the changes of malonic dialdehyde concentration as an indicator of lipid peroxidation intensity in experimental animals, the level of catalase activity in the blood of animals, and antioxidant-prooxidant balance in the dynamics of necrotizing ulcerative gingivitis.
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Affiliation(s)
- Yuliia Hafizivna Kilmukhametova
- Department of Therapeutic Dentistry, Higher State Educational Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine
| | - Viktor Markiyanovich Batig
- Department of Therapeutic Dentistry, Higher State Educational Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine
| | - Marianna Alexandrovna Ostafiichuk
- Department of Therapeutic Dentistry, Higher State Educational Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine
| | - Olha Mykhaylivna Tokar
- Department of Therapeutic Dentistry, Higher State Educational Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine
| | - Tatiana Anatoliyivna Glushchenko
- Department of Therapeutic Dentistry, Higher State Educational Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine
| | - Iryna Viktorivna Batih
- Department of Pediatric Dentistry, Higher State Educational Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine
| | - Michael Ivanovich Sheremet
- Surgery Department No.1, Higher State Educational Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine
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4
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Dhar R, Ip M, Kulkarni T, Kim SH, Perng DW, Yao X, Iwanaga T, Siyue Koh M. Challenges faced in managing adult asthma: A perspective from Asian countries. Respirology 2020; 25:1235-1242. [PMID: 32885896 DOI: 10.1111/resp.13935] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 01/30/2023]
Abstract
Asthma imposes a significant burden on the health system and patients' quality of life. Within Asia, there is large variability in several cultural, social and economic factors ultimately influencing the management of asthma. Differences in risk factors and asthma management practices across Asia make asthma a truly 'mixed-bag' phenomenon. With the advent of biological agents and the consequent emphasis on asthma phenotyping and endotyping, it is more important than ever to understand the diverse nature of asthma as a disease. This is a collaborative review within Asia to highlight the differences in management of adult asthma, and the local modifications that are made to international guidelines. This review paves the way for a future Asian collaborative network in asthma epidemiological research.
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Affiliation(s)
- Raja Dhar
- Center of Excellence in Lung Care, Fortis Hospital, Kolkata, India
| | - Mary Ip
- Respiratory and Critical Care Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Tarang Kulkarni
- Center of Excellence in Lung Care, Fortis Hospital, Kolkata, India
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Xin Yao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing, Medical University, Nanjing, China
| | - Takashi Iwanaga
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Mariko Siyue Koh
- Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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5
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Majellano EC, Clark VL, Winter NA, Gibson PG, McDonald VM. Approaches to the assessment of severe asthma: barriers and strategies. J Asthma Allergy 2019; 12:235-251. [PMID: 31692528 PMCID: PMC6712210 DOI: 10.2147/jaa.s178927] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/25/2019] [Indexed: 12/12/2022] Open
Abstract
Asthma is a chronic condition with great variability. It is characterized by intermittent episodes of wheeze, cough, chest tightness, dyspnea and backed by variable airflow limitation, airway inflammation and airway hyper-responsiveness. Asthma severity varies uniquely between individuals and may change over time. Stratification of asthma severity is an integral part of asthma management linking appropriate treatment to establish asthma control. Precision assessment of severe asthma is crucial for monitoring the health of people with this disease. The literature suggests multiple factors that impede the assessment of severe asthma, these can be grouped into health care professional, patient and organizational related barriers. These barriers do not exist in isolation but interact and influence one another. Recognition of these barriers is necessary to promote precision in the assessment and management of severe asthma in the era of targeted therapy. In this review, we discuss the current knowledge of the barriers that impede assessment in severe asthma and recommend potential strategies for overcoming these barriers. We highlight the relevance of multidimensional assessment as an ideal approach to the assessment and management of severe asthma.
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Affiliation(s)
- Eleanor C Majellano
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
| | - Vanessa L Clark
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
| | - Natasha A Winter
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Peter G Gibson
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Vanessa M McDonald
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia
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6
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Tay TR, Lee JWY, Hew M. Diagnosis of severe asthma. Med J Aust 2019; 209:S3-S10. [PMID: 30453866 DOI: 10.5694/mja18.00125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023]
Abstract
Patients with asthma that is uncontrolled despite high intensity medication can present in both primary and specialist care. An increasing number of novel (and expensive) treatments are available for patients who fail conventional asthma therapy, but these may not be appropriate for all such patients. It is essential that a rigorous evaluation process be undertaken for these patients to identify those with biologically severe asthma who will require novel therapies, and those who may improve with control of contributory factors. In this article, we describe three key steps in the diagnostic evaluation process for severe asthma. The first step is confirmation of asthma diagnosis with objective evidence of variable airflow obstruction. The second involves management of contributory factors such as non-adherence, poor inhaler technique, ongoing asthma triggers, and comorbidities. The third step involves phenotyping and endotyping of patients with severe asthma. We provide a practical approach to implementing these measures in both primary and secondary care.
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Affiliation(s)
| | | | - Mark Hew
- The Alfred Hospital, Melbourne, VIC
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7
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Severe Asthma Global Evaluation (SAGE): An Electronic Platform for Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1440-1449. [PMID: 30954467 DOI: 10.1016/j.jaip.2019.02.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 01/26/2023]
Abstract
Severe asthma is complex and heterogeneous; ad hoc outpatient assessment can be suboptimal. Systematic evaluation improves outcomes and is recommended by international guidelines. Electronic templates improve physician performance and clinical processes, and may be useful in severe asthma systematic evaluation. We developed the Severe Asthma Global Evaluation (SAGE) electronic platform to streamline this process, via Research Electronic Data Capture (REDCap). It incorporates: a questionnaire battery for patient completion before clinical consultation; asthma and comorbidity modules; a clinical summary page in an asthma management module; a nurse educator module; a structured panel discussion record; and an automatically generated report incorporating all key data. SAGE incorporates 282 clinician input fields, with a typical consultation requiring completion of 169. To streamline the process SAGE contains 34 autocalculations and 20 decision support tools. It incorporates all 95 core variables of the International Severe Asthma Registry, with which it is directly compatible. SAGE improves symptom control and exacerbations in patients with difficult asthma. In conclusion, we developed and validated an electronic platform that facilitates a comprehensive but streamlined systematic evaluation of severe asthma that is available for free download via REDCap. Its use enhances management of patients with severe asthma and facilitates audit and international research collaboration.
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8
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Baggott C, Beasley R. Triaging treatable traits in asthma. Respirology 2018; 24:5-6. [PMID: 30230655 DOI: 10.1111/resp.13406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 08/28/2018] [Indexed: 01/12/2023]
Affiliation(s)
- Christina Baggott
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Respiratory Medicine, Capital & Coast District Health Board, Wellington, New Zealand.,School of Biological Science, Victoria University of Wellington, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Respiratory Medicine, Capital & Coast District Health Board, Wellington, New Zealand.,School of Biological Science, Victoria University of Wellington, Wellington, New Zealand
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9
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Abstract
PURPOSE OF REVIEW To describe the rationale on which the treatable traits approach to the management of airways disease is based and the issues that need to be considered for its implementation in clinical practice. RECENT FINDINGS In clinical practice, treatable traits can be classified according to both endotypes and phenotypes, broadly grouped within pulmonary, extrapulmonary, environmental and behavioural factors. Specific investigations and treatments are undertaken for each of the traits rather than a 'one size fits all' stepwise approach to pharmacological treatment which currently represents the core of asthma and chronic obstructive pulmonary disease (COPD) guidelines. Although there is strong evidence of the benefit of the treatable traits approach to specific traits in asthma and/or COPD, there is uncertainty regarding the preferred method of implementation, efficacy and cost-effectiveness of multidimensional intervention programmes in clinical practice. It is likely that 'master protocols' for randomized controlled trials will be required to evaluate such multiple interventions in broad populations of patients with airways disease. SUMMARY Current evidence suggests that the precision medicine approach based on the identification and treatment of treatable traits is preferable to a 'one-size-fits-all' stepwise approach to the treatment of airways disease, although high-quality evidence to guide the practical application of this multidimensional management strategy is now required. VIDEO ABSTRACT.
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10
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Colodenco D, Palomares O, Celis C, Kaplan A, Domingo C. Moving toward consensus on diagnosis and management of severe asthma in adults. Curr Med Res Opin 2018; 34:387-399. [PMID: 28906154 DOI: 10.1080/03007995.2017.1380617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Asthma is a considerable health problem with an increasing global prevalence. The burden of severe asthma is expected to notably increase in the following years. Some misleading concepts that sometimes appear in the literature can drive the physician responsible for a patient's management to make incorrect decisions. Furthermore, some of the concepts that appear in the literature and in the guidelines may not be clear to understand, follow or adapt to regional and local realities. This could again drive the physicians responsible for a patient's management to make incorrect clinical judgments. In this article, we review the definition, prevalence and immunopathology of severe asthma, describe the asthma phenotypes, clinical features and comorbidities, the diagnosis of severe asthma and personalized asthma treatment. At the end, we offer a treatment approach based on literature publications, personalized medicine and marketed biologic treatment options.
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Affiliation(s)
- Daniel Colodenco
- a Pulmonology , Hospital De Rehabilitación Respiratoria María Ferrer , Buenos Aires , Argentina
| | - Oscar Palomares
- b Department of Biochemistry and Molecular Biology , School of Chemistry, Complutense University of Madrid , Madrid , Spain
| | - Carlos Celis
- c Pulmonary Unit, Internal Medicine Department , Hospital Universitario San Ignacio , Bogota , Colombia
| | - Alan Kaplan
- d University of Toronto , Thornhill , Ontario , Canada
| | - Christian Domingo
- e Servei de Pneumologia , Corporació Sanitària Parc Taulí , Barcelona , Spain
- f Department of Medicine , Universitat Autònoma de Barcelona (UAB) , Barcelona , Spain
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11
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Thomson NC. Bronchial thermoplasty as a treatment for severe asthma: controversies, progress and uncertainties. Expert Rev Respir Med 2018; 12:269-282. [PMID: 29471685 DOI: 10.1080/17476348.2018.1444991] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Bronchial thermoplasty is a licensed non-pharmacological treatment for severe asthma. Area covered: This article considers evidence for the efficacy and safety of bronchial thermoplasty from clinical trials and observational studies in clinical practice. Its place in the management of severe asthma, predictors of response and mechanisms of action are reviewed. Expert commentary: Bronchial thermoplasty improves quality of life and reduces exacerbations in moderate to severe asthma. Morbidity from asthma is increased during treatment. Overall, patients treated in clinical practice have worse baseline characteristics and comparable clinical outcomes to trial data. Follow-up studies provide reassurance on long-term safety. Despite some progress, future research needs to investigate uncertainties about predictors of response, mechanism of action and place in management of asthma.
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Affiliation(s)
- Neil C Thomson
- a Institute of Infection, Immunity & Inflammation , University of Glasgow , Glasgow , UK
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12
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Ramratnam SK, Bacharier LB, Guilbert TW. Severe Asthma in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:889-898. [PMID: 28689839 DOI: 10.1016/j.jaip.2017.04.031] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/18/2017] [Accepted: 04/19/2017] [Indexed: 12/28/2022]
Abstract
Severe asthma in children is associated with significant morbidity and is a highly heterogeneous disorder with multiple clinical phenotypes. Cluster analyses have been performed in several groups to explain some of the heterogeneity of pediatric severe asthma, which is reviewed in this article. The evaluation of a child with severe asthma includes a detailed diagnostic assessment and excluding other possible diagnoses and addressing poor control due to comorbidities, lack of adherence to asthma controller medications, poor technique, and other psychological and environmental factors. Children with severe asthma require significant resources including regular follow-up appointments with asthma education, written asthma action plan, and care by a multidisciplinary team. Management of pediatric severe asthma now includes emerging phenotypic-directed therapies; however, continued research is still needed to further study the long-term outcomes of pediatric severe asthma and its treatment.
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Affiliation(s)
- Sima K Ramratnam
- University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Leonard B Bacharier
- Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Theresa W Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Cincinnati, Ohio
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13
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Price D, Bjermer L, Bergin DA, Martinez R. Asthma referrals: a key component of asthma management that needs to be addressed. J Asthma Allergy 2017; 10:209-223. [PMID: 28794645 PMCID: PMC5536139 DOI: 10.2147/jaa.s134300] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Heterogeneity of asthma and difficulty in achieving optimal control are the major challenges in the management of asthma. To help attain the best possible clinical outcomes in patients with asthma, several guidelines provide recommendations for patients who will require a referral to a specialist. Such referrals can help in clearing the uncertainty from the initial diagnosis, provide tailored treatment options to patients with persistent symptoms and offer the patients access to health care providers with expertise in the management of the asthma; thus, specialist referrals have a substantial impact on disease prognosis and the patient's health status. Hurdles in implementing these recommendations include lack of their dissemination among health care providers and nonadherence to these guidelines; these hurdles considerably limit the implementation of specialist referrals, eventually affecting the rate of referrals. In this review, recommendations for specialist referrals from several key international and national asthma guidelines and other relevant published literature are evaluated. Furthermore, we highlight why referrals are not happening, how this can be improved, and ultimately, what should be done in the specialist setting, based on existing evidence in published literature.
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Affiliation(s)
- David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
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14
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Tay TR, Lee J, Radhakrishna N, Hore-Lacy F, Stirling R, Hoy R, Dabscheck E, O'Hehir R, Hew M. A Structured Approach to Specialist-referred Difficult Asthma Patients Improves Control of Comorbidities and Enhances Asthma Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:956-964.e3. [PMID: 28284780 DOI: 10.1016/j.jaip.2016.12.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/05/2016] [Accepted: 12/20/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Systematic evaluation is advocated for difficult asthma, but how best to deliver such care is unclear and outcome data are scarce. OBJECTIVE We describe our institution's structured approach to difficult asthma management and report on the outcomes of such an approach. METHODS Eighty-two consecutive patients with difficult asthma referred to our clinic from respiratory specialists were evaluated in 3 key areas: diagnostic confirmation, comorbidity detection, and inflammatory phenotyping. We then optimized treatment including relevant comorbidity interventions. The outpatient protocol was supported by comorbidity questionnaires, an electronic clinic template, and standardized panel discussion. Asthma outcomes were assessed at 6 months. RESULTS Sixty-eight patients completed follow-up. Asthma diagnosis was refuted in 3 patients and the remaining 65 patients were included in the study analysis. There was no overall escalation of inhaled or oral corticosteroids. Patients had a median of 3 comorbidities, and a median of 3 comorbidity interventions. Control of chronic rhinosinusitis and dysfunctional breathing improved among patients with these diagnoses (22-item Sino-Nasal Outcome Test score from 47 ± 20 to 37 ± 22, P = .017; Nijmegen score from 32 ± 6 to 25 ± 9, P = .003). There were overall improvements in the Asthma Control Test score (from 14 ± 5 to 16 ± 6, P < .001), the Asthma Quality of Life Questionnaire (from 4.29 ± 1.4 to 4.65 ± 1.5, P = .073), and the frequency of exacerbations over 6 months (from 2 [interquartile range, 0-4] to 0 [interquartile range, 0-2], P < .001). CONCLUSIONS In patients referred with difficult asthma from respiratory specialists, a structured approach coupled with targeted comorbidity interventions improved control of key comorbidities and enhanced asthma outcomes.
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Affiliation(s)
- Tunn Ren Tay
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - Joy Lee
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Robert Stirling
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ryan Hoy
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eli Dabscheck
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robyn O'Hehir
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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15
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Al Said A, Cushen B, Costello RW. Targeting patients with asthma for omalizumab therapy: choosing the right patient to get the best value for money. Ther Adv Chronic Dis 2017; 8:31-45. [PMID: 28348726 DOI: 10.1177/2040622317690494] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/22/2016] [Indexed: 11/15/2022] Open
Abstract
The asthma syndrome has many manifestations, termed phenotypes, that arise by specific cellular and molecular mechanisms, termed endotypes. Understanding an individual's asthma phenotype helps clinicians make rational therapeutic decisions while the understanding of endotypes has led to the development of specific precision medications. Allergic asthma is an example of an asthma phenotype and omalizumab, a monoclonal antibody that neutralizes serum immunoglobulin (Ig)E, is a specific targeted treatment which was developed as a result of an understanding of the endotype of allergic asthma. Omalizumab has been widely used in clinical practice in Europe for over a decade as an add-on therapy to treat patients who have severe refractory allergic asthma. Over this period, many centres have reported their experience with omalizumab as an add-on therapy in patients with severe asthma. These 'real world' clinical effectiveness studies have confirmed the benefits, cost-effectiveness and clinical utility of this medication. Combining the outcomes of both sources of research has yielded important insights that may benefit patients with severe asthma, clinicians who treat them, as well as the funding agencies that reimburse the cost of this medication. The purpose of this review is to describe how to identify and evaluate a patient with asthma for whom treatment with omalizumab may be of clinical and cost-effective benefit. The assessment and investigations used to confirm allergic asthma, the objective assessment of adherence to asthma therapy and the expected benefits of add-on omalizumab treatment are described.
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Affiliation(s)
| | | | - Richard W Costello
- Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland
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McDonald VM, Maltby S, Reddel HK, King GG, Wark PAB, Smith L, Upham JW, James AL, Marks GB, Gibson PG. Severe asthma: Current management, targeted therapies and future directions-A roundtable report. Respirology 2016; 22:53-60. [PMID: 27905186 DOI: 10.1111/resp.12957] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 12/01/2022]
Abstract
Asthma is a chronic respiratory disease characterized by respiratory symptoms, airway inflammation, airway obstruction and airway hyper-responsiveness. Asthma is common and directly affects 10% of Australians, 1-5% of adults in Asia and 300 million people worldwide. It is a heterogeneous disorder with many clinical, molecular, biological and pathophysiological phenotypes. Current management strategies successfully treat the majority of patients with asthma who have access to them. However, there is a subset of an estimated 5-10% of patients with asthma who have severe disease and are disproportionately impacted by symptoms, exacerbations and overall illness burden. The care required for this relatively small proportion of patients is also significant and has a major impact on the healthcare system. A number of new therapies that hold promise for severe asthma are currently in clinical trials or are entering the Australian and international market. However, recognition of severe asthma in clinical practice is variable, and there is little consensus on the best models of care or how to integrate emerging and often costly therapies into current practice. In this article, we report on roundtable discussions held with severe asthma experts from around Australia, and make recommendations about approaches for better patient diagnosis and assessment. We assess current models of care for patient management and discuss how approaches may be optimized to improve patient outcomes. Finally, we propose mechanisms to assess new therapies and how to best integrate these approaches into future treatment.
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Affiliation(s)
- Vanessa M McDonald
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Steven Maltby
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Helen K Reddel
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Gregory G King
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Peter A B Wark
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Lorraine Smith
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,The University of Sydney Faculty of Pharmacy, Sydney, New South Wales, Australia
| | - John W Upham
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Alan L James
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Guy B Marks
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
| | - Peter G Gibson
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, New South Wales, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
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