Could FeNO Predict Asthma in Patients with House Dust Mites Allergic Rhinitis?

Guidance for type 2 inflammatory biomarkers

Type 2 inflammation in the airways and lungs is inflammation induced by type 2 cytokines such as IL-4, IL-5, and IL-13, produced primarily by type 2 helper T cells and type 2 innate lymphoid cells, and causes changes in the physiology and structure of the airways. Type 2 inflammation is currently in the spotlight because of its direct link to the treatment of several airway and lung diseases. Abundant evidences have accumulated that inflammatory biomarkers such as blood eosinophils, fractional exhaled nitric oxide, and IgE are essential clinical tools in the diagnosis and management of asthma and COPD. It is well known that asthma and COPD have diverse inflammatory phenotypes even when clinical features are similar, and it has been demonstrated that assessment of airway inflammation with biomarkers can improve diagnostic accuracy, determine safer and more effective treatment strategies, and predict future risks such as exacerbations and lung function decline. The Japanese Respiratory Society has published clinical practice guidelines for the evaluation of type 2 inflammation in the airways and lungs. In addition to asthma and COPD, the guide covers a wide range of airway and lung diseases, including interstitial lung disease, allergic bronchopulmonary mycosis, allergic rhinitis, and eosinophilic chronic rhinosinusitis. It also provides comprehensive guidelines covering a variety of clinical biomarkers. The purpose of this guidance is to provide evidences for the interpretation of type 2 inflammation measurements and to promote the widespread use of inflammation assessment to further improve the efficiency of airway and respiratory disease management.

Update on the Role of FeNO in Asthma Management

Asthma is a heterogenous disorder characterized by presence of different phenotypes and endotypes. Up to 10% of the individuals suffer from severe asthma and are at increased risk of morbidity and mortality. Fractional exhaled nitric oxide (FeNO) is a cost-effective, point of care biomarker that is used to detect type 2 airway inflammation. Guidelines have proposed to measure FeNO as an adjunct to diagnostic evaluation in individuals with suspected asthma and to monitor airway inflammation. FeNO has lower sensitivity, suggesting that it may not be a good biomarker to rule out asthma. FeNO may also be used to predict response to inhaled corticosteroids, predict adherence and deciding on biologic therapy. Higher levels of FeNO have been associated with lower lung function and increased risk for future asthma exacerbations and its predictive value increases when combined with other standard measurements of asthma assessment.

Allergic sensitisation and type-2 inflammation is associated with new-onset and persistent allergic disease

BACKGROUND

Allergic disease is common. The aim of this study was to look at the change in asthma and rhinitis over time and to characterise factors contributing to remission and persistence of disease.

METHODS

This cohort study included 255 individuals with or without asthma and or rhinitis that participated in a population survey and a follow-up 10 years later. The participants were tested for allergic sensitisation, total IgE, multiplex allergen component analysis and type-2 inflammatory markers: exhaled nitric oxide (FE NO), eosinophil cationic protein (ECP) and eosinophil-derived neurotoxin (EDN).

RESULTS

Of the 132 healthy individuals, 112 remained healthy, 16 developed rhinitis, 4 asthma and rhinitis over the 10 years. Out of 82 subjects with rhinitis, 26 went into remission, 53 remained unchanged and 3 developed asthma in addition to rhinitis. None of the 41 participants with asthma and rhinitis went into remission. Subjects with persistent rhinitis and asthma had higher levels of total IgE (odds ratio [OR] 95% confidence interval [CI]: 6.16 [3.05-12.5]) at baseline and after 10 years, and FE NO and ECP at baseline (OR per log unit increase, 95% CI 5.21 [1.20-22.7] and 6.32 [1.52-26.4], respectively), compared with those that remained healthy. Subjects with persistent rhinitis were more likely to be sensitised to grass pollen and had higher total IgE levels than those that went into remission. Individuals with persistent asthma were more likely to be sensitised to tree pollen and furry animals than those with only persistent rhinitis (OR 95% CI: 3.50 [1.29-9.49] and 6.73 [2.00-22.6], respectively).

CONCLUSION

IgE sensitisation and total IgE levels are associated with the persistence of rhinitis and asthma. Participants with persistent allergic disease had higher levels of allergen sensitisation and type 2 inflammation markers at baseline than those who remained healthy.

A retrospective study regarding the influence of COVID-19 disease on asthma

BACKGROUND

During the Covid-19 pandemic patients suffering from asthma raised many concerns regarding the outcome ofthe impact of COVID-19 disease on their preexisting condition. The 2021 GINA report indicates that people with asthma do not appear to be at increased risk of a severe form of COVID-19.

METHOD

This study is a retrospective study of patients (n = 163) median age = 27.8 years, M:F = 1:1.26, with asthma evaluated using ACT (asthma control test) and VAS (visual analog scale) before and after COVID-19 disease. An ACT score over 20 points placed patients in the controlled asthma group.

RESULTS

The overall evaluation for COVID-19 in our asthma patients revealed that 22.7% of the studied group had the COVID-19 disease (21.5% in the controlled asthma group and 24.5% in uncontrolled asthma group). Asthma disease history was longer in the uncontroled asthma group (128 ± 96.8 months vs. 296 ± 59.7 months, p = 0.05). Asthma treatment was conducted according to the GINA guideline, and 18.4% (30 pts) of the patients were on allergen immunotherapy treatment. Significantly more uncontrolled patients were significantly more in Step 1 and 5 of treatment (p = 0.05 and p = 0.03). During the COVID-19 pandemic, patients in the GINA step 5 of treatment experienced a worsening of asthma, often twice as severe as compared to patients with asthma in GINA step 1-4. In these patients, even mild COVID-19 disease led to worsened asthma symptoms, while severe COVID-19 led to a severe asthma impairment measured by ACT score (p = 0.03) and VAS scale (p = 0.02), with increased oral corticosteroids consumption.

CONCLUSION

Maintaining optimal asthma control should be able to reduce risk of severe outcomes after COVID-19 disease. Communication via phone with the specialist involved in their asthma care was very comforting for patients, thus confirming the necessity to include phone calls, smart phone's application or online evaluations and counseling in long-term care of chronic diseases.

Screening Accuracy of FeNO Measurement for Childhood Asthma in a Community Setting

(1) Background: The exhaled fractional nitric oxide is a well-recognized biomarker used in clinical settings for controlling and managing asthma. Less is known about the value of Fractional Exhaled Nitric Oxide (FeNO) measurement in epidemiological studies on childhood asthma, although available evidence suggests that an increased FeNO is associated with an increased risk of asthma. (2) Aim: The aim of the study was to assess FeNO accuracy in the identification of children with asthma, participants in a population-based respiratory survey. (3) Material and methods: The cross-sectional study included 449 children, 224 (49.9%) boys and 225 (50.1%) girls aged 6−10 years. The FeNO was measured in 449 children; Spirometry tests were completed with 441 children, but technically acceptable spirometry was done in 350. All participants fulfilled the questionnaire (ISAAC) for assessment of the status of their respiratory system on which diagnosis was based on. FeNO and Spirometry were performed according to ERS/ATS recommendations. (4) Results: The FeNO was significantly higher in asthmatic children (n = 22): 27.3 ± 21.3 ppb; with allergic rhinitis (n = 106): 9.9 ± 21.6 ppb, with atopic dermatitis (n = 67) 20.8 ± 25.0 ppb, with an asthmatic tendency (n = 27): 19.8 ± 16.0 ppb in comparison to children without any respiratory/atopy symptoms. The highest diagnostic odds ratio and area under the curve were found in any treated asthma or asthma without any atopic symptoms in relation to FeNO cutoff > 35 ppb; DOR 4.85 and 8.37; AUC 0.615 and 0.795, respectively. The adjustment for spirometry parameters did not improve the diagnostic accuracy of FeNO. In each FeNO cutoff, there were more false positive than true positive subjects. (5) Conclusions. The best diagnostic accuracy of FeNO was for isolated asthma without any atopy against children without any coexisting respiratory or allergic disease. The sensitivity and specificity did not reach the required values for a good screening tool; therefore, it should not be used in epidemiological settings.

Are Markers of Allergic Inflammation in Grass Pollen Allergy Influenced by H1 Antihistamines?

Soluble intercellular adhesion molecule-1 (ICAM-1) and soluble vascular adhesion molecule-1 (VCAM-1) play important roles in allergic rhinitis (AR). Treatment with H1 antihistamines improves AR symptoms and in vitro reduces the levels of adhesion molecules. The aim of the study was to evaluate serum levels of ICAM-1 and VCAM-1 in patients with AR to grass pollen and their response to different H1 antihistamines.

MATERIAL AND METHODS

A total of 50 patients with grass pollen AR were clinically and biologically evaluated. ICAM-1 and VCAM-1 serum levels were evaluated during pollen season before and after treatment with levocetirizine and desloratadine through the ELISA method.

RESULTS

ICAM-1, VCAM-1, eosinophils, and total IgE were elevated in patients with AR, compared with healthy subjects. Both antihistamines improved specific symptoms of AR and increased patients' quality of life during pollen season after one month of treatment. H1 antihistamines reduced VCAM-1, ICAM-1, and total IgE after one-month treatment but not significantly. Patients with increased baseline values tend to remain with increased values after one-month AH1 treatment.

CONCLUSIONS

ICAM-1 and sVCAM-1 levels are higher in patients with grass pollen-induced AR than healthy controls during pollen exposure. Their serum levels tend to remain at high values during pollen season despite antihistaminic therapy.

Cross-sectional study on exhaled nitric oxide in relation to upper airway inflammatory disorders with regard to asthma and perennial sensitization

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is a well-known marker of type-2 inflammation. FeNO is elevated in asthma and allergic rhinitis, with IgE sensitization as a major determinant.

OBJECTIVE

We aimed to see whether there was an independent association between upper airway inflammatory disorders (UAID) and FeNO, after adjustment for asthma and sensitization, in a multi-centre population-based study.

METHODS

A total of 741 subjects with current asthma and 4155 non-asthmatic subjects participating in the second follow-up of the European Community Respiratory Health Survey (ECRHS III) underwent FeNO measurements. Sensitization status was based on measurement of IgE against airborne allergens; information on asthma, UAID and medication was collected through interview-led questionnaires. Independent associations between UAID and FeNO were assessed in adjusted multivariate regression models and test for interaction with perennial sensitization and asthma on the relation between UAID and FeNO were made.

RESULTS

UAID were associated with higher FeNO after adjusting for perennial sensitization, asthma and other confounders: with 4.4 (0.9-7.9) % higher FeNO in relation to current rhinitis and 4.8 (0.7-9.2) % higher FeNO in relation to rhinoconjunctivitis. A significant interaction with perennial sensitization was found in the relationship between current rhinitis and FeNO (p = .03) and between rhinoconjunctivitis and FeNO (p = .03). After stratification by asthma and perennial sensitization, the association between current rhinitis and FeNO remained in non-asthmatic subjects with perennial sensitization, with 12.1 (0.2-25.5) % higher FeNO in subjects with current rhinitis than in those without.

CONCLUSIONS & CLINICAL RELEVANCE

Current rhinitis and rhinoconjunctivitis was associated with higher FeNO, with an interaction with perennial sensitization. This further highlights the concept of united airway disease, with correlations between symptoms and inflammation in the upper and lower airways and that sensitization needs to be accounted for in the relation between FeNO and rhinitis.

sCD48 is elevated in non-allergic but not in allergic persistent rhinitis

BACKGROUND

CD48 is a costimulatory receptor of the immune response. Interactions between CD48 and CD244 (2B4) on mast cells and eosinophils suggest that these cells can act synergistically in the 'allergic effector unit' to promote inflammation. This report explores the role of CD48 in persistent allergic (PAR) and non-allergic rhinitis (NAR).

METHODS

In this study, serum was obtained from 70 subjects (45 female, 64%; mean age, 36; range 18-70 years) to estimate the levels of sCD48 and two eosinophils-related parameters, ECP and eotaxin-1/CCL11. Twenty patients with PAR, 15 patients with NAR, and 35 healthy controls were included. The intensity of rhinitis symptoms was estimated by the Total Nasal Symptom Score. We also assessed the fractional exhaled nitric oxide bronchial and nasal fractions (FeNO) and neutrophil to lymphocyte (NLR) and eosinophil to lymphocyte (ELR) ratios.

RESULTS

Significantly higher sCD48 serum levels were observed in the NAR group than in the PAR and control groups, and significant correlations were found between the serum level of sCD48 and the number and percentage of eosinophils. ECP and eotaxin-1/CCL11 serum levels were also found to be significantly higher in the NAR group.

CONCLUSIONS

CD48 may be involved in eosinophilic pathophysiological reactions in non-allergic rhinitis.

Allergen immunotherapy for house dust mite-induced rhinitis: prescriptive criteria

Allergic rhinitis (AR) is a very common disease. In most cases, therapy is based on symptomatic drugs, while allergen immunotherapy (AIT), which is the only one to act on the cause of the disease, is reserved for patients with a greater burden of disease. In particular, the possible evolution towards asthma substantiates the use of AIT, but requires the availability of diagnostic indices related to the risk of developing asthma. We analyzed the available literature on risk factors for onset of asthma in patients with AR, including bronchial hyperresponsiveness, uncovering by respiratory function tests of airway impairment, measurement of fractioned exhaled nitric oxide, given IgE sensitization pattern, and respiratory infections detected by nasal mucus samples or by particular microbiomes. Most of these risk predictors have been investigated too little or do not have consistent results, while various studies have confirmed that early bronchial impairment in AR patients, particularly concerning small airways, should be considered as prescriptive criteria for AIT.