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Aung HWW, Boddy CE, Hampson E, Bell M, Parnell LA, Balasundaram K, Murphy AC, Naveed S, Bradding P. Assessing Inhaled Corticosteroid Adherence and Responsiveness in Severe Asthma Using Beclometasone Dipropionate/Formoterol NEXThaler Dose-Counting and Nitric Oxide Monitoring. J Allergy Clin Immunol Pract 2024:S2213-2198(24)00288-5. [PMID: 38518866 DOI: 10.1016/j.jaip.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/21/2024] [Accepted: 03/13/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Sixty-five percent of people with severe asthma and a fractional exhaled nitric oxide (Feno) greater than or equal to 45 parts per billion (ppb) are nonadherent to inhaled corticosteroids (ICSs). Digital devices recording both time of use and inhaler technique identify nonadherence and ICS responsiveness but are not widely available. As the NEXThaler dose counter activates only at an inspiratory flow rate of 35 L/min, this may provide an alternative to identifying ICS responsiveness. OBJECTIVE To assess ICS adherence and responsiveness in severe asthma using beclometasone/formoterol (200/6 μg) NEXThaler (BFN) dose-counting. METHODS Patients with severe asthma with a Feno greater than or equal to 45 ppb were invited to use BFN in place of their usual ICS/long-acting β2-agonist. Feno, 6-item Asthma Control Questionnaire score, lung function, and blood eosinophil count were monitored for 3 months. A log10ΔFeno of greater than or equal to 0.24 was used to define Feno suppression as the primary marker of ICS responsiveness at day 28. RESULTS Twenty-seven of 48 (56%) patients demonstrated significant Feno suppression at month 1 (median pre-114, post-48 ppb, P < .001). A small but significant reduction occurred in Feno nonsuppressors. The 6-item Asthma Control Questionnaire score fell a median 1.2 units in Feno suppressors (P < .001) and 0.5 units in nonsuppressors (P = .025). These effects were sustained until month 3 in Feno suppressors, with a significant improvement in FEV1 and blood eosinophils. Sixty-seven percent (18 of 27) of those with baseline ICS/long-acting β2-agonist prescription refills of 80% or more were Feno suppressors, suggesting prior nonadherence despite adequate prescription collection. Seventy-nine percent of Feno suppressors did not require biologics within mean 11.4 months from initial dose counting. CONCLUSIONS BFN dose-counting identifies ICS responsiveness in severe asthma with the implication that these patients may not need to progress to biological therapies.
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Affiliation(s)
- Hnin W W Aung
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom; Institute for Lung Health, NIHR Respiratory Biomedical Research Centre, Leicester, United Kingdom; Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Claire E Boddy
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Eleanor Hampson
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Mark Bell
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Lauren A Parnell
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Kumaran Balasundaram
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Anna C Murphy
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Shamsa Naveed
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom; Institute for Lung Health, NIHR Respiratory Biomedical Research Centre, Leicester, United Kingdom; Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Peter Bradding
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom; Institute for Lung Health, NIHR Respiratory Biomedical Research Centre, Leicester, United Kingdom; Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
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Collaro AJ, Chang AB, Marchant JM, Vicendese D, Chatfield MD, Cole JF, Blake TL, McElrea MS. Developing Fractional Exhaled Nitric Oxide Predicted and Upper Limit of Normal Values for a Disadvantaged Population. Chest 2023; 163:624-633. [PMID: 36279906 DOI: 10.1016/j.chest.2022.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/08/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (Feno), used as a biomarker, is influenced by several factors including ethnicity. Normative data are essential for interpretation, and currently single cutoff values are used in children and adults. RESEARCH QUESTION Accounting for factors that influence Feno, (1) what are appropriate predicted and upper limit of normal (ULN) Feno values in an underserved population (First Nations Australians), (2) how do these values compare with age-based interpretive guidelines, and (3) what factors influence Feno and what is the size of the effect? STUDY DESIGN AND METHODS Feno data of First Nations Australians (age < 16 years, n = 862; age ≥ 16 years, n = 348) were obtained. Medical history using participant questionnaires and medical records were used to define healthy participants. Flexible regression using spline functions, as used by the Global Lung Function Initiative, were used to generate predicted and ULN values. RESULTS Look-up tables for predicted and ULN values using age (4-76 years) and height (100-200 cm) were generated and are supplied with a calculator for clinician use. In healthy First Nations children (age < 18 years), ULN values ranged between 25 and 60 parts per billion (ppb) when considering only biologically plausible age and height combinations. For healthy adults, ULN values ranged between 39 and 88 ppb. Neither the current Feno interpretation guidelines, nor the currently recommended cutoff of 50 ppb for First Nations children 16 years of age or younger were appropriate for use in this cohort. Our modelling revealed that predicted and ULN values of healthy participants varied nonlinearly with age and height. INTERPRETATION Because single pediatric, adult, or all-age Feno cutoff values used by current interpretive guidelines to define abnormality fail to account for factors that modify Feno values, we propose predicted and ULN values for First Nations Australians 4 to 76 years of age. Creating age- and height-adjusted predicted and ULN values could be considered for other ethnicities.
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Affiliation(s)
- Andrew J Collaro
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia; Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Anne B Chang
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia; Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD, Australia; Child Health Division, Menzies School of Health Research, Casuarina, NT, Australia
| | - Julie M Marchant
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia; Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Don Vicendese
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; School of Engineering and Mathematical Sciences, La Trobe University, Bundoora, VIC, Australia
| | - Mark D Chatfield
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Child Health Division, Menzies School of Health Research, Casuarina, NT, Australia
| | - Johanna F Cole
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia; Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Tamara L Blake
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia; Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Margaret S McElrea
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia; Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Vandenborght LE, Enaud R, Urien C, Coron N, Girodet PO, Ferreira S, Berger P, Delhaes L. Type 2-high asthma is associated with a specific indoor mycobiome and microbiome. J Allergy Clin Immunol 2020; 147:1296-1305.e6. [PMID: 32926879 PMCID: PMC7486598 DOI: 10.1016/j.jaci.2020.08.035] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/17/2022]
Abstract
Background The links between microbial environmental exposures and asthma are well documented, but no study has combined deep sequencing results from pulmonary and indoor microbiomes of patients with asthma with spirometry, clinical, and endotype parameters. Objective The goal of this study was to investigate the links between indoor microbial exposures and pulmonary microbial communities and to document the role of microbial exposures on inflammatory and clinical outcomes of patients with severe asthma (SA). Methods A total of 55 patients with SA from the national Cohort of Bronchial Obstruction and Asthma cohort were enrolled for analyzing their indoor microbial flora through the use of electrostatic dust collectors (EDCs). Among these patients, 22 were able to produce sputum during “stable” or pulmonary “exacerbation” periods and had complete pairs of EDC and sputum samples, both collected and analyzed. We used amplicon targeted metagenomics to compare microbial communities from EDC and sputum samples of patients according to type 2 (T2)-asthma endotypes. Results Compared with patients with T2-low SA, patients with T2-high SA exhibited an increase in bacterial α-diversity and a decrease in fungal α-diversity of their indoor microbial florae, the latter being significantly correlated with fraction of exhaled nitric oxide levels. The β-diversity of the EDC mycobiome clustered significantly according to T2 endotypes. Moreover, the proportion of fungal taxa in common between the sputum and EDC samples was significantly higher when patients exhibited acute exacerbation. Conclusion These results illustrated, for the first time, a potential association between the indoor mycobiome and clinical features of patients with SA, which should renew interest in deciphering the interactions between indoor environment, fungi, and host in asthma.
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Affiliation(s)
- Louise-Eva Vandenborght
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, F-33000 Bordeaux, France; Centre de Recherche Cardio-thoracique de Bordeaux, INSERM, U1045, CIC 1401, F-33000 Bordeaux, France; Microbiota Team, Research and Development Department, GenoScreen, Lille, France
| | - Raphaël Enaud
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, F-33000 Bordeaux, France; Centre de Recherche Cardio-thoracique de Bordeaux, INSERM, U1045, CIC 1401, F-33000 Bordeaux, France; Laboratoire de Parasitologie-Mycologie, Service D'exploration Fonctionnelle Respiratoire, Service de pharmacologie, CIC 1401, CHU de Bordeaux, F-33604 Pessac, France
| | - Charlotte Urien
- Microbiota Team, Research and Development Department, GenoScreen, Lille, France
| | - Noémie Coron
- Laboratoire de Parasitologie-Mycologie, Service D'exploration Fonctionnelle Respiratoire, Service de pharmacologie, CIC 1401, CHU de Bordeaux, F-33604 Pessac, France
| | - Pierre-Olivier Girodet
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, F-33000 Bordeaux, France; Centre de Recherche Cardio-thoracique de Bordeaux, INSERM, U1045, CIC 1401, F-33000 Bordeaux, France; Laboratoire de Parasitologie-Mycologie, Service D'exploration Fonctionnelle Respiratoire, Service de pharmacologie, CIC 1401, CHU de Bordeaux, F-33604 Pessac, France
| | - Stéphanie Ferreira
- Microbiota Team, Research and Development Department, GenoScreen, Lille, France
| | - Patrick Berger
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, F-33000 Bordeaux, France; Centre de Recherche Cardio-thoracique de Bordeaux, INSERM, U1045, CIC 1401, F-33000 Bordeaux, France; Laboratoire de Parasitologie-Mycologie, Service D'exploration Fonctionnelle Respiratoire, Service de pharmacologie, CIC 1401, CHU de Bordeaux, F-33604 Pessac, France
| | - Laurence Delhaes
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, F-33000 Bordeaux, France; Centre de Recherche Cardio-thoracique de Bordeaux, INSERM, U1045, CIC 1401, F-33000 Bordeaux, France; Laboratoire de Parasitologie-Mycologie, Service D'exploration Fonctionnelle Respiratoire, Service de pharmacologie, CIC 1401, CHU de Bordeaux, F-33604 Pessac, France.
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Diver S, Russell RJ, Brightling CE. Cough and Eosinophilia. J Allergy Clin Immunol Pract 2020; 7:1740-1747. [PMID: 31279462 DOI: 10.1016/j.jaip.2019.04.048] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/25/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
Eosinophilic airway inflammation is observed in 30% to 50% of chronic cough sufferers. It is a common feature of asthma and upper airway cough syndrome, and it is required in the diagnosis of nonasthmatic eosinophilic bronchitis. Our understanding of the mechanisms underlying allergic and nonallergic eosinophilic inflammation have evolved tremendously in the last 2 decades, but the cause of this inflammation in any individual is often uncertain. Inhaled corticosteroids are the mainstay therapy for cough due to asthma or nonasthmatic eosinophilic bronchitis, and response is related to the presence of biomarkers of eosinophilic airway inflammation. In upper airway cough syndrome, nasal topical corticosteroids are beneficial in allergic rhinitis and chronic rhinosinusitis with polyposis. This review will describe the diagnosis, current and possible future treatments, and prognosis of chronic cough in adults with eosinophilic inflammation.
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Affiliation(s)
- Sarah Diver
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Richard J Russell
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Christopher E Brightling
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom.
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Chan R, RuiWen Kuo C, Lipworth B. Pragmatic Clinical Perspective on Biologics for Severe Refractory Type 2 Asthma. J Allergy Clin Immunol Pract 2020; 8:3363-3370. [PMID: 32673880 DOI: 10.1016/j.jaip.2020.06.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/07/2020] [Accepted: 06/28/2020] [Indexed: 12/18/2022]
Abstract
Patients with severe refractory asthma present a challenging clinical conundrum for practicing clinicians. Biologics that target key mediators in the type 2 inflammation cascade, including IL-4, IL-5, IL-13, and IgE, can be effective strategies for these patients. However, with various biologics available, choosing the optimal one for a particular patient becomes a nuanced decision. We propose a pragmatic algorithm that identifies the optimal biologic class for patients who have specific type 2 disease endotypes. Patients with eosinophilic endotypes fare well with anti-IL-5(rα) medications, comprising mepolizumab, benralizumab, and reslizumab because they have been shown to reduce exacerbations in severe eosinophilic asthma by approximately 50%. In patients with fractional exhaled nitric oxide-high endotypes, anti-IL-4rα such as dupilumab is deemed to be most effective and has demonstrated a 47% reduction in asthma exacerbations. For patients with severe uncontrolled allergic asthma, anti-IgE (omalizumab) is effective and has been shown to confer a 25% reduction in asthma exacerbations. Type 2 comorbidities including chronic rhinosinusitis with nasal polyps, atopic dermatitis, chronic idiopathic urticaria, and eosinophilic esophagitis are important to bear in mind before the prescription of biologics. Further head-to-head studies are indicated to compare biologics in patients with mixed endotypes according to peripheral blood eosinophils, fractional exhaled nitric oxide, and allergic status. The evidence strongly supports endotype-driven prescribing of biologics to achieve clinically relevant outcomes in severe refractory asthma and related comorbidities.
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Affiliation(s)
- Rory Chan
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom.
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Bulkhi AA, Shepard KV 2nd, Casale TB, Cardet JC. Elevated Testosterone Is Associated with Decreased Likelihood of Current Asthma Regardless of Sex. J Allergy Clin Immunol Pract 2020; 8:3029-3035.e4. [PMID: 32485237 DOI: 10.1016/j.jaip.2020.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 05/09/2020] [Accepted: 05/19/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Asthma prevalence decreases postpuberty in males. Testosterone inhibits airway smooth muscle contraction and attenuates type 2 inflammation. OBJECTIVE To investigate the relationship between serum testosterone and current asthma prevalence and lung function in a nationally representative data set. METHODS Serum testosterone and self-reported physician-diagnosed current asthma data were obtained from 7584 participants aged 6 to 80 years from the cross-sectional 2011-2012 National Health and Nutrition Examination Survey. We used logistic regression to test associations between testosterone and current asthma, adjusting for demographic characteristics and stratifying by sex and age; linear regression to evaluate correlations between testosterone and lung function among patients with asthma; and interaction terms to test for effect modification by blood eosinophils and fractional exhaled nitric oxide. RESULTS Serum testosterone inversely associated with odds of current asthma in both men and women, but this association was nonlinear. Similar protective effect sizes were observed for both sexes after log2-transformation of serum testosterone. For every 1-unit increase in log2 testosterone, the odds of current asthma decreased by 11% in men and 10% in women, although the association was statistically significant in women only among those 12 years or older after multiple imputation. Serum testosterone did not associate with current asthma prevalence among those younger than 12 years. Testosterone associated with increases in FEV1 in participants with asthma of both sexes. Neither blood eosinophils nor fractional exhaled nitric oxide modified the association between testosterone and current asthma. CONCLUSIONS Serum testosterone inversely associates with current asthma prevalence regardless of sex and correlates with better lung function in a nationally representative database. Androgen therapy for asthma should be further investigated.
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Wang E, Wechsler ME, Tran TN, Heaney LG, Jones RC, Menzies-Gow AN, Busby J, Jackson DJ, Pfeffer PE, Rhee CK, Cho YS, Canonica GW, Heffler E, Gibson PG, Hew M, Peters M, Harvey ES, Alacqua M, Zangrilli J, Bulathsinhala L, Carter VA, Chaudhry I, Eleangovan N, Hosseini N, Murray RB, Price DB. Characterization of Severe Asthma Worldwide: Data From the International Severe Asthma Registry. Chest 2019; 157:790-804. [PMID: 31785254 DOI: 10.1016/j.chest.2019.10.053] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/01/2019] [Accepted: 10/14/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinical characteristics of the international population with severe asthma are unknown. Intercountry comparisons are hindered by variable data collection within regional and national severe asthma registries. We aimed to describe demographic and clinical characteristics of patients treated in severe asthma services in the United States, Europe, and the Asia-Pacific region. METHODS The International Severe Asthma Registry retrospectively and prospectively collected data in patients with severe asthma (≥ 18 years old), receiving Global Initiative for Asthma (GINA) Step 5 treatment or with severe asthma remaining uncontrolled at GINA Step 4. Baseline demographic and clinical data were collected from the United States, United Kingdom, South Korea, Italy, and the Severe Asthma Web-based Database registry (including Australia, Singapore, and New Zealand) from December 2014 to December 2017. RESULTS We included 4,990 patients. Mean (SD) age was 55.0 (15.9) years, and mean (SD) age at asthma onset was 30.7 (17.7) years. Patients were predominantly female (59.3%) and white (72.6%), had never smoked (60.5%), and were overweight or obese (70.4%); 34.9% were at GINA Step 5; and 57.2% had poorly controlled disease. A total of 51.1% of patients were receiving regular intermittent oral corticosteroids, and 25.4% were receiving biologics (72.6% for those at GINA Step 5). Mean (SD) exacerbation rate was 1.7 (2.7) per year. Intercountry variation was observed in clinical characteristics, prescribed treatments, and biomarker profiles. CONCLUSIONS Using a common data set and definitions, this study describes severe asthma characteristics of a large patient cohort included in multiple severe asthma registries and identifies country differences. Whether these are related to underlying epidemiological factors, environmental factors, phenotypes, asthma management systems, treatment access, and/or cultural factors requires further study.
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Affiliation(s)
- Eileen Wang
- Division of Allergy & Clinical Immunology, Department of Medicine, National Jewish Health, Denver, CO, and Division of Allergy & Clinical Immunology, Department of Internal Medicine, University of Colorado Hospital, Aurora, CO
| | - Michael E Wechsler
- NJH Cohen Family Asthma Institute, Department of Medicine, National Jewish Health, Denver, CO
| | | | - Liam G Heaney
- UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland
| | - Rupert C Jones
- Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, United Kingdom
| | - Andrew N Menzies-Gow
- UK Severe Asthma Network and National Registry, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - John Busby
- UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland
| | - David J Jackson
- UK Severe Asthma Network and National Registry, Guy's and St Thomas' NHS Trust and Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom
| | - Paul E Pfeffer
- UK Severe Asthma Network, Barts Health NHS Trust and Queen Mary University of London, London, United Kingdom
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - You Sook Cho
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - G Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic, Humanitas University & Research Hospital, Milan, Italy and SANI-Severe Asthma Network Italy, Italy
| | - Enrico Heffler
- Personalized Medicine Asthma & Allergy Clinic, Humanitas University & Research Hospital, Milan, Italy and SANI-Severe Asthma Network Italy, Italy
| | - Peter G Gibson
- Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Matthew Peters
- Department of Thoracic Medicine, Concord Hospital, Sydney, NSW, Australia
| | - Erin S Harvey
- Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW, Australia
| | | | | | | | | | | | | | | | | | - David B Price
- Optimum Patient Care Global Ltd, Cambridge, England; Observational and Pragmatic Research Institute, Singapore, Republic of Singapore; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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Rabito FA, Carlson JC, He H, Werthmann D, Schal C. A single intervention for cockroach control reduces cockroach exposure and asthma morbidity in children. J Allergy Clin Immunol 2017; 140:565-570. [PMID: 28108117 DOI: 10.1016/j.jaci.2016.10.019] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 10/11/2016] [Accepted: 10/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Exposure to cockroaches is an important asthma trigger, particularly for children with asthma living in inner cities. Integrated pest management is the recommended approach to cockroach abatement; however, it is costly and difficult to implement. The impact of reducing cockroach exposure on asthma outcomes is not known. OBJECTIVE We sought to test the use of a single intervention, insecticidal bait, to reduce cockroach exposure in the home of children with asthma in New Orleans and to examine the impact of cockroach reduction on asthma outcomes. METHODS One hundred two children aged 5 to 17 years with moderate to severe asthma were enrolled in a 12-month randomized controlled trial testing the use of insecticidal bait on cockroach counts and asthma morbidity. Homes were visited 6 times and asthma symptoms were assessed every 2 months. RESULTS After adjustment, intervention homes had significantly fewer cockroaches than did control homes (mean change in cockroaches trapped, 13.14; 95% CI, 6.88-19.39; P < .01). Children in control homes had more asthma symptoms and unscheduled health care utilization in the previous 2 weeks (1.82, 95% CI, 0.14-3.50, P = .03; 1.17, 95% CI, 0.11-2.24, P = .03, respectively) and a higher proportion of children with FEV1 of less than 80% predicted (odds ratio, 5.74; 95% CI, 1.60-20.57; P = .01) compared with children living in intervention homes. CONCLUSIONS Previous research has demonstrated improvement in asthma health outcomes using multifaceted interventions. The strategic placement of insecticidal bait, which is inexpensive, has low toxicity, and is widely available, resulted in sustained cockroach elimination over 12 months and was associated with improved asthma outcomes. This single intervention may be an alternative to multifaceted interventions currently recommended to improve asthma morbidity.
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Affiliation(s)
- Felicia A Rabito
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, La.
| | - John C Carlson
- Department of Pediatrics, School of Medicine, Tulane University, New Orleans, La
| | - Hua He
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, La
| | - Derek Werthmann
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, La
| | - Coby Schal
- Department of Entomology, North Carolina State University, Raleigh, NC
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Abstract
In 2013, several themes emerged: (1) a dedicated search for new therapies using new mechanisms; (2) the importance of the plasticity of the immune system (eg, that molecules that mediate inflammation in one setting can promote its resolution and return to homeostasis in other circumstances); (3) the complex role of viruses in asthma exacerbations; (4) the similarities and differences among asthma, asthma in smokers, and chronic obstructive pulmonary disease; and (5) the importance of understanding asthma phenotypes and their stability over time. Once new therapeutics pass the initial clinical trials, patient-oriented and real-world research will be needed.
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Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pa.
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Szefler SJ, Chmiel JF, Fitzpatrick AM, Giacoia G, Green TP, Jackson DJ, Nielsen HC, Phipatanakul W, Raissy HH. Asthma across the ages: knowledge gaps in childhood asthma. J Allergy Clin Immunol 2014; 133:3-13; quiz 14. [PMID: 24290281 PMCID: PMC3925634 DOI: 10.1016/j.jaci.2013.10.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/17/2013] [Accepted: 10/21/2013] [Indexed: 01/01/2023]
Abstract
The Eunice Kennedy Shriver National Institute of Child Health and Human Development convened an Asthma Group in response to the Best Pharmaceuticals for Children Act. The overall goal of the Best Pharmaceuticals for Children Act Program is to improve pediatric therapeutics through preclinical and clinical drug trials that lead to drug-labeling changes. Although significant advances have been made in the understanding and management of asthma in adults with appropriately labeled medications, less information is available on the management of asthma in children. Indeed, many medications are inadequately labeled for use in children. In general, the younger the child, the less information there is available to guide clinicians. Because asthma often begins in early childhood, it is incumbent on us to continue to address the primary questions raised in this review and carefully evaluate the medications used to manage asthma in children. Meanwhile, continued efforts should be made in defining effective strategies that reduce the risk of exacerbations. If the areas of defined need are addressed in the coming years, namely prevention of exacerbations and progression of disease, as well as primary intervention, we will see continuing reduction in asthma mortality and morbidity along with improved quality of life for children with asthma.
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Affiliation(s)
- Stanley J Szefler
- Department of Pediatrics and Pharmacology, National Jewish Health, and the University of Colorado School of Medicine, Denver, Colo.
| | - James F Chmiel
- University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Anne M Fitzpatrick
- Emory University Department of Pediatrics and Children's Healthcare of Atlanta Center for Developmental Lung Biology, Atlanta, Ga
| | - George Giacoia
- National Institute of Child Health and Development, Bethesda, Md
| | - Thomas P Green
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Heber C Nielsen
- Floating Hospital for Children at Tufts Medical Center, Tufts University School of Medicine, Boston, Mass
| | | | - Hengameh H Raissy
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM
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11
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Renz H. Advances in in vitro diagnostics in allergy, asthma, and immunology in 2012. J Allergy Clin Immunol 2013; 132:1287-92. [PMID: 24139605 DOI: 10.1016/j.jaci.2013.08.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 08/22/2013] [Accepted: 08/26/2013] [Indexed: 11/15/2022]
Abstract
Laboratory tests play an increasing role in risk assessment, diagnostics, and disease monitoring. Great advances have been achieved lately, particularly in the field of clinical immunology and allergy. These include neonatal screening of immunodeficiencies and asthma biomarkers and investigation into the role of recombinant allergens in in vitro testing. The latter area has implications for the diagnostics of food allergy, pollen-induced allergies, asthma, and insect allergies.
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Affiliation(s)
- Harald Renz
- Institute of Laboratory Medicine, Philipps-Universität Marburg, Marburg, Germany.
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12
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Ahluwalia SK, Peng RD, Breysse PN, Diette GB, Curtin-Brosnan J, Aloe C, Matsui EC. Mouse allergen is the major allergen of public health relevance in Baltimore City. J Allergy Clin Immunol 2013; 132:830-5.e1-2. [PMID: 23810154 PMCID: PMC3800085 DOI: 10.1016/j.jaci.2013.05.005] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 04/12/2013] [Accepted: 05/14/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cockroach and mouse allergens have both been implicated as causes in inner-city asthma morbidity in multicenter studies, but whether both allergens are clinically relevant within specific inner-city communities is unclear. OBJECTIVE Our study aimed to identify relevant allergens in Baltimore City. METHODS One hundred forty-four children (5-17 years old) with asthma underwent skin prick tests at baseline and had clinical data collected at baseline and 3, 6, 9, and 12 months. Home settled dust samples were collected at the same time points for quantification of indoor allergens. Participants were grouped based on their sensitization and exposure status to each allergen. All analyses were adjusted for age, sex, and serum total IgE level. RESULTS Forty-one percent were mouse sensitized/exposed, and 41% were cockroach sensitized/exposed based on bedroom floor exposure data. Mouse sensitization/exposure was associated with acute care visits, decreased FEV1/forced vital capacity percentage values, fraction of exhaled nitric oxide levels, and bronchodilator reversibility. Cockroach sensitization/exposure was only associated with acute care visits and bronchodilator reversibility when exposure was defined by using bedroom floor allergen levels. Mouse-specific IgE levels were associated with poor asthma health across a range of outcomes, whereas cockroach-specific IgE levels were not. The relationships between asthma outcomes and mouse allergen were independent of cockroach allergen. Although sensitization/exposure to both mouse and cockroach was generally associated with worse asthma, mouse sensitization/exposure was the primary contributor to these relationships. CONCLUSIONS In a community with high levels of both mouse and cockroach allergens, mouse allergen appears to be more strongly and consistently associated with poor asthma outcomes than cockroach allergen. Community-level asthma interventions in Baltimore should prioritize reducing mouse allergen exposure.
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Affiliation(s)
- Sharon K. Ahluwalia
- Division of Pediatric Allergy and Immunology, Johns Hopkins School
of Medicine, Baltimore, Md
| | - Roger D. Peng
- Department of Biostatistics, Johns Hopkins Bloomberg School of
Public Health, Baltimore, Md
| | - Patrick N. Breysse
- Department of Environmental Health Sciences, Johns Hopkins Bloomberg
School of Public Health, Baltimore, Md
| | - Gregory B. Diette
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins
School of Medicine, Baltimore, Md
| | - Jean Curtin-Brosnan
- Division of Pediatric Allergy and Immunology, Johns Hopkins School
of Medicine, Baltimore, Md
| | - Charles Aloe
- Division of Pediatric Allergy and Immunology, Johns Hopkins School
of Medicine, Baltimore, Md
| | - Elizabeth C. Matsui
- Division of Pediatric Allergy and Immunology, Johns Hopkins School
of Medicine, Baltimore, Md
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13
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Rabinovitch N, Mauger DT, Reisdorph N, Covar R, Malka J, Lemanske RF, Morgan WJ, Guilbert TW, Zeiger RS, Bacharier LB, Szefler SJ. Predictors of asthma control and lung function responsiveness to step 3 therapy in children with uncontrolled asthma. J Allergy Clin Immunol 2013; 133:350-6. [PMID: 24084071 DOI: 10.1016/j.jaci.2013.07.039] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/29/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Predictors of improvement in asthma control and lung function to step 3 therapy in children with persistent asthma have not been identified despite reported heterogeneity in responsiveness. OBJECTIVE We sought to evaluate potential predictors of asthma control and lung function responsiveness to step 3 therapy. METHODS A post hoc analysis from the Best Add-On Giving Effective Response (BADGER) study tested the association between baseline biological, asthma control, pulmonary function, and demographic markers and responsiveness to step-up to a higher dose of inhaled corticosteroid (ICS step-up therapy) or addition of leukotriene receptor antagonist (LTRA step-up therapy) or long-acting β₂-agonist (LABA step-up therapy). RESULTS In multivariate analyses higher impulse oscillometry reactance area was associated (P = .048) with a differential FEV₁ response favoring LABA over ICS step-up therapy, whereas higher urinary leukotriene E₄ levels were marginally (P = .053) related to a differential FEV₁ response favoring LTRA over LABA step-up therapy. Predictors of differential responses comparing ICS with LTRA step-up therapy were not apparent, probably because of suppression of allergic markers with low-dose ICS treatment. Minimal overlap was seen across FEV₁ and asthma control day predictors, suggesting distinct mechanisms related to lung function and asthma control day responses. CONCLUSION Levels of impulse oscillometry reactance area indicating peripheral airway obstruction and urinary leukotriene E₄ levels indicating cysteinyl leukotriene inflammation can differentiate LABA step-up responses from responses to LTRA or ICS step-up therapy. Further studies with physiologic, genetic, and biological markers related to these phenotypes will be needed to predict individual responses to LABA step-up therapy.
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Affiliation(s)
- Nathan Rabinovitch
- Department of Pediatrics, National Jewish Health and University of Colorado Denver School of Medicine, Denver, Colo.
| | - David T Mauger
- Department of Health Evaluation Sciences, Pennsylvania State University, Hershey, Pa
| | - Nichole Reisdorph
- Department of Pediatrics, National Jewish Health and University of Colorado Denver School of Medicine, Denver, Colo
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health and University of Colorado Denver School of Medicine, Denver, Colo
| | - Jonathan Malka
- Department of Pediatrics, National Jewish Health and University of Colorado Denver School of Medicine, Denver, Colo
| | - Robert F Lemanske
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Wayne J Morgan
- Arizona Respiratory Center, University of Arizona, Tucson, Ariz
| | - Theresa W Guilbert
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente, and the Department of Pediatrics, University of California-San Diego, San Diego, Calif
| | | | - Stanley J Szefler
- Department of Pediatrics, National Jewish Health and University of Colorado Denver School of Medicine, Denver, Colo
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14
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Peters MC, Mekonnen ZK, Yuan S, Bhakta NR, Woodruff PG, Fahy JV. Measures of gene expression in sputum cells can identify TH2-high and TH2-low subtypes of asthma. J Allergy Clin Immunol 2013; 133:388-94. [PMID: 24075231 DOI: 10.1016/j.jaci.2013.07.036] [Citation(s) in RCA: 210] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 07/15/2013] [Accepted: 07/30/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND The 3-gene signature of periostin, chloride channel accessory 1 (CLCA1), and Serpin β2 (SERPINB2) in airway epithelial brushings is used to classify asthma into TH2-high and TH2-low endotypes. Little is known about the utility of gene profiling in sputum as a molecular phenotyping method. OBJECTIVE We sought to determine whether gene profiling in sputum cells can identify T(H)2-high and T(H)2-low subtypes of asthma. METHODS In induced sputum cell pellets from 37 asthmatic patients and 15 healthy control subjects, PCR was used to profile gene expression of the epithelial cell signature of IL-13 activation (periostin, CLCA1, and SERPINB2), TH2 genes (IL4, IL5, and IL13), and other genes associated with airway TH2 inflammation. RESULTS Gene expression levels of CLCA1 and periostin, but not SerpinB2, were significantly higher than normal in sputum cells from asthmatic subjects. Expression levels of IL-4, IL-5, and IL-13 were also significantly increased in asthmatic patients and highly correlated within individual subjects. By combining the expression levels of IL-4, IL-5, and IL-13 in a single quantitative metric ("T(H)2 gene mean"), 26 (70%) of the 37 asthmatic patients had T(H)2-high asthma, which was characterized by more severe measures of asthma and increased blood and sputum eosinophilia. TH2 gene mean values tended to be stable when initial values were very high or very low but fluctuated above or below the T(H)2-high cutoff when initial values were intermediate. CONCLUSION IL-4, IL-5, and IL-13 transcripts are easily detected in sputum cells from asthmatic patients, and their expression levels can be used to classify asthma into T(H)2-high and T(H)2-low endotypes.
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Affiliation(s)
- Michael C Peters
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif; Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - Zesemayat K Mekonnen
- Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - Shaopeng Yuan
- Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - Nirav R Bhakta
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif; Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - Prescott G Woodruff
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif; Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif; Cardiovascular Research Institute, University of California, San Francisco, Calif.
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15
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Malinovschi A, Fonseca JA, Jacinto T, Alving K, Janson C. Exhaled nitric oxide levels and blood eosinophil counts independently associate with wheeze and asthma events in National Health and Nutrition Examination Survey subjects. J Allergy Clin Immunol 2013; 132:821-7.e1-5. [PMID: 23890753 DOI: 10.1016/j.jaci.2013.06.007] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 06/03/2013] [Accepted: 06/05/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND Fraction of exhaled nitric oxide (Feno) and blood eosinophil count (B-Eos) values, markers of local and systemic eosinophilic inflammation, respectively, are increased in asthmatic patients. Little is known about the relation of these markers to reported wheeze and asthma events in a random population sample. OBJECTIVES We sought to determine the individual and independent values of B-Eos and Feno in relation to wheeze, asthma diagnosis, and asthma events in a cross-sectional study. METHODS Feno and B-Eos values were measured in 12,408 subjects aged 6 to 80 years from the National Health and Nutrition Examination Survey 2007-2008 and 2009-2010. Current wheeze and asthma diagnosis, as well as asthma attacks and asthma-related emergency department (ED) visits within the last 12 months, were assessed by means of questionnaires. RESULTS Intermediate or high Feno values and intermediate or high B-Eos values were independently associated with having asthma, wheeze, and asthma attacks. However, only intermediate and high B-Eos values were independently associated with asthma-related ED visits. High Feno (≥ 50 ppb) and B-Eos (≥ 500 cells/mm(3)) values rendered an adjusted odds ratio of 4.5 of having wheeze, 5.1 of having asthma, 5.4 for asthma attacks, and 2.9 for asthma-related ED visits compared with normal Feno (<25 ppb) and B-Eos (<300 cells/mm(3)) values. CONCLUSIONS Exhaled nitric oxide and B-Eos values offered independent information in relation to the prevalence of wheeze, asthma diagnosis, and asthma events in this random population sample. The clinical importance of these findings in asthmatic patients with regard to phenotyping and individualized treatment, considering both local and systemic eosinophilic inflammation, needs to be determined.
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Affiliation(s)
- Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden.
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16
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Amelink M, de Groot JC, de Nijs SB, Lutter R, Zwinderman AH, Sterk PJ, ten Brinke A, Bel EH. Severe adult-onset asthma: A distinct phenotype. J Allergy Clin Immunol 2013; 132:336-41. [PMID: 23806634 DOI: 10.1016/j.jaci.2013.04.052] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 04/29/2013] [Accepted: 04/29/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Some patients with adult-onset asthma have severe disease, whereas others have mild transient disease. It is currently unknown whether patients with severe adult-onset asthma represent a distinct clinical phenotype. OBJECTIVE We sought to investigate whether disease severity in patients with adult-onset asthma is associated with specific phenotypic characteristics. METHODS One hundred seventy-six patients with adult-onset asthma were recruited from 1 academic and 3 nonacademic outpatient clinics. Severe refractory asthma was defined according to international Innovative Medicines Initiative criteria, and mild-to-moderate persistent asthma was defined according to Global Initiative for Asthma criteria. Patients were characterized with respect to clinical, functional, and inflammatory parameters. Unpaired t tests and χ(2) tests were used for group comparisons; both univariate and multivariate logistic regression were used to determine factors associated with disease severity. RESULTS Apart from the expected high symptom scores, poor quality of life, need for high-intensity treatment, low lung function, and high exacerbation rate, patients with severe adult-onset asthma were more often nonatopic (52% vs 34%, P = .02) and had more nasal symptoms and nasal polyposis (54% vs 27%, P ≤ .001), higher exhaled nitric oxide levels (38 vs 27 ppb, P = .02) and blood neutrophil counts (5.3 vs 4.0 10(9)/L, P ≤ .001) and sputum eosinophilia (11.8% vs 0.8%, P ≤ .001). Multiple logistic regression analysis showed that increased blood neutrophil (odds ratio, 10.9; P = .002) and sputum eosinophil (odds ratio, 1.5; P = .005) counts were independently associated with severe adult-onset disease. CONCLUSION The majority of patients with severe adult-onset asthma are nonatopic and have persistent eosinophilic airway inflammation. This suggests that severe adult-onset asthma has a distinct underlying mechanism compared with milder disease.
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17
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Noonan M, Korenblat P, Mosesova S, Scheerens H, Arron JR, Zheng Y, Putnam WS, Parsey MV, Bohen SP, Matthews JG. Dose-ranging study of lebrikizumab in asthmatic patients not receiving inhaled steroids. J Allergy Clin Immunol 2013; 132:567-574.e12. [PMID: 23726041 DOI: 10.1016/j.jaci.2013.03.051] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 03/21/2013] [Accepted: 03/27/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Asthma is a disease with marked heterogeneity in its clinical course and response to treatment. IL-13 is central to type 2 inflammation, which contributes to many key features of asthma. Lebrikizumab is an anti-IL-13 mAb previously reported to significantly improve lung function in patients with inadequately controlled asthma despite inhaled corticosteroid therapy, especially in periostin-high patients. OBJECTIVE This phase II study investigated the efficacy and safety of IL-13 blockade with different doses of lebrikizumab in asthmatic patients not receiving inhaled corticosteroids. METHODS Patients were randomized to receive 125, 250, or 500 mg of lebrikizumab or placebo subcutaneously monthly for 12 weeks with an 8-week follow-up period. The primary efficacy end point was the relative change in prebronchodilator FEV1 from baseline to week 12. RESULTS A total of 212 patients were randomized. The mean relative change in FEV1 was numerically higher in all lebrikizumab dose groups versus the placebo group, although the difference was neither statistically nor clinically significant. There were no meaningful differences in changes in FEV1 between the dose groups and the placebo group by the periostin subgroup. Lebrikizumab treatment was associated with a reduced risk of treatment failure at all doses versus placebo (P < .001), and results were similar by the periostin subgroup, with no apparent differences between doses of lebrikizumab. Lebrikizumab was generally well tolerated. CONCLUSION Blocking IL-13, a single cytokine, in this population of asthmatic patients is insufficient to improve lung function. There is evidence that IL-13 blockade may improve disease control, as measured by prevention of protocol-defined treatment failure in these patients.
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18
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Konradsen JR, James A, Nordlund B, Reinius LE, Söderhäll C, Melén E, Wheelock AM, Wheelock A, Lödrup Carlsen KC, Lidegran M, Verhoek M, Boot RG, Dahlén B, Dahlén SE, Hedlin G. The chitinase-like protein YKL-40: a possible biomarker of inflammation and airway remodeling in severe pediatric asthma. J Allergy Clin Immunol 2013; 132:328-35.e5. [PMID: 23628340 DOI: 10.1016/j.jaci.2013.03.003] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 03/06/2013] [Accepted: 03/08/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Problematic severe childhood asthma includes a subgroup of patients who are resistant to therapy. The specific mechanisms involved are unknown, and novel biomarkers are required to facilitate treatment and diagnosis of therapy-resistant asthma. The chitinase-like protein YKL-40 has been related to asthma and airway remodeling. OBJECTIVES To compare serum YKL-40 levels in children with severe, therapy-resistant asthma (n = 34), children with controlled persistent asthma (n = 39), and healthy controls (n = 27), and to investigate correlations with biomarkers of inflammation and airway remodeling. METHODS The study protocol included questionnaires, measurement of exhaled nitric oxide in exhaled air, blood sampling for inflammatory biomarkers, and high-resolution computed tomography of the lungs to identify bronchial wall thickening (therapy-resistant only). Serum YKL-40 levels were measured by ELISA, and all asthmatic children were genotyped for a CHI3L1 promoter single nucleotide polymorphism (rs4950928). RESULTS Serum YKL-40 levels were significantly higher in children with therapy-resistant asthma than in healthy children (19.2 ng/mL vs 13.8 ng/mL, P = .03). Among children with severe, therapy-resistant asthma, YKL-40 levels correlated with fraction of exhaled nitric oxide in exhaled air (r = 0.48, P = .004), blood neutrophils (r = 0.63, P < .001), and bronchial wall thickening on high-resolution computed tomography (r = 0.45, P = .01). Following adjustment for CHI3L1 genotype, significantly greater levels of YKL-40 were found in children with therapy-resistant asthma than in children with controlled asthma. CONCLUSIONS YKL-40 levels are increased in children with severe, therapy-resistant asthma compared to healthy children, and also compared to children with controlled asthma following correction for genotype.
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Affiliation(s)
- Jon R Konradsen
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
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19
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Kazani S, Planaguma A, Ono E, Bonini M, Zahid M, Marigowda G, Wechsler ME, Levy BD, Israel E. Exhaled breath condensate eicosanoid levels associate with asthma and its severity. J Allergy Clin Immunol 2013; 132:547-553. [PMID: 23608729 DOI: 10.1016/j.jaci.2013.01.058] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 01/28/2013] [Accepted: 01/31/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The relationship between anti-inflammatory lipoxins and proinflammatory leukotrienes might be important in the pathobiology and severity of asthma. OBJECTIVE We sought to investigate whether exhaled breath condensate (EBC) lipoxin and leukotriene measurements can noninvasively characterize the asthmatic diathesis and its severity. METHODS We measured lipoxin A4 (LXA4) and leukotriene B4 (LTB4) levels in EBC collected from patients with asthma of different severities and from healthy control subjects. RESULTS EBC LXA4 and LTB4 levels are increased in asthmatic patients compared with those seen in healthy control subjects (LXA4: 31.40 vs 2.41 pg/mL EBC, respectively [P < .001]; LTB4: 45.62 vs 3.82 pg/mL EBC, respectively [P < .001]). Although levels of both eicosanoids are increased in asthmatic patients, the LXA4/LTB4 ratio decreases with increasing asthma severity. It is 41% lower in patients with severe versus moderate asthma (0.52 vs 0.88, P = .034). EBC LXA4 levels correlate with the degree of airflow obstruction measured by using FEV1 (r = 0.28, P = .018). An LXA4 cutoff value of 7 pg/mL EBC provides 90% sensitivity and 92% specificity for the diagnosis of asthma (area under the curve, 0.96; P < .001). An LTB4 cutoff value of 11 pg/mL EBC provides 100% sensitivity and 100% specificity for the diagnosis of asthma (area under the curve, 1; P < .001). CONCLUSIONS Proresolving and proinflammatory eicosanoids are generated in the airways of all asthmatic patients. The proportion of proresolving compounds decreases with asthma severity. These findings support the role for EBC eicosanoid measurements in the noninvasive diagnosis of asthma and suggest that proresolving eicosanoid pathways are dysregulated in patients with severe asthma.
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Affiliation(s)
- Shamsah Kazani
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Anna Planaguma
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Emiko Ono
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Matteo Bonini
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Muhammad Zahid
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gautham Marigowda
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Michael E Wechsler
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Bruce D Levy
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Elliot Israel
- Pulmonary and Critical Care Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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