Fractional exhaled nitric oxide and eosinophil count in induced sputum to guide the management of children with asthma: a cost-utility analysis

Introduction

Previous evidence has shown that fractional exhaled nitric oxide (FeNO) and eosinophil count in induced sputum (EO) are cost-effective relative to standard of care in guiding the management of children with persistent asthma. There is some doubt as if there are differences between these two biomarkers in terms of costs and benefits. Clarifying this doubt would allow prioritization of the design of clinical practice guidelines. The study aimed to compare in terms of costs and benefits these biomarkers in patients with asthma between 4 and 18 years of age.

Methods

A Markov model was used to estimate the cost-utility of asthma management using FeNO and EO in patients between 4 and 18 years of age. Transition probabilities, cost and utilities were estimated from previously published local studies, while relative risks were obtained from the systematic review of published randomized clinical trials. The analysis was carried out from a societal perspective.

Results

The expected annual cost per patient with EO was US $1376 (CI 95% US $1376–US $1377) and for FeNO was US $1934 (CI 95% US $1333–US $1334), with a difference of US $42.3 between these strategies. The Quality-adjusted life years (QALYs) per person estimated with EO was 0.95 (CI 95% 0.951–0.952) and for FeNO was 0.94 (CI 95% 0.930–0.940), with a difference of 0.01 between these strategies. The NMB with EO was US $4902 (CI 95% 4900–4904) and for FeNO was US $4841 (CI 95% 4839–4843). The incremental cost-effectiveness ratio of EO was $3566 per QALY gained regarding FeNO.

Conclusion

Our study demonstrates that induced sputum-guided management is a strategy cost-effective over FeNO and standard asthma management in Colombia. This evidence should encourage the adoption of any of these techniques to objectively guide the management of children with asthma in routine clinical practice in low-resource settings.

Update on Omalizumab for Urticaria: What's New in the Literature from Mechanisms to Clinic

PURPOSE OF REVIEW

Since omalizumab has been approved for urticaria, numerous randomized and real-life observational trials have been published. We reviewed the period January 2017-February 2018.

RECENT FINDINGS

Omalizumab is effective for the control of urticaria recalcitrant to antihistamines in different populations globally. The ratio of total serum IgE 4-week/baseline ≥2 can predict response with a high likelihood. In observational real-life trials, doses have been adjusted on an individual basis: in some populations, up to two-thirds of the patients can be controlled with 150 mg/month; however, others are still not controlled with 300 mg/month. In these, 150 mg bimonthly could be tried, before up-dosing to 450 mg/month. On the long run (up to 3 years) omalizumab kept its efficacy. In many patients, dosing intervals could be augmented (6-8 weeks, some even more). After a 12-month treatment, about 20% showed long-term remission without relapse. Some biomarkers are being detected. Adjusting omalizumab doses in urticaria patients could enhance efficacy (shortening dosing interval and/or augmenting dose) and save costs (after 12 months: extending dosing interval and/or reducing dose).

Inmunoterapia con alérgenos, ¿cuándo y por qué?

La inmunoterapia específica con alérgenos es el único tratamiento que modifica el curso natural de algunas enfermedades alérgicas como asma, rinitis, conjuntivitis, dermatitis atópica y alergia al veneno de himenópteros. Sin embargo, aún existe cierta controversia respecto a su seguridad y su utilidad clínica. En el presente artículo se presenta una revisión de los mecanismos moleculares, las indicaciones y contraindicaciones de dicha inmunoterapia, y se evalúan su seguridad y eficacia en cada una de estas enfermedades mediante casos ilustrativos y una breve revisión del tema.

Desensibilización al ácido acetil-salicílico como tratamiento para la enfermedad respiratoria exacerbada por antiinflamatorios no esteroides

La coexistencia de hipersensibilidad al ácido acetil salicílico (ASA) y a otros antiinflamatorios no esteroides (AINE) con enfermedad de la vía aérea superior (rinosinusitis/poliposis nasosinusal) o inferior (asma) se denomina enfermedad respiratoria exacerbada por ASA (EREA). Las opciones de tratamiento incluyen la evitación de todos los analgésicos inhibidores de la ciclooxigenasa 1 (COX-1) o la desensibilización a ASA, continuando su consumo diario. Esta última opción terapéutica ha demostrado mejorar la calidad de vida, reducir la formación de pólipos nasosinusales, los episodios de sinusitis infecciosa, la frecuencia de las hospitalizaciones y de las cirugías para resección de pólipos; también mejora la hiposmia y reduce la necesidad de tratamiento con esteroides sistémicos. Se han usado múltiples esquemas de desensibilización, tratando de reducir el riesgo asociado con el procedimiento y los efectos adversos derivados del consumo crónico de ASA. En este artículo se presentan una revisión de los diferentes esquemas de desensibilización y dos casos clínicos ilustrativos que sirven de ejemplo para comprender mejor los factores que influyen en la elección del tratamiento para los pacientes con esta enfermedad.

Características fisicoquímicas de los gases y partículas contaminantes del aire. Su impacto en el asma

El Asma es una enfermedad multifactorial caracterizada por un proceso inflamatorio que afecta las vías respiratorias. El incremento epidemiológico que ha tenido en los últimos años parece deberse principalmente a factores ambientales. El aumento en las concentraciones de los contaminantes atmosféricos secundario a la liberación de gases y pequeñas partículas producidos a partir de la combustión de derivados del petróleo, el humo del cigarrillo y otras fuentes antropogénicas, parecen tener una fuerte asociación con el aumento de las enfermedades alérgicas, tanto como disparadores de las exacerbaciones asmáticas, como posibles mediadores importantes en el inicio del asma, la rinitis y la sensibilización con aeroalergenos. A continuación presentamos una revisión de las principales características de los gases y partículas que han sido asociados como factores de riesgo para el desarrollo de asma.

Clinical and immunological changes of immunotherapy in patients with atopic dermatitis: randomized controlled trial

Background. Immunotherapy has proven to be an useful tool in the management of allergic respiratory diseases; however, little has been studied in atopic dermatitis. Objective. To evaluate the clinical and immunological impact of immunotherapy with mites allergen extracts in atopic dermatitis. Methods. Patients with atopic dermatitis were assigned with computer-generated randomization to either of the following groups: (a) controls received only topical treatment with steroids and/or tacrolimus and (b) actively treated patients received topical treatment plus immunotherapy. Levels of serum total IgE, mites-specific IgE and IgG4 were assessed at study start and after one year of immunotherapy. Results. 31 patients in the active group and 29 in the control group completed the study. Symptoms and medication scores were significantly reduced in the active group after six months. Three patients in the control group showed new sensitizations to mites, while 3 patients in the active group showed neosensitization to shrimp with negative oral food challenge. We observed significant increase of mites-specific IgG4 levels in active group. Conclusion. Specific allergen immunotherapy induced a tolerogenic IgG4 response to mite allergens associated with favorable clinical effects in atopic dermatitis patients.