The Brussels Declaration: the need for change in asthma management

The treatable traits approach to adults with obstructive airways disease in primary and secondary care

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.

Impact of asthma in Europe: A comparison of web search data in 21 European countries

Background

Asthma is a chronic inflammatory disorder of the airways and one of the most important non-communicable diseases worldwide. Analyzing crowdsourced data can help understand public interest and unmet needs as well as potential factors influencing search behavior.

Objective

The study aimed to investigate asthma-related web search data in Europe to identify possible regional and seasonal variations and to assess public interest.

Methods

Google Ads Keyword Planner was used to measure search volume for search terms related to asthma, allergic asthma, and bronchial asthma in 21 European countries between January 2018 and December 2021. The top 10 keywords of each country were categorized qualitatively. Search volume per 100 000 inhabitants was descriptively assessed in terms of regional and seasonal trends. Spearman correlations between search volume and pollen concentration as well as coronavirus disease (COVID-19) cases were investigated.

Results

The median search volume per 100 000 inhabitants for asthma and allergic asthma was highest in Northern and Western Europe, while the highest search volume for bronchial asthma was observed in Western and Eastern regions. A seasonal trend was identified for all search terms and in all regions. Correlations were found between search frequency and pollen load and search behavior and COVID-19 cases. Overall, Europeans were most interested in the diseases in general, their treatment options, and symptoms.

Conclusion

These results highlighted the need for reliable and region-specific information about the disease and for public campaigns to improve asthma control. The study also emphasizes the importance of using crowdsourced data for a more encompassing overview beyond conventional healthcare data.

Strength of association between comorbidities and asthma: a meta-analysis

BACKGROUND

The strength of association between comorbidities and asthma has never been ranked in relation to the prevalence of the comorbidity in the nonasthma population. We investigated the strength of association between comorbidities and asthma.

METHODS

A comprehensive literature search was performed for observational studies reporting data on comorbidities in asthma and nonasthma populations. A pairwise meta-analysis was performed and the strength of association calculated by anchoring odds ratios and 95% confidence intervals with the rate of comorbidities in nonasthma populations via Cohen's d method. Cohen's d=0.2, 0.5 and 0.8 were cut-off values for small, medium and large effect sizes, respectively; very large effect size resulted for Cohen's d >0.8. The review was registered in the PROSPERO database; identifier number CRD42022295657.

RESULTS

Data from 5 493 776 subjects were analysed. Allergic rhinitis (OR 4.24, 95% CI 3.82-4.71), allergic conjunctivitis (OR 2.63, 95% CI 2.22-3.11), bronchiectasis (OR 4.89, 95% CI 4.48-5.34), hypertensive cardiomyopathy (OR 4.24, 95% CI 2.06-8.90) and nasal congestion (OR 3.30, 95% CI 2.96-3.67) were strongly associated with asthma (Cohen's d >0.5 and ≤0.8); COPD (OR 6.23, 95% CI 4.43-8.77) and other chronic respiratory diseases (OR 12.85, 95% CI 10.14-16.29) were very strongly associated with asthma (Cohen's d >0.8). Stronger associations were detected between comorbidities and severe asthma. No bias resulted according to funnel plots and Egger's test.

CONCLUSION

This meta-analysis supports the relevance of individualised strategies for disease management that look beyond asthma. A multidimensional approach should be used to assess whether poor symptom control is related to uncontrolled asthma or to uncontrolled underlying comorbidities.

Symptom control and health-related quality of life in allergic rhinitis with and without comorbid asthma: A multicentre European study

BACKGROUND

Allergic rhinitis (AR) is a major non-communicable disease that affects the health-related quality of life (HRQoL) of patients. However, data on HRQoL and symptom control in AR patients with comorbid asthma (AR + asthma) are lacking.

METHODS

In this multicentre, cross-sectional study, patients with AR were screened and administered questionnaires of demographic characteristics and health conditions (symptoms/diagnosis of AR and asthma, disease severity level, and allergic conditions). HRQoL was assessed using a modified version of the RHINASTHMA questionnaire (30, 'not at all bothered' - 150 'very much bothered') and symptom control was evaluated by a modified version of the Control of Allergic Rhinitis/Asthma Test (CARAT) (0, 'no control' - 30, 'very high control').

RESULTS

Out of 643 patients with AR, 500 (78%) had asthma as a comorbidity, and 54% had moderate-severe intermittent AR, followed by moderate-severe persistent AR (34%). Compared to the patients with AR alone, patients with AR + asthma had significantly higher RHINASTHMA (e.g., median RHINASTHMA-total score 48.5 vs. 84, respectively) and a significantly lower CARAT score (median CARAT-total score 23 vs. 16.5, respectively). Upon stratifying asthma based on severity, AR patients with severe persistent asthma had worse HRQoL and control than those with mild persistent asthma. The association was significantly higher among non-obese participants compared to obese ones, with RHINASTHMA-upper symptoms score but not with CARAT.

CONCLUSIONS

Our observation of poorer HRQoL and symptoms control in AR patients with comorbid asthma supports the importance of a comprehensive approach for the management of AR in case of a comorbid allergic condition.

Medication beliefs, adherence, and outcomes in people with asthma: The importance of treatment beliefs in understanding inhaled corticosteroid nonadherence-a retrospective analysis of a real-world data set

Background

Poor adherence to inhaled corticosteroids (ICSs) increases asthma morbidity and mortality and is influenced by patients' treatment beliefs. This study maps patients' beliefs about ICSs across 6 countries examining variations in beliefs, and their relationship with adherence and outcomes.

Objective

We sought to explore the relationship between patient treatment beliefs, and adherence and outcomes in asthma across 6 countries.

Methods

Patients 18 years or older with asthma, receiving ICS alone or in combination with a long-acting β2-agonist, were included from a point-in-time paper survey of patients with asthma in Europe and the United States. Clinical characteristics, such as adherence and asthma control, were collected by self- and physician-report. Patients completed the Beliefs about Medicines Questionnaire, adapted for ICSs. Relationships between patient treatment beliefs, adherence, and outcomes were examined using regression analyses.

Results

Data from 1312 patients were analyzed. Patients were from Germany (24%), the United States (21%), France (21%), Spain (16%), Italy (10%), and the United Kingdom (9%). Most had physician-reported mild-intermittent asthma (87%), and mean age was 40 ± 15.5 years. There was considerable variation in necessity beliefs between countries, with respondents in Italy having more doubts about treatment necessity and respondents in Spain showing higher concerns. Patients with doubts about ICS necessity and high concerns had lower self-reported (necessity: χ2(2) = 34.31, P < .001; concerns: χ2(2) = 20.98, P < .001) and physician-reported adherence (necessity: χ2(2) = 11.70, P = .003; concerns: χ2(2) = 34.45, P < .001). Patients with high necessity beliefs (F(2, 483) = 3.33; P = .037) and high concerns (F(2,483) = 23.46; P < .001) reported poorer control. Physician estimates of adherence did not correlate well with patient self-report (ρ = 0.178, P < .001).

Conclusions

ICS necessity beliefs and concerns were associated with adherence and asthma control. This has implications for the design of adherence interventions.

Impact of an Asthma Education Program During Admission

OBJECTIVES

Health educational interventions improve health outcomes and quality of life in children with asthma. The main purpose of this study was to evaluate the effect of an education intervention for an asthma inhaler technique during hospital admission for an asthma exacerbation.

METHODS

This prospective study was conducted in a pediatric hospitalization unit of a third-level hospital. Children admitted for an asthma exacerbation were eligible for inclusion. It was developed in 2 phases: during hospital admission (T1) and 1 month after discharge (T2). In the T1 phase, caregivers completed the questionnaire to assess asthma control in children (CAN questionnaire) and performed the inhaler technique, which was evaluated with a 6-step checklist. An educational intervention was performed. In the T2 phase, caregivers completed the CAN questionnaire, and the inhaler technique was reevaluated. We hypothesized that the inhaler technique improved after the implementation of an asthma education program.

RESULTS

A total of 101 children were included, of whom 85 completed the T2 phase (84%). At baseline, 11.8% of participants performed the inhaler technique correctly. All steps of the inhaler technique upgraded in the T2 phase significantly (P < .01), except for the step "assemble the inhaler device correctly." Former evaluation by a pediatric pneumologist was associated with a higher score in the inhaler technique in the T1 phase. The median CAN questionnaire score in the T1 phase was 8 (interquartile range 4-16), which reduced to 4 (interquartile range 1.2-6) in the T2 phase (P < .01).

CONCLUSIONS

The development of an educational intervention during admission improved inhaler technique as well as asthma knowledge.

Treatment Eligibility of Real-Life Mepolizumab-Treated Severe Asthma Patients

BACKGROUND

Patients with severe asthma not meeting the strict trial eligibility criteria for mepolizumab are now routinely treated with this biological in clinical practice, but it remains unclear whether these ineligible patients respond differently to mepolizumab treatment.

OBJECTIVE

This study investigated the extent and reasons for trial ineligibility of real-life, mepolizumab-treated patients with severe asthma and compared the characteristics of these patients with trial populations. Subsequently, therapeutic response in ineligible patients was assessed on the basis of oral corticosteroid (OCS) reduction.

METHODS

Trial eligibility, population differences, and therapeutic response were assessed using the baseline characteristics of mepolizumab-receiving patients with severe asthma treated in the Amsterdam University Medical Centres and OCS dose at 6 months for OCS-dependent patients extracted from patients' electronic health records. Eligibility criteria and population characteristics from trials investigating mepolizumab were extracted from their original publications.

RESULTS

A total of 82.4% of 119 mepolizumab-receiving, real-life patients with severe asthma were ineligible for trial inclusion, wherein 42.9% and 39.5% were excluded on the basis of inclusion and exclusion criteria, respectively. The clinical care population was older, more often male and demonstrating a better lung function under lower OCS maintenance dosages in comparison with trial populations. A total of 50% of 66 ineligible, OCS-dependent mepolizumab-treated patients were able to reduce their maintenance OCS dosage to ≤5 mg prednisone/day.

CONCLUSIONS

A large proportion of the real-life, mepolizumab-treated population with severe asthma would be excluded from trial participation, and significant differences in population characteristics exist. Regardless, a large fraction of ineligible patients in clinical care can reduce maintenance OCS dosage under mepolizumab therapy.

Real-life effect of a microcrystalline tyrosine adjuvanted mite immunotherapy in patients with allergic rhinitis

Aim: Evaluate the effectiveness and safety of immunotherapy with Acarovac Plus^® in a 1-year prospective multicentered real-life study. Methods: A total of 118 adults with allergic rhinitis sensitized to Dermatophagoides received subcutaneous immunotherapy with Acarovac Plus. Treatment outcomes were evaluated at baseline, 6 months and 1 year after treatment initiation. Primary end point was the evolution of the combined symptom and medication score. Secondary end points included other effectiveness outcomes and measurement of product tolerability. Results: Acarovac Plus induced significant improvements in primary and secondary end points after 6 months compared with baseline. These differences persisted after 1 year of treatment (p < 0.001; baseline vs 1 year): combined symptom and medication score (1.60 vs 0.79). No serious adverse events were recorded. Conclusion: Acarovac Plus for 1 year was effective and well tolerated in a real-life setting.

Impact of COPD diagnosis timing on clinical and economic outcomes: the ARCTIC observational cohort study

Purpose: Assess the clinical and economic consequences associated with an early versus late diagnosis in patients with COPD.

Patients and methods: In a retrospective, observational cohort study, electronic medical record data (2000–2014) were collected from Swedish primary care patients with COPD. COPD indicators (pneumonia, other respiratory diseases, oral corticosteroids, antibiotics for respiratory infections, prescribed drugs for respiratory symptoms, lung function measurement) registered prior to diagnosis were applied to categorize patients into those receiving early (2 or less indicators) or late diagnosis (3 or more indicators registered >90 days preceding a COPD diagnosis). Outcome measures included annual rate of and time to first exacerbation, mortality risk, prevalence of comorbidities and health care utilization.

Results: More patients with late diagnosis (n=8827) than with early diagnosis (n=3870) had a recent comorbid diagnosis of asthma (22.0% vs 3.9%; P<0.0001). Compared with early diagnosis, patients with late diagnosis had a higher exacerbation rate (hazard ratio [HR] 1.89, 95% confidence interval [CI]: 1.83–1.96; P<0.0001) and shorter time to first exacerbation (HR 1.61, 95% CI: 1.54–1.69; P<0.0001). Mortality was not different between groups overall but higher for late versus early diagnosis, after excluding patients with past asthma diagnosis (HR 1.10, 95% CI: 1.02–1.18; P=0.0095). Late diagnosis was also associated with higher direct costs than early diagnosis.

Conclusion: Late COPD diagnosis is associated with higher exacerbation rate and increased comorbidities and costs compared with early diagnosis. The study highlights the need for accurate diagnosis of COPD in primary care in order to reduce exacerbations and the economic burden of COPD.

Community-based survey as a basis for evidence-based public health: children living in Upper Silesian Industrial Zone

OBJECTIVE

The aim of the study was to estimate changes in the prevalence of respiratory diseases and disorders between 2003/2004 and 2011/2012 in 13-16 years old children living in Bytom, one of the biggest cities in the Silesia agglomeration and provide the evidence for local policy makers.

METHODS

Data from two cross-sectional surveys, based on the Polish version of the International Study of Allergy and Asthma in Childhood (ISAAC) questionnaire, conducted in 2003/2004 and 2011/2012 was used. Response rate in the first and the second survey was 68% and 35%, respectively. The number of analyzed observations was 4,041 and 707 from the first and the second survey. The selection bias was controlled with the propensity score matching and potential determinants of analyzed respiratory diseases and disorders were controlled in the multivariable logistic regression model.

RESULTS

We found statistically significant increase in asthma ever diagnosed by medical doctor (4.5% vs. 9.6%; p < 0.01), seizures of dyspnea (8.2% vs. 27.7%; p < 0.01), and chest wheeze (9.6% vs. 19.2%; p < 0.01).

CONCLUSION

Our study revealed significant increase in the prevalence of respiratory diseases and disorders after 8 years in adolescents living in the Upper Silesian Industrial Zone. This is a relevant finding which provides the evidence for decision makers in the scope of local public health policies.

Effectiveness trials: critical data to help understand how respiratory medicines really work?

Most of the information about the benefits, safety aspects, and cost effectiveness of pharmacological treatment in the respiratory field has been obtained from traditional efficacy studies, such as randomised controlled trials (RCT). The highly controlled environment of an RCT does not always reflect everyday practice. The collection, analysis, and application of effectiveness data to generate Real World Evidence (RWE) through pragmatic trials or observational studies therefore has the potential to improve decision making by regulators, payers, and clinicians.

Despite calls for more RWE, effectiveness data are not widely used in decision making in the respiratory field. Recent advances in data capture, curation, and storage combined with new analytical tools have now made it feasible for effectiveness data to become routine sources of evidence to supplement traditional efficacy data. In this paper, we will examine some of the current data gaps, diverse types of effectiveness data, look at proposed frameworks for the positioning of effectiveness data, as well as provide examples from therapeutic areas. We will give examples of both previous effectiveness studies and studies that are ongoing within the respiratory field. Effectiveness data hold the potential to address several evidentiary gaps related to the effectiveness, safety, and value of treatments in patients with respiratory diseases.

Applying UK real-world primary care data to predict asthma attacks in 3776 well-characterised children: a retrospective cohort study

Current understanding of risk factors for asthma attacks in children is based on studies of small but well-characterised populations or pharmaco-epidemiology studies of large but poorly characterised populations. We describe an observational study of factors linked to future asthma attacks in large number of well-characterised children. From two UK primary care databases (Clinical Practice Research Datalink and Optimum Patient Care research Database), a cohort of children was identified with asthma aged 5–12 years and where data were available for ≥2 consecutive years. In the “baseline” year, predictors included treatment step, number of attacks, blood eosinophil count, peak flow and obesity. In the “outcome” year the number of attacks was determined and related to predictors. There were 3776 children, of whom 525 (14%) had ≥1 attack in the outcome year. The odds ratio (OR) for one attack was 3.7 (95% Confidence Interval (CI) 2.9, 4.8) for children with 1 attack in the baseline year and increased to 7.7 (95% CI 5.6, 10.7) for those with ≥2 attacks, relative to no attacks. Higher treatment step, younger age, lower respiratory tract infections, reduced peak flow and eosinophil count >400/μL were also associated with small increases in OR for an asthma attack during the outcome year. In this large population, several factors were associated with a future asthma attack, but a past history of attacks was most strongly associated with future attacks. Interventions aimed at reducing the risk for asthma attacks could use primary care records to identify children at risk for asthma attacks.

A past history of asthma attacks in young children is a strong predictor for future attacks and should be factored into treatment regimes. Childhood asthma attacks take considerable toll on sufferers and their carers, yet risk factors for future attacks are unclear. David Price at the Observational and Pragmatic Research Institute in Singapore and co-workers searched UK primary care databases to find at least two years’ worth of consecutive data on children with asthma aged 5 to 12. The team analyzed data from 3,776 children. Their results showed that past attacks are the strongest predictor for future attacks; of 638 patients who experienced more than one asthma attack during the first year, 240 (38%) had attacks in the second year. Other risk factors included reduced peak flow, lower respiratory tract infections and younger age.

Understanding patients' perceptions of asthma control: a qualitative study

Asthma control is suboptimal for many sufferers despite the existence of effective treatments. Patients' self-management is influenced by their perceptions of asthma and its treatment. This study explored sufferers' perceptions of asthma control and their influence on self-management behaviours.Participants (n=42) recruited from primary and secondary care asthma clinics in London in the UK each underwent a qualitative interview exploring perceptions and experiences of asthma control. Purposive sampling ensured variation in disease severity, degree of asthma control, age and socioeconomic status. Grounded theory was employed in thematic analysis of transcribed interviews.Five themes relating to perceptions of asthma control and self-management were identified: personal meaning of control, intermittent prevention, compromising control to avoid medication, pharmacological agents overemphasised in control and the role of asthma review in control. Within the first theme, some participants had an internal barometer of the level of symptoms that indicated their asthma was getting "out of control" that was set much higher than Asthma Control Test criteria.The findings provide new insights into patients' perceptions of asthma control. Symptoms indicative of poor control were often tolerated as part of living with asthma. Identification of barriers and drivers to self-management highlight potential targets for strategies aimed at optimising asthma management.

Economic burden of COPD in a Swedish cohort: the ARCTIC study

Background

We assessed direct and indirect costs associated with COPD in Sweden and examined how these costs vary across time, age, and disease stage in a cohort of patients with COPD and matched controls in a real-world, primary care (PC) setting.

Patients and methods

Data from electronic medical records linked to the mandatory national health registers were collected for COPD patients and a matched reference population in 52 PC centers from 2000 to 2014. Direct health care costs (drug, outpatient or inpatient, PC, both COPD related and not COPD related) and indirect health care costs (loss of income, absenteeism, loss of productivity) were assessed.

Results

A total of 17,479 patients with COPD and 84,514 reference controls were analyzed. During 2013, direct costs were considerably higher among the COPD patient population (€13,179) versus the reference population (€2,716), largely due to hospital nights unrelated to COPD. Direct costs increased with increasing disease severity and increasing age and were driven by higher respiratory drug costs and non-COPD-related hospital nights. Indirect costs (~€28,000 per patient) were the largest economic burden in COPD patients of working age during 2013.

Conclusion

As non-COPD-related hospital nights represent the largest direct cost, management of comorbidities in COPD would offer clinical benefits and relieve the financial burden of disease.

The value of pragmatic and observational studies in health care and public health

Evidence-based practice is an important component of health care service delivery. However, there is a tendency, embodied in tools such as Grades of Recommendation, Assessment, Development, and Evaluation, to focus principally on the classification of study design, at the expense of a detailed assessment of the strengths and limitations of the individual study. Randomized controlled trials (RCTs), and in particular the classical “explanatory” RCT, have a privileged place in the hierarchy of evidence. However, classical RCTs have substantial limitations, most notably a lack of generalizability, which limit their direct applicability to clinical practice implementation. Pragmatic and observational studies can provide an invaluable perspective into real-world applicability. This evidence could be used more widely to complement ideal-condition results from classical RCTs, following the principle of triangulation. In this review article, we discuss several types of pragmatic and observational studies that could be used in this capacity. We discuss their particular strengths and how their limitations may be overcome and provide real-life examples by means of illustration.

Comparative Effectiveness of Step-up Therapies in Children with Asthma Prescribed Inhaled Corticosteroids: A Historical Cohort Study

BACKGROUND

In children with uncontrolled asthma prescribed low-dose inhaled corticosteroids (ICSs), various step-up options are available: fixed-dose combination ICS/long-acting β₂-agonist (FDC), increasing ICS dose, or adding leukotriene receptor antagonist (LTRA). However, evidence of their relative effectiveness is limited.

OBJECTIVE

To compare the effectiveness of step-up treatment to FDC in children with asthma versus increased ICS dose, or LTRA.

METHODS

This matched cohort study used UK primary-care databases to study children prescribed their first step-up treatment to FDC, increased ICS dose, or LTRA. A year of baseline data was used for matching and identifying confounders. Outcomes over the following year were examined. The primary outcome was severe exacerbation rate; secondary outcomes included overall asthma control, derived from databases (no asthma-related admissions/hospital attendances/oral corticosteroids or antibiotics prescribed with a respiratory review, and average prescribed salbutamol ≤200 μg/day).

RESULTS

There were 971 matched pairs in the FDC and increased ICS dose cohorts (59% males; mean age, 9.4 years) and 785 in the FDC and LTRA cohorts (60% males; mean age, 9.0 years). Exacerbation rates in the outcome year were similar between FDC and increased ICS (adjusted incidence rate ratio [95% CI], 1.09 [0.75-1.59]) and FDC and LTRA (incidence rate ratio, 1.36 [0.93-2.01]). Increased ICS and LTRA significantly reduced the odds of achieving overall asthma control, compared with FDC (odds ratios [95% CI], 0.52 [0.42-0.64] and 0.53 [0.42-0.66], respectively)-this was driven by reduced short-acting beta-agonist use.

CONCLUSIONS

FDC is as effective as increased ICS or LTRA in reducing severe exacerbation rate, but more effective in achieving asthma control.

Investigation into the Role of PI3K and JAK3 Kinase Inhibitors in Murine Models of Asthma

Asthma is a clinical disorder commonly characterized by chronic eosinophilic inflammation, remodeling and hyper responsiveness of the airways. However, the kinases like Phosphoinositide 3 kinase (PI3K) and Janus kinase 3 (JAK3) are involved in mast cell proliferation, activation, recruitment, migration, and prolonged survival of inflammatory cells. The present study was designed to evaluate the in-vivo comparative effects of two kinase inhibitors on airway inflammation and airway remodeling in acute and chronic models of asthma. Mice were sensitized twice intra-peritoneally and then challenged by inhalation with ovalbumin (OVA). They developed an extensive inflammatory response, goblet cell hyperplasia, collagen deposition, airway smooth muscle thickening similar to pathologies observed in human asthma. The effects of PI3K inhibitor (30 mg/kg, p.o), JAK3 inhibitor (30 mg/kg, p.o) and Dexamethasone (0.3 mg/kg) on airway inflammation and remodeling in OVA sensitized/challenged BALB/c mice were evaluated. Twenty-four hours after the final antigen challenge, bronchoalveolar lavage (BAL) and histological examinations were carried out. It was observed that kinase inhibitors significantly reduced airway inflammation as evidenced by the decrease in pro inflammatory cytokines in BALF and lung homogenate and inflammatory cell count in sensitized mice after allergen challenge. Lung histological analysis showed increased infiltration of inflammatory cells, hyperplasia of goblet cells and the collagen deposition, which were significantly reduced with kinase inhibitor. In conclusion, our data suggest that PI3K and JAK3 inhibitors showed promising alternative therapeutic activity in asthma, which might significantly counteract the airway inflammation in patients with allergic asthma.

Asthma and Environmental Factors in Children

Asthma is one of the most prevalent atopic diseases in childhood. It is characterized by inflammation of conductive airways and bronchial hyperresponsiveness. Environmental factors introduced to child in early years of life may have a protective or harmful role in developing atopic diseases. To evaluate the influence of some environmental factors such as cat or dog ownership, smoking of mother or father and environmental pollution on prevalence of wheezing in children. Subjects and methods: This was a cross sectional retrospective study. A questionnaire was designed based on International Study of Asthma and Allergies in Childhood (ISAAC). Parents of the subjects were asked to fill in the questionnaires. Children’s wheezing association with keeping cats and dogs, smoking mother and father and frequency of truck passing in place of residence was investigated. 545 children were recruited in our study. Prevalence of wheezing was 9%. Keeping cats in first year of life and last year was associated with less wheezing. But the latter association was not statistically significant. Keeping dogs was so scarce in area of our study, so we could not perform a rightful analysis. Frequency of truck passing was significantly higher in those with wheezing. Keeping cats in first year of life was a significant protective factor, whereas residence in an area with frequent truck passing increased wheezing in children. Results of our study can emphasize the need to keep children away from polluted areas. Further studies are needed to investigate whether keeping a pet in household can benefit children regarding all possible concerns and benefits.

Predicting and reducing risk of exacerbations in children with asthma in the primary care setting: current perspectives

Childhood asthma is a very common condition in western countries and is becoming more prevalent worldwide. Asthma attacks (or exacerbations) affect the quality of life for child and parent, can rarely result in death, and also come at a cost for health care providers and the economy. The aims of this review were to 1) describe the burden of asthma exacerbations, 2) describe factors that might predict a child at increased risk of having an asthma attack, and 3) explore what interventions might be delivered in primary care to reduce the risk of a child having an asthma attack. Asthma attacks are more common in younger children and those with more severe asthma, although prevalence varies between countries. Many factors are associated with asthma attacks including environmental exposures, patient–clinician relationship, and patient factors. Currently, the best predictor of an asthma attack is a history of an attack in the previous 12 months, and the more attacks, the greater the risk. Looking ahead, it is likely that surveillance of routinely collected primary care data can be used to identify an individual at increased risk. Stratified (or personalized) treatment, which might involve physiological monitoring and genetic analysis, offers the potential to reduce an individual’s risk of asthma attack. Whatever the future holds, the relationship between patient and clinician will remain central to asthma management.

Adalimumab ameliorates OVA-induced airway inflammation in mice: Role of CD4(+) CD25(+) FOXP3(+) regulatory T-cells

Asthma is a chronic inflammatory heterogeneous disorder initiated by a dysregulated immune response which drives disease development in susceptible individuals. Though T helper 2 (TH2) biased responses are usually linked to eosinophilic asthma, other Th cell subsets induce neutrophilic airway inflammation which provokes the most severe asthmatic phenotypes. A growing evidence highlights the role of T regulatory (Treg) cells in damping abnormal Th responses and thus inhibiting allergy and asthma. Therefore, strategies to induce or augment Treg cells hold promise for treatment and prevention of allergic airway inflammation. Recently, the link between Tumor necrosis factor-α (TNF-α) and Treg has been uncovered, and TNF-α antagonists are increasingly used in many autoimmune diseases. Yet, their benefits in allergic airway inflammation is not clarified. We investigated the effect of Adalimumab, a TNF-α antagonist, on Ovalbumin (OVA)-induced allergic airway inflammation in CD1 mice and explored its impact on Treg cells. Our results showed that Adalimumab treatment attenuated the OVA-induced increase in serum IgE, TH2 and TH1 derived inflammatory cytokines (IL-4 and IFN-γ, respectively) in bronchoalveolar lavage (BAL) fluid, suppressed recruitment of inflammatory cells in BAL fluid and lung, and inhibited BAL fluid neutrophilia. It also ameliorated goblet cell metaplasia and bronchial fibrosis. Splenocytes flow cytometry revealed increased percentage of CD4(+) CD25(+) FOXP3(+) Treg cells by Adalimumab that was associated with increase in their suppressive activity as shown by elevated BAL fluid IL-10. We conclude that the beneficial effects of Adalimumab in this CD1 neutrophilic model of allergic airway inflammation are attributed to augmentation of Treg cell number and activity.

Once-daily fluticasone furoate and vilanterol for adolescents and adults with symptomatic asthma: A systematic review with meta-analysis

BACKGROUND

Fluticasone furoate and vilanterol is a new inhaled corticosteroid (ICS) and long-acting β2-agonist (LABA) combination developed for once-daily administration via a dry powder inhaler.

OBJECTIVE

To assess the efficacy and safety of fluticasone furoate-vilanterol in adolescents and adults with symptomatic asthma compared with ICS monotherapy or twice-daily ICS-LABA formulations.

METHODS

Randomized, placebo-controlled trials with longer than 8 weeks of treatment duration were included. Primary outcome was pulmonary function (forced expiratory volume in 1 second [FEV1] or peak expiratory flow rate [PEF]).

RESULTS

Seven published randomized clinical trials were included (5,668 patients). Fluticasone furoate-vilanterol was associated with significant increases in trough FEV1 and morning and evening PEF compared with fluticasone furoate, 100 μg, monotherapy (90 mL, 20.1 L/min, and 18.9 L/min respectively). Fluticasone furoate-vilanterol reduced significantly the rate of severe asthma exacerbations (number need to treat for benefit = 24). Fluticasone furoate-vilanterol also produced significant increases in weighted FEV1 and morning and evening PEF (140 mL, 32.6 L/min, and 25.7 L/min, respectively) compared with fluticasone propionate, 500 μg twice daily. Fluticasone furoate-vilanterol presented a nonsignificant increase in the frequency of cardiac events (6.4% vs 1.8%) compared with fluticasone propionate. No differences were found between both available doses of fluticasone furoate-vilanterol (200/25 μg and 100/25 μg) in terms of efficacy. However, patients receiving fluticasone furoate-vilanterol, 200/25 μg, had a trend toward an increased risk of cardiac events.

CONCLUSION

Fluticasone furoate-vilanterol combination was associated with an increase in trough FEV1 compared with fluticasone furoate-fluticasone propionate; however, observed differences may not be clinically significant. Studies comparing fluticasone furoate-vilanterol with fixed twice-daily ICS-LABA combinations are required.

Maintaining Control of Chronic Obstructive Airway Disease: Adherence to Inhaled Therapy and Risks and Benefits of Switching Devices

Asthma and chronic obstructive pulmonary disease (COPD) are major obstructive airway diseases that involve underlying airway inflammation. The most widely used pharmacotherapies for asthma and COPD are inhaled agents that have been shown to be effective and safe in these patients. However, despite the availability of effective pharmacologic treatment and comprehensive treatment guidelines, the prevalence of inadequately controlled asthma and COPD is high. A main reason for this is poor adherence. Adherence is a big problem for all chronic diseases, but in asthma and COPD patients there are some additional difficulties because of poor inhalation technique and inhaler choice. Easier-to-use devices and educational strategies on proper inhaler use from health caregivers can improve inhaler technique. The type of device used and the concordance between patient and physician in the choice of inhaler can also improve adherence and are as important as the drug. Adherence to inhaled therapy is absolutely necessary for optimizing patient control. If disease control is not adequate despite good adherence, switching to a more appropriate inhaled therapy is recommended. By contrast, uninformed switching or switching to less user-friendly inhaler may impact disease control negatively. This critical review of the available literature is aimed to provide a guidance protocol on when a switch may be recommended in individual patients.

Real-life use of budesonide/formoterol in clinical practice: a 12-month follow-up assessment in a multi-national study of asthma patients established on single-inhaler maintenance and reliever therapy

Objective: The efficacy and safety of budesonide/formoterol maintenance and reliever therapy (MRT) has been demonstrated in phase III clinical studies, but limited data are available in a real-life setting. We examined the pattern of maintenance and as-needed inhaler use in routine clinical practice among patients with asthma receiving budesonide/formoterol MRT (NCT00505388). Methods: This 12-month European observational study enrolled patients prescribed budesonide/formoterol MRT and grouped them based on regimen: 80/4.5 µg one inhalation twice daily (b.i.d.); 160/4.5 µg one inhalation b.i.d.; 160/4.5 µg two inhalations b.i.d. (all plus as needed). Patient data were collected daily using an interactive voice- or web-response system. The primary outcome measure was total number of budesonide/formoterol inhalations/day. Results: Overall, 4,581 patients were included (64% female; mean age 48.4 years; regimen: 80/4.5 µg, n = 119; 160/4.5 µg, n = 3,106; 2 × 160/4.5 µg, n = 1,355). Mean (median) total numbers of budesonide/formoterol inhalations/day were 2.48 (2.11), 2.53 (2.14), and 4.27 (4.05) for 80/4.5 µg b.i.d., 160/4.5 µg b.i.d., and 2 × 160/4.5 µg b.i.d., respectively; corresponding mean (median) number of as-needed inhalations/day were 0.68 (0.17), 0.73 (0.26), and 1.08 (0.45), respectively. As-needed budesonide/formoterol use was generally low with a mean of 61 – 66% of reliever-free days; over 4 reliever inhalations/day occurred on a mean of 0.4 – 2.5% of days for all budesonide/formoterol MRT regimens. Conclusions: In routine clinical practice, all budesonide/formoterol MRT regimens were associated with a high proportion of reliever-free days and low incidence of high reliever-use days, indicating acceptable levels of asthma control with this symptom-adjusted controller regimen.

Diagnosis of asthma - new theories

INTRODUCTION

Recent studies have shown a remarkably high frequency of poorly controlled asthma. Several reasons for this treatment failure have been discussed, however, the basic question of whether the diagnosis is always correct has not been considered. Follow-up studies have shown that in many patients asthma cannot be verified despite ongoing symptoms. Mechanisms other than bronchial obstruction may therefore be responsible. The current definition of asthma may also include symptoms that are related to mechanisms other than bronchial obstruction, the clinical hallmark of asthma.

AIM

Based on a review of the four cornerstones of asthma - inflammation, hyperresponsiveness, bronchial obstruction and symptoms - the aim was to present some new aspects and suggestions related to the diagnosis of adult non-allergic asthma.

CONCLUSION

Recent studies have indicated that "classic" asthma may sometimes be confused with asthma-like disorders such as airway sensory hyperreactivity, small airways disease, dysfunctional breathing, non-obstructive dyspnea, hyperventilation and vocal cord dysfunction. This confusion may be one explanation for the high proportion of misdiagnosis and treatment failure. The current diagnosis, focusing on bronchial obstruction, may be too "narrow". As there may be common mechanisms a broadening to include also non-obstructive disorders, forming an asthma syndrome, is suggested. Such broadening requires additional diagnostic steps, such as qualitative studies with analysis of reported symptoms, non-effort demanding methods for determining lung function, capsaicin test for revealing airway sensory hyperreactivity, careful evaluation of the therapeutic as well as diagnostic effect of corticosteroids and testing of suggested theories.

Epithelial function and dysfunction in asthma

Asthma was previously defined as an allergic Th2-mediated inflammatory immune disorder. Recently, this paradigm has been challenged because not all pathological changes observed in the asthmatic airways are adequately explained simply as a result of Th2-mediated processes. Contemporary thought holds that asthma is a complex immune disorder involving innate as well as adaptive immune responses, with the clinical heterogeneity of asthma perhaps a result of the different relative contribution of these two systems to the disease. Epidemiological studies show that exposure to certain environmental substances is strongly associated with the risk of developing asthma. The airway epithelium is first barrier to interact with, and respond to, environmental agents (pollution, viral infection, allergens), suggesting that it is a key player in the pathology of asthma. Epithelial cells play a key role in the regulation of tissue homeostasis by the modulation of numerous molecules, from antioxidants and lipid mediators to growth factors, cytokines, and chemokines. Additionally, the epithelium is also able to suppress mechanisms involved in, for example, inflammation in order to maintain homeostasis. An intrinsic alteration or defect in these regulation mechanisms compromises the epithelial barrier, and therefore, the barrier may be more prone to environmental substances and thus more likely to exhibit an asthmatic phenotype. In support of this, polymorphisms in a number of genes that are expressed in the bronchial epithelium have been linked to asthma susceptibility, while environmental factors may affect epigenetic mechanisms that can alter epithelial function and response to environmental insults. A detailed understanding of the regulatory role of the airway epithelium is required to develop new therapeutic strategies for asthma that not only address the symptoms but also the underlining pathogenic mechanism(s) and prevent airway remodelling.

Initial step-up treatment changes in asthmatic children already prescribed inhaled corticosteroids: a historical cohort study

Background:

When standard doses of inhaled corticosteroids (ICS) fail to control symptoms in children aged >4 years, guidelines recommend the addition of a long-acting β₂-agonist (LABA), with other treatment options being available if symptoms persist.

Aims:

To determine the proportion of initial ‘step-up’ episodes where LABAs were prescribed and to describe characteristics of individuals not stepped up with LABA.

Methods:

Between 1999 and 2011, initial step-up episodes from ICS monotherapy were identified in children aged 5–12 years with asthma and in receipt of ICS. Data sources were the Clinical Practice Research Datalink and Optimum Patient Care Research Database.

Results:

Initial step-up episodes were identified in 10,793 children. ICS dose was increased in 6,252 children (58%), LABA was introduced in 3,436 (32%; including 1,107 where fixed dose combination inhaler (FDC) replaced the ICS inhaler), and leukotriene receptor antagonist (LTRA) was added in 1,105 (10%). Compared with children stepped up to any LABA, others were younger and prescribed lower doses of ICS and reliever medication. ICS dose increase was more likely in obese children and LTRA prescribing was more likely in children with rhinitis and in receipt of antibiotics. Compared with FDC, step-up to separate LABA inhaler was more likely in younger, obese children who were using less oral steroids.

Conclusions:

One-third of initial step-up episodes in children with asthma treated with ICS are to add LABA. Different characteristics of children prescribed therapies other than LABA suggest that prescribers tailor treatment in some clinical settings.

Changing adherence-related beliefs about ICS maintenance treatment for asthma: feasibility study of an intervention delivered by asthma nurse specialists

OBJECTIVES

The Necessity-Concerns Framework (NCF) posits that non-adherence to inhaled corticosteroids (ICS) in asthma is influenced by doubts about the necessity for ICS and concerns about their potential adverse effects. This feasibility study examined whether these beliefs could be changed by briefing asthma nurse specialists on ways of addressing necessity beliefs and concerns within consultations.

DESIGN

Pre-post intervention study.

SETTING

Secondary care.

PARTICIPANTS

Patients with a diagnosis of moderate to severe asthma who were prescribed daily ICS were recruited to either a hospital care group (n=79; 71.0% female) or intervention group (n=57; 66.7% female).

INTERVENTION

Asthma nurse specialists attended a 1.5-day NCF briefing.

PRIMARY AND SECONDARY OUTCOME MEASURES

Beliefs about ICS (primary outcome) and self-reported adherence were measured preconsultation and 1 month postconsultation. Participants also rated their satisfaction with their consultations immediately after the consultation. Consultation recordings were coded to assess intervention delivery.

RESULTS

After the NCF briefing, nurse specialists elicited and addressed beliefs about medicine more frequently. The frequency of using the NCF remained low, for example, open questions eliciting adherence were used in 0/59 hospital care versus 14/49 (28.6%) intervention consultations. Doubts about personal necessity for, and concerns about, ICS were reduced at 1 month postbriefing (p<0.05), but the intervention was not applied extensively enough to improve adherence.

CONCLUSIONS

The intervention changed nurse consultations, but not sufficiently enough to fully address non-adherence or adherence-related ICS beliefs (necessity and concerns). More effective techniques are needed to support nurse specialists and other practitioners to apply the intervention in hospital asthma review consultations.

On the biosynthesis of 15-HETE and eoxin C4 by human airway epithelial cells

Several lines of evidence indicate that 15-lipoxygenase type 1 (15-LO-1) plays a pathophysiological role in asthma. The aim for this study was to investigate the 15-LO-1 expression and activity in primary human airway epithelial cells cultivated on micro-porous filters at air-liquid interface. Incubation of human airway epithelial cells with arachidonic acid led to the formation of 15(S)-hydroxy-eicosatetraenoic acid (15-HETE) and exposing the cells to bacteria or physical injury markedly increased their production of 15-HETE. The cells were also found to convert arachidonic acid to eoxin C4 (EXC4). Subcellular fractionation revealed that the conversion of EXA4 to EXC4 was catalyzed by a soluble glutathione transferase (GST). The GST P1-1 enzyme was found to possess the highest activity of the investigated soluble GSTs. Following IL-4 treatment of airway epithelial cells, microarray analysis confirmed high expression of 15-LO-1 and GST P1-1, and immunohistochemical staining of bronchial biopsies revealed co-localization of 15-LO-1 and GST P1-1 in airway epithelial cells. These results indicate that respiratory infection and cell injury may activate the 15-LO pathway in airway epithelial cells. Furthermore, we also demonstrate that airway epithelial cells have the capacity to produce EXC4.

Non-eosinophilic airway hyper-reactivity in mice, induced by IFN-γ producing CD4(+) and CD8(+) lung T cells, is responsive to steroid treatment

Non-eosinophilic asthma is characterized by infiltration of neutrophils into the lung and variable responsiveness to glucocorticoids. The pathophysiological mechanisms have not been characterized in detail. Here, we present an experimental asthma model in mice associated with non-eosinophilic airway inflammation and airway hyper-responsiveness (AHR). For this, BALB/c mice were sensitized by biolistic DNA immunization with a plasmid encoding the model antigen β-galactosidase (pFascin-βGal mice). For comparison, eosinophilic airway inflammation was induced by subcutaneous injection of βGal protein (βGal mice). Intranasal challenge of mice in both groups induced AHR to a comparable extent as well as recruitment of inflammatory cells into the airways. In contrast to βGal mice, which exhibited extensive eosinophilic infiltration in the lung, goblet cell hyperplasia and polarization of CD4(+) T cells into Th2 and Th17 cells, pFascin-βGal mice showed considerable neutrophilia, but no goblet cell hyperplasia and a predominance of Th1 and Tc1 cells in the airways. Depletion studies in pFascin-βGal mice revealed that CD4(+) and CD8(+) cells cooperated to induce maximum inflammation, but that neutrophilic infiltration was not a prerequisite for AHR induction. Treatment of pFascin-βGal mice with dexamethasone before intranasal challenge did not affect neutrophilic infiltration, but significantly reduced AHR, infiltration of monocytes and lymphocytes as well as content of IFN-γ in the bronchoalveolar fluid. Our results suggest that non-eosinophilic asthma associated predominantly with Th1/Tc1 cells is susceptible to glucocorticoid treatment. pFascin-βGal mice might represent a mouse model to study pathophysiological mechanisms proceeding in the subgroup of asthmatics with non-eosinophilic asthma that respond to inhaled steroids.

Longitudinal measurement of airway inflammation over one year in children and adults with intermittent asthma

BACKGROUND

Asthma is an inflammatory disease of the airways, but in clinical practice inflammation is rarely monitored. The aim of this study was to assess the level of airway inflammation in steroid naïve adult and pediatric patients with intermittent asthma over one year.

METHODS

54 children and 50 adults with intermittent asthma (GINA step 1) were included. On up to 6 visits lung function, airway hyperresponsiveness to methacholine (PC20FEV1), sputum eosinophils and exhaled nitric oxide (FeNO) were assessed.

RESULTS

36 pediatric and 34 adult patients were able to produce at least three adequate sputum samples over the study period and were included into the analysis.In 8 children (22%) the percentage of sputum eosinophils was always below 2.5%. A higher level of eosinophils (>2.5%) was found on at least one visit in 16 (44%) and always >2.5% in 12 children (33%). In the adult group the respective numbers were 14 patients (41%) with always low (<2.5%), 17 (50%) with at least once over 2.5% and three patients (9%) were always above the threshold of 2.5% sputum eosinophils.

CONCLUSION

These results demonstrate that a substantial number of children and adults with intermittent asthma under ß-agonist treatment only, have variable or persistently high levels of eosinophilic airway inflammation. Long-term studies are needed to observe the progression of asthma severity in such patient populations.

Quality standards for real-world research. Focus on observational database studies of comparative effectiveness

Real-world research can use observational or clinical trial designs, in both cases putting emphasis on high external validity, to complement the classical efficacy randomized controlled trials (RCTs) with high internal validity. Real-world research is made necessary by the variety of factors that can play an important a role in modulating effectiveness in real life but are often tightly controlled in RCTs, such as comorbidities and concomitant treatments, adherence, inhalation technique, access to care, strength of doctor-caregiver communication, and socio-economic and other organizational factors. Real-world studies belong to two main categories: pragmatic trials and observational studies, which can be prospective or retrospective. Focusing on comparative database observational studies, the process aimed at ensuring high-quality research can be divided into three parts: preparation of research, analyses and reporting, and discussion of results. Key points include a priori planning of data collection and analyses, identification of appropriate database(s), proper outcomes definition, study registration with commitment to publish, bias minimization through matching and adjustment processes accounting for potential confounders, and sensitivity analyses testing the robustness of results. When these conditions are met, observational database studies can reach a sufficient level of evidence to help create guidelines (i.e., clinical and regulatory decision-making).

Effectiveness and safety of ciclesonide in the treatment of patients with persistent allergic or non-allergic asthma in medical practice (Data from a non-interventional study conducted in Austria)

BACKGROUND

Effectiveness and safety profile of ciclesonide in the treatment of persistent allergic or non-allergic asthma was evaluated in real-life setting in Austria.

METHODS

Prospective, single-arm, 3-month observational, non-interventional, open-label cohort study in patients with persistent asthma (with or without allergic component) of any severity grade was conducted. Patients were either treatment naïve or switched to treatment with ciclesonide and had an indication for treatment with inhaled corticosteroids.

RESULTS

In all, 307 patients (50.8% female; mean age, 45.7 years) were prescribed ciclesonide. After 3 months of observation, the percentage of patients with daily symptoms had declined from 33.2 to 3.9%, night-time symptoms from 21.8 to 5.2%, physical activity limitations from 73.9 to 24.4%, and rescue medication usage from 70.0 to 45.9%. The mean total Asthma Control Questionnaire (ACQ) score was 2.32 ± 1.14 at the first and 1.08 ± 0.88 at the final visit. The number of patients with well-controlled asthma (ACQ score < 1) increased considerably from 11.0% at baseline to 52.2% at study end. Clinically important mean improvements were observed in the total self-assessed Asthma Quality of Life score and all four domain scores. The mean forced expiratory volume in 1 s (FEV1) increased by 0.3 L from 2.60 ± 0.87 L to 2.89 ± 0.86 L, and the mean FEV1% predicted increased from 75.1 ± 15.4% to 83.7 ± 14.9%. Incidence of adverse drug reactions (ADRs) was low (4 ADRs in 3 of 307 patients, or 1.0%).

CONCLUSION

This study confirmed the effectiveness and safety of ciclesonide under routine conditions in Austria. Improvements in symptom control, lung function, and quality of life were observed. Ciclesonide was well tolerated.

Physiotherapy in asthma using the new Lotorp method

BACKGROUND

Physiotherapy in bronchial asthma has given various results.

AIM

To test a new method focusing on breathing exercise and massage of the thoracic muscles.

PATIENTS AND METHODS

Twenty-eight adult patients with a physician-diagnosed asthma were studied during 6 weeks. All patients were prescribed asthma medication. The new method [active group, n = 17) was compared with physical training (control group, n = 12).

RESULTS

PEF was significantly improved (p = 0.001) in the active group, however, FEV1 showed no significant change. The symptoms "tightness of the chest", "difficult breathing in", "air hunger", and the individually dominating symptom (p = 0.001) were significantly reduced in the active group. Exercise-induced breathing troubles and chest expansion were also significantly reduced.

CONCLUSION

Physiotherapy including breathing exercise and massage of the thoracic muscles (the Lotorp method) in patients with physician-diagnosed asthma resulted in significantly reduced respiratory symptoms during rest and exercise and increased chest expansion. The improvements may be due to an increased mobility of the chest and diaphragm.

Improvement in COPD management by access to asthma/COPD clinics in primary care: data from the observational PATHOS study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) guidelines emphasize the importance of patient education to improve quality of life and avoid exacerbations. Longitudinal evaluations of structured management of COPD in primary care are lacking.

AIM

To evaluate the impact of primary care asthma/COPD clinics on exacerbations, hospitalizations, and associated costs in COPD.

METHODS

This population-based, retrospective, observational study, linking primary care medical records data to mandatory Swedish national registries, included patients with COPD from 76 primary healthcare centers (1999-2009). A questionnaire on access to an asthma/COPD clinic was retrospectively answered. Propensity score matching was performed at index (COPD diagnosis) by center type (with and without an asthma/COPD clinic). Poisson regression was used to compare the yearly rate of exacerbations (hospitalization, emergency visits, or prescription for oral steroids or antibiotics) and COPD-related prescriptions at the centers. An economic analysis was performed from the Swedish healthcare perspective using 2011 unit costs and the incremental cost-effectiveness ratio was calculated.

RESULTS

The study included 21,361 patients (mean age, 68.0 years; 53% female). Access to asthma/COPD clinics increased from 34% to 85% during the study period. Patients at primary healthcare centers with asthma/COPD clinics had 27% fewer exacerbations (0.71 vs. 0.98) and 37% fewer hospitalizations annually (0.36 vs. 0.58) (p < 0.0001). Asthma/COPD clinics reduced the annual cost of medication and healthcare contacts by 37% (SEK 52,892 [€5858] to SEK 33,410 [€3700] per patient).

CONCLUSIONS

Patients at primary healthcare centers with asthma/COPD clinics experienced fewer COPD exacerbations and hospitalizations, and overall treatment costs were substantially reduced. ClinicalTrials.gov identifier: NCT01146392.

Inhaler competence and patient satisfaction with Easyhaler®: results of two real-life multicentre studies in asthma and COPD

Objective

The aim of this study was to investigate patients’ inhaler competence and satisfaction with the Easyhaler^® dry powder inhaler.

Design

Two open, uncontrolled, non-randomised studies.

Setting

Real life based on patients attending 56 respiratory clinics in Hungary.

Participants

Patients with asthma or chronic obstructive pulmonary disease (COPD) (n = 1016).

Intervention

In a 3-month study, adult patients (age range 18–88 years; n = 797) received twice-daily inhalations of formoterol via Easyhaler^®, and in a consequential study (from one visit to another, with 3–12 months in-between) children and adolescents (age range 4–17 years; n = 219) received salbutamol via Easyhaler^® as needed.

Main Outcome Measures

Control of six Easyhaler^® handling steps and patients’ satisfaction with Easyhaler^® based on questionnaires.

Results

Correct performances (minimum and maximum of the six steps) were noticed after one demonstration in 92–98 % of the adults, 87–99 % of the elderly, 81–96 % of the children and 83–99 % of the adolescents. These figures had markedly increased at the last visit. Repeat instructions were necessary in 26 % of the cases. Investigators found Easyhaler^® easy to teach in 87 % of the patients and difficult in only 0.5 %. Patients found Easyhaler^® easy to learn and use, and the patients’ (and parents’) satisfaction with the inhaler was very high. Lung function values [forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), peak expiratory flow (PEF)] improved statistically significantly during the studies, indicating good inhaler competence and treatment adherence.

Conclusion

Investigators found Easyhaler^® easy to teach and patients found it easy to use, and their satisfaction with the device was high.

Fractional exhaled nitric oxide in clinical trials: an overview

Designing clinical trials in asthma it is crucial to find the perfect primary endpoint for showing bioequivalence, especially when the investigational medicinal product is not a bronchodilator, but a substance, which suppresses the inflammatory process, e.g. inhalative corticosteroids (ICS). In the past, lung function parameters were used as the primary endpoint, which entails a long study duration and hundreds of patients. The measurement of fractional exhaled nitric oxide (FeNO) is established as a non-invasive marker for eosinophilic inflammation, and several guidelines focus on that diagnosis. FeNO is a surrogate measure of eosinophilic inflammation and at the same time, eosinophilic airway inflammation is usually steroid responsive. Thus, FeNO should be a part of the clinical management of asthma in ambulatory settings in conjunction with other conventional methods of asthma assessment. Furthermore, FeNO should be used to determine the presence or absence of eosinophilic airway inflammation, to determine the likelihood of steroid responsiveness, to measure response to steroid therapy, and level of inflammation control. In addition, FeNO is a useful tool to monitor patient ICS treatment adherence and allergen exposure. FeNO may be used to predict steroid responsiveness and as a measure to determine the optimal treatment of airway inflammation. FeNO has all characteristics of a good marker for bioequivalence measurements in the market approval process of generic ICS products. With a reliable study design in terms of patient population, concomitant medication, equipment and other factors, which can influence the measurement, efficient clinical trials can be performed, with a relatively short treatment time of 2-4 weeks and 50-100 patients.

Comparing usability of NEXThaler(®) with other inhaled corticosteroid/long-acting β2-agonist fixed combination dry powder inhalers in asthma patients

BACKGROUND

Inhaler mishandling is a common issue among patients suffering from asthma and is associated with poor clinical outcomes and greater consumption of health-care resources. Ease of use can improve inhaler technique and, possibly, patients' preference for their inhaler device, which in turn may lead to better adherence to therapy.

METHODS

This study investigated usability characteristics of NEXThaler(®) versus two other dry powder inhalers (DPIs; Diskus(®) and Turbuhaler(®)). Sixty-six adult patients with asthma (mean age 42.9±17.7 years) and with no previous experience of using a DPI were included in a randomized crossover comparison of the three devices. The main measures of usability were the number of steps failed for each device and the number of people who were able to use the device successfully (effectiveness), the time it took patients to set up the device and the time to read the instructions for use (IFU; efficiency), and patient preferences (satisfaction). Inhaler technique was evaluated after the IFU leaflet was read.

RESULTS

NEXThaler was found to be superior to the other two DPIs in terms of the number of device use failures (p<0.001), time to set up (p<0.001), and time to read IFU (p<0.001). Additionally, the proportion of participants who completed a successful inhalation without any errors at all was significantly higher for NEXThaler than for Diskus and Turbuhaler (p<0.001). Patients rated NEXThaler as the easiest to use and most preferred inhaler to own (p<0.001).

CONCLUSIONS

NEXThaler displayed better usability compared with Diskus and Turbuhaler. The improved usability and higher satisfaction with the device may contribute to increased patient adherence to asthma treatment.

Absence of gargling affects topical adverse symptoms caused by inhaled corticosteroids in females

OBJECTIVE

Topical adverse events caused by inhaled corticosteroids (ICS) are suspected to be more common in females. Although gargling or mouth washing after inhalation is recommended as the gold standard for preventing adverse events due to ICS, the preventive effects of this method have not been confirmed in real-world studies. This study aimed to examine the association between gargling or mouth washing and the incidence of topical adverse symptoms in males and females in daily practice.

METHODS

We analyzed a subpopulation of participants in the Drug Event Monitoring (DEM) project of the Japan Pharmaceutical Association. An anonymous survey was performed in February 2010, to assess the self-perception of topical adverse symptoms during ICS use by conducting interviews of pharmacists using structured questionnaires.

RESULTS

A total of 412 males and 480 females were included. The patients used a dry-powder inhaler (DPI) (71.2%), pressurized meter-dose inhaler (pMDI) with (7.5%) or without (16.6%) a spacer or inhalation solution (4.7%) as the delivery device. Topical adverse symptoms occurring after previous prescriptions were reported by 41 (4.6%) subjects. The common symptoms were hoarseness, stomatitis and dry mouth (1.3%, 1.1% and 1.1%, respectively). In the multiple regression model, the presence of symptoms was found to be significantly associated with the absence of gargling or mouth washing after inhalation [adjusted odds ratio (OR): 3.75, 95% confidence interval (95%CI): 1.33-10.59, p = 0.012]. When stratified by gender, the absence of gargling or mouth washing was identified to be a risk factor in females only (OR: 4.32, 95%CI: 1.11-16.87, p = 0.035) and not in males (OR: 3.26, 95%CI: 0.65-16.33, p = 0.151). Furthermore, the association between the absence of gargling or mouth washing and the incidence of topical adverse symptoms was significant in the patients using DPI (OR: 4.85, 95%CI: 1.66-14.14, p = 0.004), but not in those using the other devices.

CONCLUSIONS

In this study, the absence of gargling or mouth washing after ICS use was associated with topical adverse symptoms, especially in females. To achieve good adherence to treatment and improve the quality of life, female patients with asthma should strictly practice the gargling or mouth washing method.

Anti-inflammatory treatment of atopic asthma guided by exhaled nitric oxide: a randomized, controlled trial

BACKGROUND

Atopic asthma is characterized by Th2 cytokine-driven inflammation of the airway mucosa, which is signaled by the fraction of exhaled nitric oxide (FENO).

OBJECTIVE

We tested whether an FENO-guided anti-inflammatory treatment algorithm could improve asthma-related quality of life and asthma symptom control, and reduce exacerbations in atopic asthmatics within primary care.

METHODS

Altogether, 187 patients with asthma and who were nonsmokers (age range, 18-64 years) with perennial allergy and who were on regular inhaled corticosteroid treatment were recruited at 17 primary health care centers, randomly assigned to 2 groups and followed up for 1 year. For the controls (n = 88), FENO measurement was blinded to both operator and patient, and anti-inflammatory treatment was adjusted according to usual care. In the active group (n = 93), treatment was adjusted according to FENO. Questionnaires on asthma-related quality of life (Mini Asthma Quality of Life Questionnaire) and asthma control (Asthma Control Questionnaire) were completed, and asthma events were noted.

RESULTS

The Asthma Control Questionnaire score change over 1 year improved significantly more in the FENO-guided group (-0.17 [interquartile range {IQR}, -0.67 to 0.17] vs 0 [-0.33 to 0.50]; P = .045), whereas the Mini Asthma Quality of Life Questionnaire score did not (0.23 [IQR, 0.07-0.73] vs 0.07 [IQR, -0.20 to 0.80]; P = .197). The change in Asthma Control Questionnaire was clinically important in subpopulations with poor control at baseline (P = .03). Furthermore, the exacerbation rate (exacerbations/patient/y) was reduced by almost 50% in the FENO-guided group (0.22 [CI, 0.14-0.34] vs 0.41 [CI, 0.29-0.58]; P = .024). Mean overall inhaled corticosteroid use was similar in both groups (P = .95).

CONCLUSION

Use of FENO to guide anti-inflammatory treatment within primary care significantly reduced the exacerbation rate and improved asthma symptom control without increasing overall inhaled corticosteroid use.

Control of Allergic Rhinitis and Asthma Test (CARAT): dissemination and applications in primary care

Asthma frequently occurs in association with allergic rhinitis and a combined management approach has been suggested. The Control of Allergic Rhinitis and Asthma Test (CARAT) is the first questionnaire to assess control of both diseases concurrently. However, to have an impact on healthcare it needs to be disseminated and adopted. In this paper we discuss the dissemination of CARAT in different countries and its possible applications in primary care. At present, the adaptation of CARAT for use in different languages and cultures is being led by volunteer researchers and clinicians in 15 countries. Website and smartphone applications have been developed, and a free open model of distribution was adopted to contribute to the dissemination of CARAT. Examples of dissemination activities include distribution of leaflets and posters, educational sessions on the use of the questionnaire in the follow-up of patients, development of clinical studies, collaborations with professional organisations and health authorities, and the inclusion of CARAT in clinical guidelines. The adoption of innovations is an important challenge in healthcare today, and research on the degree of success of dissemination strategies using suitable methods and metrics is much needed. We propose that CARAT can be used in a range of settings and circumstances in primary care for clinical, research and audit purposes, within the overall aim of increasing awareness of the level of disease control and strengthening the partnership between patients and doctors in the management of asthma and rhinitis.

Accuracy of patient self-report as a measure of inhaled asthma medication use

BACKGROUND AND OBJECTIVE

Measuring adherence to inhaled asthma treatment is a key priority for asthma care. The aim of this study was to determine the relationship between self-report and actual medication use as measured by electronic monitoring for single and combination inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) metered-dose inhaler therapy.

METHODS

In this retrospective analysis from a previously completed prospective 24-week randomized, controlled trial of single or combination ICS/LABA therapy, medication use in the week prior to study visits determined by self-report questionnaire and electronic monitoring was compared. One hundred eleven participants received 125 µg fluticasone dipropionate and 25 µg salmeterol, two actuations twice daily, by either separate or combination ICS/LABA inhalers. Paired data for self-report and electronic monitoring were analysed. Measurement of agreement was by Bland-Altman-like plots by visit with calculation of limits of agreement.

RESULTS

For single and combination ICS/LABA therapy, self-report consistently overestimated actual inhaler use assessed by electronic monitoring by a mean of 2.2-8.4 inhalations over a 1-week period, with limits of agreement ranging from ±15.8 to 25.6 inhalations. Participants who underused their inhalers tended to overreport their use, while those who overused tended to underreport their medication use. The greater the degree of underuse, the greater the magnitude of overreport, and likewise, the greater the degree of overuse, the greater the magnitude of underreport.

CONCLUSIONS

Self-report is inaccurate in measuring actual use of inhaled asthma treatment with patients who underuse their maintenance therapy overreporting their use and those who overuse their therapy underreporting their use.

Prevalence of asthma symptoms in schoolchildren, and climate in west European countries: an ecologic study

The aim of the present study was to estimate the associations between the prevalence of asthma symptoms in schoolchildren and meteorological variables in west European countries that participated in the International Study of Asthma and Allergies in Children (ISAAC), Phase III 1997-2003. An ecologic study was carried out. The prevalence of asthma was obtained from this study from 48 centers in 14 countries, and meteorological variables from those stations closest to ISAAC centers, together with other socioeconomic and health care variables. Multilevel mixed-effects linear regression models were used. For schoolchildren aged 6-7 years, the prevalence rate of asthma decreased with an increase in mean annual sunshine hours, showed a positive association with rainy weather, and warm temperature, and a negative one with relative humidity and physician density (PD). Current wheeze prevalence was stronger in autumn/winter seasons and decreased with increasing PD. Severe current wheeze decreased with PD. For schoolchildren aged 13-14 years, the prevalence rates of asthma and current wheeze increased with rainy weather, and these rates decreased with increased PD. Current wheeze, as measured by a video questionnaire, was inversely associated with sunny weather, and nurse density. Severe current wheeze prevalence was stronger during autumn/winter seasons, decreased with PD, and indoor chlorinated public swimming pool density, and increased with rainy weather. Meteorological factors, including sunny and rainy weather, and PD may have some effect on the prevalence rates of asthma symptoms in children from west European countries.

Efficacy versus effectiveness trials: informing guidelines for asthma management

PURPOSE OF REVIEW

Randomized controlled trials, known as efficacy trials and long considered the gold standard for evidence-based asthma guidelines, are designed to test whether interventions have a benefit for selective patient populations under ideal conditions. The goal of pragmatic trials and observational studies instead is to understand real-life efficacy, known as effectiveness. This review summarizes the strengths and limitations of efficacy and effectiveness trials, results of recent effectiveness trials in asthma and initiatives promoting effectiveness research.

RECENT FINDINGS

Recent pragmatic trials and observational studies have examined outcomes of interventions for diverse real-life patient populations, including smokers and patients with variable adherence, inhaler technique and baseline asthma control. Study results challenge practice guidelines regarding relative effectiveness of leukotriene receptor antagonists and inhaled corticosteroids (ICS); supplement guidelines with regard to effectiveness of interventions in smokers; and begin to address gaps in guidelines regarding choice of ICS and inhaler device. Initiatives are ongoing to refine methods of observational research and to harmonize asthma outcomes for better integration of results from all types of trials.

SUMMARY

Results of pragmatic trials and observational studies are an important component of the evidence needed to inform guideline recommendations and decision-making by healthcare providers, patients and policymakers.

In vitro and ex vivo models of human asthma

Asthma is an inflammatory disorder of the conducting airways which undergo distinct structural and functional changes leading to non-specific bronchial hyperresponsiveness (BHR) and airflow obstruction that fluctuate over time. It is a complex disease involving multiple genetic and environmental influences whose multifactorial interactions can result in a range of asthma phenotypes. Since our understanding of these gene-gene and gene-environment interactions is very poor, this poses a major challenge to the logical development of 'models of asthma'. However, use of cells and tissues from asthmatic donors allows genetic and epigenetic influences to be evaluated and can go some way to reflect the complex interplay between genetic and environmental stimuli that occur in vivo. Current alternative approaches to in vivo animal models involve use of a plethora of systems ranging from very simple models using human cells (e.g. bronchial epithelial cells and fibroblasts) in mono- or co-culture, whole tissue explants (biopsies, muscle strips, bronchial rings) through to in vivo studies in human volunteers. Asthma research has been greatly facilitated by the introduction of fibreoptic bronchoscopy which is now a commonly used technique in the field of respiratory disease research, allowing collection of biopsy specimens, bronchial brushing samples, and bronchoalveolar lavage fluid enabling use of disease-derived cells and tissues in some of these models. Here, we will consider the merits and limitations of current models and discuss the potential of tissue engineering approaches through which we aim to advance our understanding of asthma and its treatment.

Research needs in allergy: an EAACI position paper, in collaboration with EFA

In less than half a century, allergy, originally perceived as a rare disease, has become a major public health threat, today affecting the lives of more than 60 million people in Europe, and probably close to one billion worldwide, thereby heavily impacting the budgets of public health systems. More disturbingly, its prevalence and impact are on the rise, a development that has been associated with environmental and lifestyle changes accompanying the continuous process of urbanization and globalization. Therefore, there is an urgent need to prioritize and concert research efforts in the field of allergy, in order to achieve sustainable results on prevention, diagnosis and treatment of this most prevalent chronic disease of the 21st century.The European Academy of Allergy and Clinical Immunology (EAACI) is the leading professional organization in the field of allergy, promoting excellence in clinical care, education, training and basic and translational research, all with the ultimate goal of improving the health of allergic patients. The European Federation of Allergy and Airways Diseases Patients' Associations (EFA) is a non-profit network of allergy, asthma and Chronic Obstructive Pulmonary Disorder (COPD) patients' organizations. In support of their missions, the present EAACI Position Paper, in collaboration with EFA, highlights the most important research needs in the field of allergy to serve as key recommendations for future research funding at the national and European levels.Although allergies may involve almost every organ of the body and an array of diverse external factors act as triggers, there are several common themes that need to be prioritized in research efforts. As in many other chronic diseases, effective prevention, curative treatment and accurate, rapid diagnosis represent major unmet needs. Detailed phenotyping/endotyping stands out as widely required in order to arrange or re-categorize clinical syndromes into more coherent, uniform and treatment-responsive groups. Research efforts to unveil the basic pathophysiologic pathways and mechanisms, thus leading to the comprehension and resolution of the pathophysiologic complexity of allergies will allow for the design of novel patient-oriented diagnostic and treatment protocols. Several allergic diseases require well-controlled epidemiological description and surveillance, using disease registries, pharmacoeconomic evaluation, as well as large biobanks. Additionally, there is a need for extensive studies to bring promising new biotechnological innovations, such as biological agents, vaccines of modified allergen molecules and engineered components for allergy diagnosis, closer to clinical practice. Finally, particular attention should be paid to the difficult-to-manage, precarious and costly severe disease forms and/or exacerbations. Nonetheless, currently arising treatments, mainly in the fields of immunotherapy and biologicals, hold great promise for targeted and causal management of allergic conditions. Active involvement of all stakeholders, including Patient Organizations and policy makers are necessary to achieve the aims emphasized herein.

Resveratrol attenuates experimental allergic asthma in mice by restoring inositol polyphosphate 4 phosphatase (INPP4A). Int Immunopharmacol. 2012;14:438-443. [PMID: 22986054 DOI: 10.1016/j.intimp.2012.08.017]

Asthma is a chronic airway inflammatory disorder which is characterized by reversible airway obstruction, airway hyperresponsiveness and airway inflammation. Oxidative stress has been shown to be strongly associated with most of the features of asthma and leads to accumulation of phosphatidyl inositol (3,4) bis-phosphate {PtdIns(3,4)P2} which is the major substrate for inositol polyphosphate 4 phosphatase (INPP4A). PtdIns(3,4)P2 in turn activates PI3K pathway and contributes to oxidative stress. Thus, there exists a vicious loop between oxidative stress and lipid phosphatase signaling. In this context, we have recently shown that INPP4A, a crucial molecular checkpoint in controlling PI3K-Akt signaling pathway, is downregulated in allergic airway inflammation. Resveratrol, a potent antioxidant found in red wines, has been shown to attenuate asthma features in murine model of allergic airway inflammation (AAI), however the underlying mode of its action was not completely understood. In this study, the effect of resveratrol on mitochondrial dysfunction, PI3K-Akt signaling and inositol polyphosphate 4 phosphatase was studied in murine model of allergic airway inflammation. We observed that resveratrol treatment of allergic mice was found to significantly downregulate oxidative stress and restore mitochondrial function. It also decreased calpain activity and restored the expression of INPP4A in lungs which in turn reduced Akt kinase activity and Akt phosphorylation. These results suggest a novel mechanism of action of resveratrol in attenuating asthma phenotype by downregulating PI3K-Akt pathway via upregulating INPP4A.

Assessment of the level of asthma control among adult patients in two tertiary care centers in Nigeria

BACKGROUND

According to the Global Initiative for Asthma (GINA) guidelines, the goal of asthma management is to achieve clinical control. Uncontrolled asthma places a significant social and economic burden on patients.

OBJECTIVE

The two aims of this study were to (1) assess the level of asthma control (according to the GINA definition of "control") among adult patients attending two tertiary care centers in Nigeria and (2) to determine the predictors associated with uncontrolled asthma.

METHODS

This cross-sectional study was carried out from June 2009 to December 2010. The participants were all 18 years old or older with physician-diagnosed asthma. First, the participants completed an interviewer-administered questionnaire, which included items that collected their socio-demographic information and clinical data. Second, anthropometric indices were measured and spirometry was conducted to determine each participant's lung function. Finally, the researcher team members assessed each participant's inhaler device technique. The outcome measures were (1) uncontrolled asthma, (2) partly controlled asthma, and (3) controlled asthma.

RESULTS

One hundred and twenty-four asthma patients participated in the study. Of these, 69.3% had uncontrolled asthma, 22.6% had partly controlled asthma, and 8.1% had controlled asthma. Multivariate analysis showed that uncontrolled asthma was strongly associated with asthma severity based on clinical features, the incorrect use of an inhaler device, the use of oral corticosteroids, an abnormal pulmonary function test, the presence of comorbidity, and the lack of adherence to inhaled corticosteroids (ICSs). The results also revealed that increasing age and a lack of tertiary education were weakly associated with asthma control. In this study, gender, marriage, smoking status, occupation, socioeconomic status, income, and the duration of the asthma were not associated with asthma control.

CONCLUSION

A significant proportion of the sampled patients had uncontrolled asthma. To reduce this number, health care providers must reinforce the education of each asthma patient and promote the regular assessment of asthma control at every clinic visit, identify those with poor control, and institute the appropriate therapy needed to achieve clinical control.

Specific IgE against Staphylococcus aureus enterotoxins: an independent risk factor for asthma

BACKGROUND

The role of IgE in patients with severe asthma is not fully understood.

OBJECTIVE

We sought to investigate whether IgE to Staphylococcus aureus enterotoxins might be relevant to disease severity in adult asthmatic patients.

METHODS

Specific IgE antibody concentrations in serum against enterotoxins, grass pollen (GP), and house dust mite allergens and total IgE levels were measured in adult cohorts of 69 control subjects, 152 patients with nonsevere asthma, and 166 patients with severe asthma. Severe asthma was defined as inadequately controlled disease despite high-dose inhaled corticosteroids plus at least 2 other controller therapies, including oral steroids.

RESULTS

Enterotoxin IgE positivity was significantly greater in patients with severe asthma (59.6%) than in healthy control subjects (13%, P< .001). Twenty-one percent of patients with severe asthma with enterotoxin IgE were considered nonatopic. Logistic regression analyses demonstrated significantly increased risks for enterotoxin IgE-positive subjects to have any asthma (OR, 7.25; 95% CI, 2.7-19.1) or severe asthma (OR, 11.09; 95% CI, 4.1-29.6) versus enterotoxin IgE-negative subjects. The presence of GP or house dust mite IgE antibodies was not associated with either significantly increased risk for asthma or severity. Oral steroid use and hospitalizations were significantly increased in patients with enterotoxin IgE and nonatopic asthma. GP IgE was associated with a higher FEV(1) percent predicted value, and enterotoxin IgE was associated with a lower FEV(1) percent predicted value.

CONCLUSIONS

Staphylococcal enterotoxin IgE antibodies, but not IgE against inhalant allergens, are risk factors for asthma severity. We hypothesize that the presence of enterotoxin IgE in serum indicates the involvement of staphylococcal superantigens in the pathophysiology of patients with severe asthma.