Asthma symptoms in obese adults: The challenge of achieving asthma control

A Simulation Study of the Effect of Clinical Characteristics and Treatment Choice on Reliever Medication Use, Symptom Control and Exacerbation Risk in Moderate-Severe Asthma

INTRODUCTION

The relationship between immediate symptom control, reliever medication use and exacerbation risk on treatment response and factors that modify it have not been assessed in an integrated manner. Here we apply simulation scenarios to evaluate the effect of individual baseline characteristics on treatment response in patients with moderate-severe asthma on regular maintenance dosing monotherapy with fluticasone propionate (FP) or combination therapy with fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR).

METHODS

Reduction in reliever medication use (puffs/24 h), change in symptom control scores (ACQ-5), and annualised exacerbation rate over 12 months were simulated in a cohort of patients with different baseline characteristics (e.g. time since diagnosis, asthma control questionnaire (ACQ-5) symptom score, smoking status, body mass index (BMI) and sex) using drug-disease models derived from large phase III/IV clinical studies.

RESULTS

Simulation scenarios show that being a smoker, having higher baseline ACQ-5 and BMI, and long asthma history is associated with increased reliever medication use (p < 0.01). This increase correlates with a higher exacerbation risk and higher ACQ-5 scores over the course of treatment, irrespective of the underlying maintenance therapy. Switching non-responders to ICS monotherapy to combination therapy after 3 months resulted in immediate reduction in reliever medication use (i.e. 1.3 vs. 1.0 puffs/24 h for FP/SAL and BUD/FOR, respectively). In addition, switching patients with ACQ-5 > 1.5 at baseline to FP/SAL resulted in 34% less exacerbations than those receiving regular dosing BUD/FOR (p < 0.01).

CONCLUSIONS

We have identified baseline characteristics of patients with moderate to severe asthma that are associated with greater reliever medication use, poor symptom control and higher exacerbation risk. Moreover, the effects of different inhaled corticosteroid (ICS)/long-acting beta agonist (LABA) combinations vary significantly when considering long-term treatment performance. These factors should be considered in clinical practice as a basis for personalised management of patients with moderate-severe asthma symptoms.

The association between waist circumference and adult asthma attack using nationally representative samples

AIMS

This study aims to explore the relationship between waist circumference and asthma attack in adults.

METHODS

In this cross-sectional study, we analysed data from 5,530 U.S. adults diagnosed with asthma. Participants were categorized into two groups based on their experience of asthma attacks: with or without asthma attacks. We employed adjusted weighted logistic regression models, weighted restricted cubic splines, subgroup and sensitivity analyses to assess the association between waist circumference and asthma attack.

RESULTS

The median age of all participants was 43 years, and the median waist circumference was 98.9 cm, with a median BMI was 28.50 kg/m2. Participants in the asthma attack group had significantly higher waist circumferences than those in the non-attack group (P < 0.001). After full adjustment for body mass index-defined obesity, age, gender, race, education levels, poverty income ratio levels, smoking status, and metabolic syndrome, every 5 cm increase in waist circumference exhibited a 1.06 times higher likelihood of asthma attack probability. The weighted restricted cubic spline analysis demonstrated an increased risk of asthma attacks with rising waist circumference. Subgroup analyses confirmed this relationship across various groups differentiated by gender, age, and smoking status. When applying a stricter definition of asthma attack, the weighted logistic regression models showed robust association between waist circumference and asthma attack.

CONCLUSION

Waist circumference is an independent predictor of asthma attacks. Our findings underscore the importance of waist circumference measurement in evaluating the risk of asthma attacks.

Enhancement in medication adherence amidst COVID-19 using active reminders

The aim of this study is to enhance medication adherence amidst COVID-19 with the help of active reminders. Effect of: patients' perception of side effect, importance of physicians' instructions, and their beliefs, on medication adherence were measured. Sample size was 583. The study was conducted in the state of Sikkim in India. Responses were analyzed and a structural equation model was framed to test the paths. It was found that reminders had a significant impact on patients' perception about importance given to physician instruction ( β = 0.433 ) and their beliefs ( β = 0.224 ). These mediators helped to increase the adherence rate of patients.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1140/epjs/s11734-022-00532-7.

Evaluation of the obesity influence on the life quality in patients with bronchial asthma

The obese asthma is characterized by a more severe course. The feature of this comorbid condition is the reduced effectiveness of basic therapy with inhaled corticosteroids, which prevents optimal control of symptoms, requires increasing doses and increases the number of exacerbations and hospitalizations. The problem of life quality (LQ) research in patients with asthma and obesity is highly relevant today, which made it the reason for this study. The aim of the study was to determine the effect of obesity on LQ in patients with asthma. Materials and methods. We selected for participating in the study 46 patients with moderate severity asthma. Examination of the patients included: objective examination with an anthropometric evaluation, the test of the LQ with two questionnaires: general one – Medical Outcome Study SF-36 (MOS SF-36) and specialized Asthma Quality of Life Questionnaire (AQLQ). Results. The increase in body mass index (BMI) in patients with asthma according to the questionnaires MOS SF-36 and AQLQ is associated with significant reductions in viability (r=–0.33, p<0.05), physical activity (r=–0.37, p<0.01), social activity (r=–0.36, p <0.01) and the degree of reduction of the patient's tolerance to adverse environmental factors (r=–0.29, p<0.05) Conclusions. The presence of concomitant obesity in patients with asthma is associated with significant reductions in the parameters of physical and social activity, viability and with an increase in the subjective pain assessment (according to the questionnaire MOS SF-36) and characterized by significantly lower rates of activity, tolerance to adverse environmental factors and general life quality (according to the AQLQ questionnaire).

Relationship between cough reflex sensitivity and body mass index in children with chronic cough - a pilot study

Obesity is characterized by chronic, low-grade systemic inflammation. Obesity may also be associated with chronic cough. The aim of this pilot study was to clarify relation of cough reflex sensitivity and body mass index (BMI) in children with chronic cough. Altogether 41 children having symptoms of chronic cough were submitted to cough reflex sensitivity measurement. We assessed the relation of cough reflex sensitivity (CKR) due to BMI. Cough reflex sensitivity was defined as the lowest capsaicin concentration which evoked two (C2) or five (C5) coughs. Capsaicin aerosol in doubling concentrations (from 0.61 to 1250 micromol/l) was inhaled by a single breath method (KoKo DigiDoser; nSpire heath Inc, Louisville, CO, USA), modified by the addition of an inspiratory flow regulator valve (RIFR; nSpire heath Inc, Louisville, CO, USA). BMI was calculated. Pulmonary function was within normal range. Concentrations of capsaicin causing two (C2) and five coughs (C5) were reported. Children (22 boys and 19 girls, mean age 6.8 years) cough reflex sensitivity (median, with the Inter-Quartile Range) for C2 was 19.5 (73.4) micromol/l; for C5 it was 78.1 (605.5) micromol/l. We have noticed statistically significant relation of the cough reflex sensitivity (C5) and body mass index (P<0.0001); however, the effect size was small, R2=0.03. Increase of body mass index in one unit is associated with -34.959 micromol/l decrease of C5. We did not find a statistically significant relation between C2 and BMI (P=0.41). The median value of CKR (C2) in boys is not statistically significantly different than the median value of CKR (C2) in girls (P-value 0.5). The median value of CKR (C5) in boys is not statistically significantly different than the median value of CKR (C5) in girls (P-value 0.5). Increase of body mass index in children suffering from chronic cough relates to decrease of cough reflex sensitivity (C5 value).

Tiotropium Respimat® add-on therapy to inhaled corticosteroids in patients with symptomatic asthma improves clinical outcomes regardless of baseline characteristics

BACKGROUND

Despite currently available therapies and detailed treatment guidelines, many patients with asthma remain symptomatic. Tiotropium delivered by the soft mist inhaler Respimat®, as add-on therapy to medium-dose inhaled corticosteroids (ICS), has been shown to improve lung function and asthma control in patients with symptomatic moderate asthma.

OBJECTIVE

To determine whether the efficacy of tiotropium Respimat® in asthma differs by patients' study baseline characteristics.

METHODS

Two replicate Phase III, randomized, double-blind, placebo-controlled, parallel-group studies (MezzoTinA-asthma®; NCT01172808 and NCT01172821) of once-daily tiotropium Respimat 5 μg and 2.5 μg add-on to ICS were conducted in patients with symptomatic asthma despite treatment with medium-dose ICS with or without additional controllers. Subgroup analyses of peak forced expiratory volume in 1 s (FEV₁), trough FEV₁, risk of severe asthma exacerbation and Asthma Control Questionnaire responder rate were performed to determine whether results were influenced by patients' baseline characteristics.

RESULTS

In this analysis, 523 patients received placebo while 517 and 519 patients received the 5 μg and 2.5 μg dose of tiotropium Respimat, respectively. The magnitude of the improvements in lung function and asthma control, as well as the reduced risk of severe exacerbation with both doses of tiotropium Respimat versus placebo, was independent of a broad range of baseline characteristics.

CONCLUSIONS

Once-daily tiotropium Respimat as add-on to ICS is a beneficial treatment option for patients with asthma who remain symptomatic despite at least medium-dose ICS, regardless of baseline characteristics.

The impact of weight loss beyond lung function: benefit with respect to asthma outcomes

OBJECTIVE

We evaluated the effect of weight loss (WL) on lung function (LF) in obese individuals who underwent bariatric surgery, and on asthma control, quality of life, LF, and controller medication in a sub-group of obese asthma (OA) patients.

MATERIALS AND METHODS

Obese individuals who underwent bariatric surgery between July 2015 and July 2017 were included in this prospective longitudinal study. They were classified as OA or obese non-asthmatics (O-NA). LF was assessed preoperatively and 6-9 months postoperatively. In OA patients, asthma control, quality of life, and treatment step were evaluated. P < 0.05 was considered significant.

RESULTS

Twenty-six patients (OA: n = 8; O-NA: n = 18), 84.6% with class III obesity were enrolled. Preoperatively, OA patients showed worse values of LF parameters, with upper and lower airway CARAT scores of 6.1 ± 3.1 and 13.4 ± 4.1, respectively, and 75% were in step 4 of treatment. After WL, improvements in dynamic volumes, lung capacities, and total resistance were observed in both groups. Despite greater increases in OA patients, no significant differences were observed between groups. In OA patients, improvements in CARAT score of upper (3.9 ± 1.9, p = 0.017) and lower (4.2 ± 4.4, p = 0.027) airways, and in Asthma Life Quality scores (8.1 ± 5.6, p = 0.017) were observed along with a decrease (-1.8 ± 1.0, p = 0.017) in treatment step.

CONCLUSIONS

All LF parameters improved after WL. Although the improvement was greater in OA patients, the difference between groups was not significant. Significant improvement from baseline in uncontrolled symptoms of OA patients and quality of life was observed after WL, along with a significant decrease in treatment step.

A review on the pathophysiology of asthma remission

Asthma is a chronic respiratory condition, which is highly prevalent worldwide. Although no cure is currently available, it is well recognized that some asthma patients can spontaneously enter remission of the disease later in life. Asthma remission is characterized by absence of symptoms and lack of asthma-medication use. Subjects in asthma remission can be divided into two groups: those in clinical remission and those in complete remission. In clinical asthma remission, subjects still have a degree of lung functional impairment or bronchial hyperresponsiveness, while in complete asthma remission, these features are no longer present. Over longer periods, the latter group is less likely to relapse. This remission group is of great scientific interest due to the higher potential to find biomarkers or biological pathways that elicit or are associated with asthma remission. Despite the fact that the definition of asthma remission varies between studies, some factors are reproducibly observed to be associated with remitted asthma. Among these are lower levels of inflammatory markers, which are lowest in complete remission. Additionally, in both groups some degree of airway remodeling is present. Still, the pathological disease state of asthma remission has been poorly investigated. Future research should focus on at least two aspects: further characterisation of the small airways and airway walls in order to determine histologically true remission, and more thorough biological pathway analyses to explore triggers that elicit this phenomenon. Ultimately, this will result in pharmacological targets that provide the potential to steer the course of asthma towards remission.

Exercise Improves Physical Activity and Comorbidities in Obese Adults with Asthma

INTRODUCTION

Obese adults with asthma have an increased number of comorbidities and reduced daily life physical activity (DLPA), which may worsen asthma symptoms. Exercise is recommended to improve asthma outcomes; however, the benefits of exercise for psychosocial comorbidities and physical activity levels in obese adults with asthma have been poorly investigated.

OBJECTIVE

This study aimed to assess the effects of exercise on DLPA, asthma symptoms, and psychosocial comorbidities in obese adults with asthma.

METHODS

Fifty-five grade II obese adults with asthma were randomly assigned to either a weight loss program + exercise program (WL + E group, n = 28) or a weight loss program + sham (WL + S group, n = 27). The WL + E group incorporated aerobic and resistance muscle training into the weight loss program (nutrition and psychological therapies), whereas the WL + S group performed breathing and stretching exercises. DLPA, asthma symptoms, sleep quality, and anxiety and depression symptoms were quantified before and after treatment.

RESULTS

After 3 months, the WL + E group presented a significant increase in daily step counts (3068 ± 2325 vs 729 ± 1118 steps per day) and the number of asthma symptom-free days (14.5 ± 9.6 vs 8.6 ± 11.4 d·month) compared with the WL + S group. The proportion of participants with improvements in depression symptoms (76.4% vs 16.6%) and a lower risk of developing obstructive sleep apnea (56.5% vs 16.3%) was greater in the WL + E group than that in the WL + S group (P < 0.05). Significant improvements in sleep efficiency (6.6% ± 5.1% vs 1.3% ± 4.7%) and latency (-3.7 ± 5.9 vs 0.2 ± 5.6 min) were also observed in the WL + E group.

CONCLUSIONS

Our results strongly suggest that exercise training plus a weight loss program improves DLPA, sleep efficiency, and depression and asthma symptoms in obese adults with asthma.

Effect of a Carbohydrate-Rich Diet on Rat Detrusor Smooth Muscle Contractility: An Experimental Study

OBJECTIVES

We aimed to investigate the effect of a carbohydrate-rich diet on detrusor contractility in rats.

MATERIALS AND METHODS

Sprague-Dawley rats were randomized into two groups. The control group received regular food and water. The study group received carbohydrate-rich diet for six weeks. The rats' detrusor muscle was isolated for pharmacological and histopathological examinations.

RESULTS

In the control and study groups, mean body weights were 431.5 ± 27.6 g and 528.0 ± 36.2 g, respectively (p < 0.001). Electrical stimulation of the detrusor strips of the control group resulted in gradual contraction. A decreased contractile response was shown in the study group. Acetylcholine in 10-7-10-3 molar concentration produced a decreased contractile response in the study group, compared to the control group (p < 0.01). The study group showed marked subepithelial and intermuscular fibrosis in the bladder.

CONCLUSION

Carbohydrate-rich diet causes marked subepithelial and extracellular fibrosis and changes in contractility in the detrusor within a six-week period. Changes have higher costs in therapeutic choices and correction of these changes remains difficult. Putting an end to carbohydrate-rich diet would seem to be more cost-effective than dealing with the effects of consuming it in high proportions which should be the national policy worldwide.

Uncontrolled asthma and its risk factors in adult Chinese asthma patients

Background:

Asthma affects a large number of patients in China, but relatively little is known about asthma management among Chinese patients. This study aims to estimate asthma control rate among adult Chinese patients and to identify predictors associated with uncontrolled asthma.

Methods:

A total of 4125 asthma patients aged ⩾17 years and representing all regions of mainland China except Tibet were surveyed. Asthma control status was assessed using the Asthma Control Test (ACT) and classified as controlled (ACT score ⩾ 20) and uncontrolled (ACT score ⩽ 19). A multivariate logistic regression model was used to identify predictors associated with uncontrolled asthma from the factors including demographics, rhinitis, allergic rhinitis, and treatment adherence.

Results:

Asthma was controlled in 44.9%, and uncontrolled in 55.1% of the study participants. High rates of uncontrolled asthma were found in patients with treatment nonadherence (77.3%), poor adherence (66.2%), no schooling (64.8%), or obesity (62.9%). The risk of uncontrolled asthma was much higher in the treatment nonadherence group than the complete adherence group [odds ratio (OR) = 4.55 (3.68–5.62), p < 0.001]. Other predictors for uncontrolled asthma included concomitant rhinitis [OR = 1.31 (1.14–1.50), p < 0.001], obesity [OR = 1.31 (1.05–1.64), p = 0.019], asthma duration > 3 years [OR = 1.22 (1.07–1.39), p = 0.004] and age ⩾ 45 years [OR = 1.23 (1.07–1.41), p = 0.004].

Conclusions:

About half of the participants in this study had uncontrolled asthma. Treatment nonadherence is one of the significant predictors, which is very strongly associated with uncontrolled asthma. Efforts should be prioritized to promote patients’ treatment adherence to improve asthma control while attention is needed on rhinitis or obesity.

Obesity: systemic and pulmonary complications, biochemical abnormalities, and impairment of lung function

Obesity is currently one of the major epidemics of this millennium and affects individuals throughout the world. It causes multiple systemic complications, some of which result in severe impairment of organs and tissues. These complications involve mechanical changes caused by the accumulation of adipose tissue and the numerous cytokines produced by adipocytes. Obesity also significantly interferes with respiratory function by decreasing lung volume, particularly the expiratory reserve volume and functional residual capacity. Because of the ineffectiveness of the respiratory muscles, strength and resistance may be reduced. All these factors lead to inspiratory overload, which increases respiratory effort, oxygen consumption, and respiratory energy expenditure. It is noteworthy that patterns of body fat distribution significantly influence the function of the respiratory system, likely via the direct mechanical effect of fat accumulation in the chest and abdominal regions. Weight loss caused by various types of treatment, including low-calorie diet, intragastric balloon, and bariatric surgery, significantly improves lung function and metabolic syndrome and reduces body mass index. Despite advances in the knowledge of pulmonary and systemic complications associated with obesity, longitudinal randomized studies are needed to assess the impact of weight loss on metabolic syndrome and lung function.