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Corren J, Szefler SJ, Sher E, Korenblat P, Soong W, Hanania NA, Berman G, Brusselle G, Zitnik R, Natalie CR, Sun L, Siu K, Wu WS, Lio P, Armstrong AW. Lebrikizumab in Uncontrolled Asthma: Reanalysis in a Well-Defined Type 2 Population. J Allergy Clin Immunol Pract 2024; 12:1215-1224.e3. [PMID: 38360213 DOI: 10.1016/j.jaip.2024.02.007] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND LAVOLTA (L)I, LII, and ACOUSTICS were randomized, placebo-controlled, Phase 3 trials of lebrikizumab, a monoclonal antibody targeting IL-13 in patients with uncontrolled asthma. Failure to demonstrate efficacy may have been related to patient selection in those trials. OBJECTIVE To assess the efficacy in a well-defined subpopulation of patients with elevated blood eosinophil counts and a minimum number of prior asthma exacerbations. We performed an additional analysis in a subpopulation of patients with elevated FeNO and prior exacerbations. METHODS Adult (LI and LII) and adolescent patients (aged 12-17 years weighing ≥40 kg, ACOUSTICS) with uncontrolled asthma received lebrikizumab (125 mg, n = 832; or 37.5 mg, n = 829) or placebo (n = 833) subcutaneously every 4 weeks. Post hoc analysis of the annualized adjusted exacerbation rate (AER) was performed in a subpopulation of patients with baseline blood eosinophils of 300 cells/μL or greater and history of one or more exacerbations. In this subpopulation, there were 227 patients in the placebo group, 222 in the lebrikizumab 37.5-mg group, and 217 in the lebrikizumab 125-mg group. We summarized safety in patients who received at least one dose of lebrikizumab using adverse events. RESULTS Lebrikizumab significantly reduced AER compared with placebo in adults (AER reduction: 125 mg [38%]; and 37.5 mg [41%]) and adolescents (AER reduction:125 mg [59%]; 37.5 mg [64%]) with baseline blood eosinophils of 300 cells/μL or greater and one or more exacerbations. Most adverse events were mild or moderate in severity and did not lead to treatment discontinuation. CONCLUSION Lebrikizumab significantly reduced asthma exacerbations in a subpopulation of patients with elevated blood eosinophils, elevated FeNO, and a history of asthma exacerbation.
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Affiliation(s)
- Jonathan Corren
- David Geffen School of Medicine at UCLA, Los Angeles, Calif.
| | - Stanley J Szefler
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | | | | | - Weily Soong
- Allervie Clinical Research-Alabama Allergy & Asthma Center, Birmingham, Ala
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | - Gary Berman
- Clinical Research Institute and Allergy & Asthma Specialists, Minneapolis, Minn
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | | | | | - Luna Sun
- Eli Lilly and Company, Indianapolis, Ind
| | | | | | - Peter Lio
- Northwestern University Feinberg School of Medicine, Medical Dermatology Associates of Chicago, Chicago, Ill
| | - April W Armstrong
- Keck School of Medicine at University of Southern California and Clinical Research for the Southern California Clinical and Translational Research Institute (SC CTSI), Los Angeles, Calif
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Stempel DA, Szefler SJ. Is the assessment of asthma treatment efficacy sufficiently comprehensive? J Allergy Clin Immunol 2024; 153:629-636. [PMID: 38135011 DOI: 10.1016/j.jaci.2023.12.006] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/21/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
The goal of asthma guideline therapy is to achieve disease control, by minimizing impairment and decreasing the risk of exacerbations and adverse effects of the disease and its treatment. The primary objective of most clinical trials of biologics for severe asthma is a reduction in exacerbation rate. Recently, studies with patients at the lower guideline steps have also selected exacerbation reduction as a primary objective. These trials in patients with milder disease frequently demonstrate statistically significantly fewer exacerbations, but their power calculations reflect larger sample size and smaller effect size. Exacerbations have a precise consensus definition, although a minimal clinically important difference has not been established. Reduction of exacerbations in severe asthma is commonly 10-fold greater than in mild disease. Further, reduction in exacerbations is not always associated with reduced impairment. If superior control is the objective, both domains should demonstrate consistent and parallel improvement. The disconnect may reflect the need for alternative tools for measurement of impairment or, possibly, different therapeutic mechanisms of action. Determining response to biologics or discussion of disease remission requires assessing symptoms that may occur daily rather than focusing on exacerbations that occur once or twice a year for patients at the highest steps of care according to the guidelines.
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Affiliation(s)
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
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Kyler KE, Szefler SJ. Fifty Years of Unraveling the Clinical Pharmacology of Corticosteroids. J Pharm Sci 2024; 113:47-54. [PMID: 37844761 DOI: 10.1016/j.xphs.2023.10.016] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
This review will highlight portions of Dr. William Jusko's and colleagues' work that affected the clinical use and study of corticosteroids in acute and chronic disease management. Selected publications related to corticosteroid pharmacokinetics and pharmacodynamics from the 1970s through today were included in this review, with a focus on the foundational human-based studies conducted in the 1970s-1990s. Dr. Jusko contributed significantly to early corticosteroid pharmacology across several domains including: 1) foundational corticosteroid pharmacokinetic methods and parameter development, 2) disease state-variation in corticosteroid pharmacokinetics, 3) drug interaction effects on corticosteroid pharmacokinetics, and 4) early corticosteroid pharmacodynamic studies. In an era where little was known about the pharmacokinetics and pharmacodynamics of corticosteroids, Dr. Jusko's work opened the eyes of researchers and clinicians to the potential for disease and drug interactions that could reduce or enhance the effects of corticosteroids. This significant body of work paved the way for alternative routes of administration that would be useful in concentrating the activity at the site of action and markedly reduced systemic drug exposure, minimizing the risk of adverse effects through application of the dose-sparing pharmacokinetic and pharmacodynamic principles.
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Affiliation(s)
- Kathryn E Kyler
- Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, MO, United States; School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Stanley J Szefler
- University of Colorado School of Medicine, Department of Pediatrics Pediatric Pulmonary and Sleep Medicine Section, United States; Children's Hospital Colorado, Breathing Institute, United States.
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Keyser HHD, Brinton JT, Bothwell S, Camacho M, Kempe A, Szefler SJ. Encouraging adherence in adolescents with asthma using financial incentives: An RCT. Pediatr Pulmonol 2023; 58:2823-2831. [PMID: 37449768 PMCID: PMC10538420 DOI: 10.1002/ppul.26594] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Medication adherence in adolescents remains a significant management challenge and innovative strategies are needed to improve medication adherence. Financial incentives have been used to improve outcomes for health behaviors among adults, but have not been well-studied among adolescents. The objective of this study was to test if a modest financial incentive improved medication adherence in adolescents with asthma compared with a control group. METHODS Participants were randomized to either control (electronic medication monitoring [EMM] with App reminders/feedback for 4 months) or intervention (EMM + $1 per day for perfect medication adherence for 3 months [maximum $84] followed by 1 month of EMM only). A repeated measures mixed model, with a first order autoregressive correlation structure between errors, was used to test the null hypothesis for an interaction of treatment group and week. RESULTS Fifty-two participants were enrolled, and 48 completed primary analysis. Mean adherence rates declined in both groups over time, and there was no significant difference in the change in adherence rates between the groups (F-statistic = 0.72, ndf = 15, ddf = 625, p = 0.76). Adherence rates (during the 12 weeks when incentives were given) declined from 80% to 64% in the control group, and from 90% to 58% in the incentive group. There was no significant change in the slope of decline in the incentives group in the month following payment discontinuation. CONCLUSION A modest financial incentive did not lead to significantly different medication adherence rates in adolescents with asthma who were receiving a monitoring and reminder intervention. Further study is needed to determine viable interventions to optimize medication use in this group.
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Affiliation(s)
- Heather H De Keyser
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
| | - John T Brinton
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Samantha Bothwell
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Megan Camacho
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
| | - Allison Kempe
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
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Papadopoulos NG, Szefler SJ, Bacharier LB, Maspero JF, Domingo C, Fiocchi A, Lee JK, Daizadeh N, Lederer DJ, Hardin M, Gall R, Djandji M, Siddiqui S, Jacob-Nara JA, Deniz Y, Rowe PJ. Assessment of dupilumab in children with moderate-to-severe type 2 asthma with or without evidence of allergic asthma. Allergy 2023; 78:2157-2167. [PMID: 37059696 DOI: 10.1111/all.15743] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Cytokines, such as interleukins (IL)-4/5/13, play a key role in multiple type 2 inflammatory diseases, including allergic asthma. Dupilumab, a human monoclonal antibody, blocks the shared receptor component for IL-4/IL-13, inhibiting signaling. In this post hoc analysis of VOYAGE (NCT02948959), dupilumab efficacy was evaluated in patients aged 6-11 years with type 2 asthma with or without evidence of allergic asthma (baseline serum total IgE ≥30 IU/mL and ≥1 perennial aeroallergen-specific IgE ≥0.35kU/L). METHODS Annualized severe exacerbation rates (AER) and changes in pre-bronchodilator (Pre-BD) forced expiratory volume in one second (FEV1 ), percent-predicted pre-BD FEV1 (ppFEV1 ), and Asthma Control Score (ACQ)-7 were assessed during the treatment period. RESULTS 350 children (261 with and 89 without evidence of allergic asthma) were included. Dupilumab versus placebo significantly reduced AER in patients with (0.24 vs. 0.62, relative risk reduction [RRR]: 62% [95% CI, 39-76], P < .0001) and without (0.39 vs. 0.80, RRR: 51% [95% CI, 0-76], P < .05) evidence of allergic asthma. Significant improvements in ppFEV1 , pre-bronchodilator FEV1 , and ACQ-7 scores were observed in dupilumab versus placebo throughout the treatment period in patients with evidence of allergic asthma. In patients without evidence of allergic asthma, numerical improvements in pre-bronchodilator FEV1 and asthma control were observed by Week 52. CONCLUSION Dupilumab versus placebo reduced asthma exacerbations in children with type 2 asthma irrespective of evidence of allergic asthma; similar trends were observed in changes in lung function. Significant improvement in asthma control was observed in patients with evidence of allergic asthma, but not in those without.
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Affiliation(s)
| | - Stanley J Szefler
- Department of Pediatrics, The Breathing Institute, The University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, The Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jorge F Maspero
- Allergy and Respiratory Medicine, The Fundación CIDEA, Buenos Aires, Argentina
| | - Christian Domingo
- Pulmonary Service, The Corporació Sanitària Parc Taulí, Sabadell, Autonomous University of Barcelona, Barcelona, Spain
| | - Alessandro Fiocchi
- Department of Allergy, The Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Jason K Lee
- Division of Adult Clinical Immunology and Allergy, Internal Medicine, Evidence Based Medical Educator and Toronto Allergy and Asthma Clinic, Toronto, Ontario, Canada
| | | | | | | | - Rebecca Gall
- Regeneron Pharmaceuticals Inc., Tarrytown, New York, USA
| | | | | | | | - Yamo Deniz
- Regeneron Pharmaceuticals Inc., Tarrytown, New York, USA
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Busse WW, Szefler SJ. Digital health in difficult-to-treat severe asthma. Lancet Respir Med 2023; 11:578-579. [PMID: 36963416 DOI: 10.1016/s2213-2600(23)00012-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/26/2023]
Affiliation(s)
- William W Busse
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
| | - Stanley J Szefler
- Department of Pediatrics, Section for Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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Carr TF, Fajt ML, Kraft M, Phipatanakul W, Szefler SJ, Zeki AA, Peden DB, White SR. Treating asthma in the time of COVID. J Allergy Clin Immunol 2023; 151:809-817. [PMID: 36528110 PMCID: PMC9749385 DOI: 10.1016/j.jaci.2022.12.800] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
The Precision Interventions for Severe and/or Exacerbation-Prone Asthma clinical trials network is actively assessing novel treatments for severe asthma during the coronavirus disease (COVID-19) pandemic and has needed to adapt to various clinical dilemmas posed by the COVID-19 pandemic. Pharmacologic interactions between established asthma therapies and novel drug interventions for COVID-19 infection, including antivirals, biologics, and vaccines, have emerged as a critical and unanticipated issue in the clinical care of asthma. In particular, impaired metabolism of some long-acting beta-2 agonists by the cytochrome P4503A4 enzyme in the setting of antiviral treatment using ritonavir-boosted nirmatrelvir (NVM/r, brand name Paxlovid) may increase risk for adverse cardiovascular events. Although available data have documented the potential for such interactions, these issues are largely unappreciated by clinicians who treat asthma, or those dispensing COVID-19 interventions in patients who happen to have asthma. Because these drug-drug interactions have not previously been relevant to patient care, clinicians have had no guidance on management strategies to reduce potentially serious interactions between treatments for asthma and COVID-19. The Precision Interventions for Severe and/or Exacerbation-Prone Asthma network considered the available literature and product information, and herein share our considerations and plans for treating asthma within the context of these novel COVID-19-related therapies.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | - Merritt L Fajt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh
| | - Monica Kraft
- Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Department of Pediatrics, Boston Children's Hospital, Boston
| | - Stanley J Szefler
- The University of Colorado School of Medicine and Children's Hospital Colorado, Department of Pediatrics, The Breathing Institute, Aurora
| | - Amir A Zeki
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, UC Davis Lung Center, Sacramento
| | - David B Peden
- Division of Allergy and Immunology, Department of Pediatrics, University of North Carolina, Chapel Hill
| | - Steven R White
- Department of Medicine, the University of Chicago, Chicago.
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Anderson WC, Banzon TM, Chawes B, Papadopoulos NG, Phipatanakul W, Szefler SJ. Factors to Consider in Prescribing Asthma Biologic Therapies to Children. J Allergy Clin Immunol Pract 2023; 11:693-701. [PMID: 36646381 DOI: 10.1016/j.jaip.2022.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023]
Abstract
The increasing availability of biologics, both by expanding age indications and by development of new therapies, provides additional options to treat children and adolescents with severe asthma. However, the evidence for these biologics in these populations is limited compared with that for adult studies. As such, before initiation of therapy, possible alternative therapies that can also provide asthma control, confirmation of the diagnosis of asthma, management of comorbidities, and assessment of adherence should be explored. The choice of a biologic should be a shared decision-making process between providers and families, balancing biologic efficacy, goals of care, administration, and ability to treat multiple conditions. Response to treatment should be periodically evaluated not only to ensure an ineffective treatment is not continued but also to consider when to potentially discontinue therapy should it be beneficial. The utilization of biologics in children and adolescents with severe asthma also leads to unanswered questions on their role in disease remission and long-term outcomes.
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Affiliation(s)
- William C Anderson
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Tina M Banzon
- Division of Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Wanda Phipatanakul
- Division of Asthma, Allergy, Dermatology, Rheumatology, Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Stanley J Szefler
- Section of Pediatric Pulmonary and Sleep Medicine, Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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Stempel DA, Szefler SJ. Adding a Biologic to Asthma Therapy: The Role of Adherence in Selecting the Right Patient. The Journal of Allergy and Clinical Immunology: In Practice 2022; 10:2949-2950. [DOI: 10.1016/j.jaip.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 11/09/2022]
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Szefler SJ, Cicutto L, Brewer SE, Gleason M, McFarlane A, DeCamp LR, Brinton JT, Huebschmann AG. Applying dissemination and implementation research methods to translate a school-based asthma program. J Allergy Clin Immunol 2022; 150:535-548. [PMID: 35569568 PMCID: PMC9590448 DOI: 10.1016/j.jaci.2022.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 05/26/2021] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022]
Abstract
Our school-based asthma program has reduced asthma exacerbations for youth with health disparities in the Denver metropolitan area, due partly to addressing social determinants of health, such as access to health care and medications. Dissemination and implementation (D&I) science approaches accelerate the translation of evidence-based programs into routine practice. D&I methods are being applied more commonly to improve health equity. The purpose of this publication was to give an overview of D&I research methods, using our school-based asthma program as an example. To successfully scale out our program across the state of Colorado, we are applying a D&I framework that guides the adaptation of our existing implementation approach to better meet our stakeholders' local context-the Exploration, Preparation, Implementation, Sustainment framework. In a pragmatic trial design, we will evaluate the outcomes of implementing the program across 5 Colorado regions, with attention to health equity, using a second commonly used D&I framework-Reach, Effectiveness, Adoption, Implementation, and Maintenance. Our central hypothesis is that our program will have broad and equitable reach to eligible students (primary outcome) and will reduce asthma attacks and symptoms. This D&I approach accelerates dissemination of our program and is an applicable process for translating other effective allergy/asthma programs to address asthma and allergy-related disparities.
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Affiliation(s)
- Stanley J Szefler
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colo; Children's Hospital Colorado Breathing Institute, Aurora, Colo; Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Anschutz Medical Campus, Aurora, Colo.
| | - Lisa Cicutto
- National Jewish Health, Aurora, Colo; Clinical Science and College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colo
| | - Sarah E Brewer
- Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Anschutz Medical Campus, Aurora, Colo; Department of Family Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colo
| | - Melanie Gleason
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colo; Children's Hospital Colorado Breathing Institute, Aurora, Colo
| | | | - Lisa Ross DeCamp
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colo; Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Anschutz Medical Campus, Aurora, Colo; Latino Research and Policy Center, Colorado School of Public Health, Aurora, Colo
| | - John T Brinton
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colo; Children's Hospital Colorado Breathing Institute, Aurora, Colo
| | - Amy G Huebschmann
- Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Anschutz Medical Campus, Aurora, Colo; Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora, Colo; Ludeman Family Center for Women's Health Research, Aurora, Colo
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May KR, Oppenheimer JJ, Szefler SJ. Over-the-Counter Availability of Rescue Inhalers for Asthma. JAMA 2022; 328:215. [PMID: 35819430 DOI: 10.1001/jama.2022.8769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kathleen R May
- Department of Pediatrics, Children's Hospital of Georgia and Medical College of Georgia at Augusta University, Augusta
| | - John J Oppenheimer
- Department of Medicine, University of Medicine and Dentistry of New Jersey-Rutgers, Newark
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
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Szefler SJ, Roberts G, Rubin AS, Zielen S, Kuna P, Alpan O, Anzures-Cabrera J, Chen Q, Holweg CTJ, Kaminski J, Putnam WS, Matthews JG, Kamath N. Efficacy, safety, and tolerability of lebrikizumab in adolescent patients with uncontrolled asthma (ACOUSTICS). Clin Transl Allergy 2022; 12:e12176. [PMID: 35846226 PMCID: PMC9281483 DOI: 10.1002/clt2.12176] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Lebrikizumab is a monoclonal antibody that modulates activity of interleukin‐13. The Phase 3 ACOUSTICS study assessed lebrikizumab efficacy and safety in adolescents with uncontrolled asthma despite standard‐of‐care treatment. Methods Adolescents (aged 12–17 years) with uncontrolled asthma, prebronchodilator forced expiratory volume in 1 s 40%–90% predicted, and stable background therapy were randomised 1:1:1 to receive lebrikizumab 125 or 37.5 mg or placebo subcutaneously once every 4 weeks. Primary efficacy endpoint was asthma exacerbation rate over 52 weeks. Results Between August 2013 and July 2016, 579 patients were screened and 346 were randomised; 224 (65%) completed the study with 52 weeks of treatment. Lebrikizumab 125 mg (n = 116) reduced the exacerbation rate at 52 weeks versus placebo (n = 117; adjusted rate ratio [RR] 0.49 [95% CI 0.28–0.83]; 51% rate reduction). Lebrikizumab 37.5 mg (n = 113) was less effective at reducing exacerbations (RR 0.60 [95% CI 0.35–1.03]; 40% rate reduction). In patients with blood eosinophil counts ≥300 cells/μl, both lebrikizumab doses reduced exacerbations (125 mg: RR 0.44 [95% CI 0.21–0.89]; 37.5 mg: 0.42 [95% CI 0.19–0.93]). Treatment‐emergent adverse events, serious adverse events, and adverse events leading to study discontinuation occurred in 155 (68%), 7 (3%), and 5 (2%) of 229 patients who received lebrikizumab (both 125 and 37.5 mg doses) and in 72 (62%), 4 (3%), and 1 (1%) of 117 who received placebo, respectively. No deaths occurred. Conclusion Lebrikizumab 125 mg reduced asthma exacerbation rates in adolescents with uncontrolled asthma. However, the study was prematurely terminated (sponsor's decision) potentially limiting interpretation of results. Clinical trial registration NCT01875003 (www.ClinicalTrials.gov).
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Affiliation(s)
- Stanley J Szefler
- Department of Pediatrics Children's Hospital Colorado and the University of Colorado School of Medicine Anschutz Medical Campus Aurora Colorado USA
| | - Graham Roberts
- University of Southampton School of Medicine and Southampton Biomedical Research Centre University Hospital Southampton NHS Foundation Trust Southampton UK.,David Hide Asthma and Allergy Research Centre Isle of Wight UK
| | - Adalberto S Rubin
- Federal University of Health Sciences of Porto Alegre and Santa Casa de Misericórdia Hospital Porto Alegre Brazil
| | - Stefan Zielen
- Goethe-Universität Klinik für Kinder- und Jugendmedizin Frankfurt Germany
| | | | | | | | - Qiang Chen
- Roche (China) Holding Ltd Shanghai China
| | - Cécile T J Holweg
- Genentech, Inc. South San Francisco California USA.,Present address: Abbvie, IL USA
| | - Janusz Kaminski
- Roche Products Ltd Welwyn Garden City UK.,Present address: MSD London UK
| | - Wendy S Putnam
- Genentech, Inc. South San Francisco California USA.,Present address: Ultragenyx Pharmaceutical, Novato CA USA
| | - John G Matthews
- Genentech, Inc. South San Francisco California USA.,Present address: 23andMe, South San Francisco CA USA
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Kho A, Daumit GL, Truesdale KP, Brown A, Kilbourne AM, Ladapo J, Wali S, Cicutto L, Matthews AK, Smith JD, Davis PD, Schoenthaler A, Ogedegbe G, Islam N, Mills KT, He J, Watson KS, Winn RA, Stevens J, Huebschmann AG, Szefler SJ. The National Heart Lung and Blood Institute Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Alliance. Health Serv Res 2022; 57 Suppl 1:20-31. [PMID: 35383917 PMCID: PMC9108215 DOI: 10.1111/1475-6773.13983] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease. STUDY SETTING NHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma. STUDY DESIGN The initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS We provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration. CONCLUSIONS The DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.
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Affiliation(s)
- Abel Kho
- Center for Health Information Partnerships (CHiP)Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Gail L. Daumit
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Kimberly P. Truesdale
- Department of Nutrition, Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Arleen Brown
- Department of Internal MedicineUniversity of Los Angeles School of MedicineLos AngelesCAUSA
| | - Amy M. Kilbourne
- Department of Learning Health SciencesUniversity of Michigan MedicineAnn ArborMichiganUSA
- Quality Enhancement Research Initiative (QUERI)U.S. Department of Veterans AffairsWashington, D.C.USA
| | - Joseph Ladapo
- Department of MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Soma Wali
- Department of Internal MedicineUniversity of Los Angeles School of MedicineLos AngelesCAUSA
| | - Lisa Cicutto
- Department of MedicineNational Jewish Health, Community Outreach and ResearchDenverColoradoUSA
| | | | - Justin D. Smith
- Department of Population Health SciencesUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Paris D. Davis
- Total Resource Community Development OrganizationNorthwestern UniversityChicagoIllinoisUSA
| | - Antoinette Schoenthaler
- Department of Population HealthNew York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Gbenga Ogedegbe
- Department of Population HealthNew York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Nadia Islam
- Department of Population HealthNew York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Katherine T. Mills
- Department of EpidemiologyTulane University School of Public Health and Tropical MedicineNew OrleansLouisianaUSA
| | - Jiang He
- Department of EpidemiologyTulane University School of Public Health and Tropical MedicineNew OrleansLouisianaUSA
| | - Karriem S. Watson
- NIH All of Us Bethesda, MD; FormerlyUniversity of Illinois in Chicago Hospital and Health Sciences System, Mile Square Health Center ChicagoIllinoisUSA
| | - Robert A. Winn
- Massey Cancer CenterVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - June Stevens
- Department of Nutrition, Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Amy G. Huebschmann
- Department of Medicine, Division of General Internal MedicineUniversity of Colorado Denver School of MedicineAuroraColoradoUSA
| | - Stanley J. Szefler
- Department of PediatricsUniversity of Colorado Denver School of MedicineDenverColoradoUSA
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14
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Trivedi M, Pappalardo AA, Udoko M, Garg A, Phipatanakul W, Szefler SJ, Nyenhuis SM. Social Determinants of Health in Asthma Through the Life Course. J Allergy Clin Immunol Pract 2022; 10:953-961. [PMID: 35033702 DOI: 10.1016/j.jaip.2021.12.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Abstract
There is strong evidence supporting the influence of social determinants of health (SDOH) on the development and progression of asthma. SDOH are defined as conditions in which people are born, grow up, live, work, and age, which influence their opportunity to be healthy, risk of illness, and life expectancy. The goal of this article was to describe 2 case-based approaches (pediatric and adult) to assessing and addressing SDOH in asthma across the life course and in community settings. As asthma providers and specialists, the role of SDOH is complex in our clinical care; however, it is critical to address social needs identified through clinical care for our patients with asthma. Clinical-community partnerships, through grant and cost-sharing mechanisms with resource agencies, are necessary to ameliorate social needs for patients and their communities and have the potential to improve asthma outcomes. Although this is a unique and exciting time in health care to promote individual and population health, knowledge gaps remain, including best practices to integrate holistic SDOH care into the care of patients with asthma.
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Affiliation(s)
- Michelle Trivedi
- Division of Pediatric Pulmonology, University of Massachusetts Chan Medical School, Worcester, Mass; Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Mass; Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Mass
| | - Andrea A Pappalardo
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Ill; Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Mfonobong Udoko
- Department of Pediatrics, Anschutz Medical Campus, Children's Hospital Colorado Breathing Institute, University of Colorado, Denver, Colo
| | - Arvin Garg
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Mass
| | - Wanda Phipatanakul
- Division of Asthma, Allergy, and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Stanley J Szefler
- Department of Pediatrics, Anschutz Medical Campus, Children's Hospital Colorado Breathing Institute, University of Colorado, Denver, Colo; Anschutz Medical Campus, Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Denver, Colo
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15
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Georas SN, Wright RJ, Ivanova A, Israel E, LaVange LM, Akuthota P, Carr TF, Denlinger LC, Fajt ML, Kumar R, O'Neal WK, Phipatanakul W, Szefler SJ, Aronica MA, Bacharier LB, Burbank AJ, Castro M, Crotty Alexander L, Bamdad J, Cardet JC, Comhair SAA, Covar RA, DiMango EA, Erwin K, Erzurum SC, Fahy JV, Gaffin JM, Gaston B, Gerald LB, Hoffman EA, Holguin F, Jackson DJ, James J, Jarjour NN, Kenyon NJ, Khatri S, Kirwan JP, Kraft M, Krishnan JA, Liu AH, Liu MC, Marquis MA, Martinez F, Mey J, Moore WC, Moy JN, Ortega VE, Peden DB, Pennington E, Peters MC, Ross K, Sanchez M, Smith LJ, Sorkness RL, Wechsler ME, Wenzel SE, White SR, Zein J, Zeki AA, Noel P. The Precision Interventions for Severe and/or Exacerbation-Prone (PrecISE) Asthma Network: An overview of Network organization, procedures, and interventions. J Allergy Clin Immunol 2022; 149:488-516.e9. [PMID: 34848210 PMCID: PMC8821377 DOI: 10.1016/j.jaci.2021.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/24/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022]
Abstract
Asthma is a heterogeneous disease, with multiple underlying inflammatory pathways and structural airway abnormalities that impact disease persistence and severity. Recent progress has been made in developing targeted asthma therapeutics, especially for subjects with eosinophilic asthma. However, there is an unmet need for new approaches to treat patients with severe and exacerbation-prone asthma, who contribute disproportionately to disease burden. Extensive deep phenotyping has revealed the heterogeneous nature of severe asthma and identified distinct disease subtypes. A current challenge in the field is to translate new and emerging knowledge about different pathobiologic mechanisms in asthma into patient-specific therapies, with the ultimate goal of modifying the natural history of disease. Here, we describe the Precision Interventions for Severe and/or Exacerbation-Prone Asthma (PrecISE) Network, a groundbreaking collaborative effort of asthma researchers and biostatisticians from around the United States. The PrecISE Network was designed to conduct phase II/proof-of-concept clinical trials of precision interventions in the population with severe asthma, and is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Using an innovative adaptive platform trial design, the PrecISE Network will evaluate up to 6 interventions simultaneously in biomarker-defined subgroups of subjects. We review the development and organizational structure of the PrecISE Network, and choice of interventions being studied. We hope that the PrecISE Network will enhance our understanding of asthma subtypes and accelerate the development of therapeutics for severe asthma.
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Affiliation(s)
- Steve N Georas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, Rochester, NY.
| | | | - Anastasia Ivanova
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Elliot Israel
- Department of Medicine, Divisions of Pulmonary & Critical Care Medicine & Allergy & Immunology, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass
| | - Lisa M LaVange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Praveen Akuthota
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Merritt L Fajt
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | | | - Wanda K O'Neal
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | | | - Stanley J Szefler
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Mark A Aronica
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Allison J Burbank
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Mo
| | - Laura Crotty Alexander
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Julie Bamdad
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Md
| | | | | | | | | | - Kim Erwin
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, Chicago, Ill
| | | | - John V Fahy
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | | | - Benjamin Gaston
- Wells Center for Pediatric Research, Indiana University, Indianapolis, Ind
| | - Lynn B Gerald
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | - Daniel J Jackson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - John James
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Nicholas J Kenyon
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Sumita Khatri
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - John P Kirwan
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, La
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jerry A Krishnan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Andrew H Liu
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Mark C Liu
- Pulmonary and Critical Care Medicine, Department of Medicine, the Johns Hopkins University, Baltimore, Md
| | - M Alison Marquis
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Fernando Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jacob Mey
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, La
| | - Wendy C Moore
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - James N Moy
- Rush University Medical Center, Chicago, Ill
| | - Victor E Ortega
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - David B Peden
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | | | - Michael C Peters
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Kristie Ross
- The Cleveland Clinic, Cleveland, Ohio; UH Rainbow Babies and Children's Hospitals, Cleveland, Ohio
| | - Maria Sanchez
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | | | - Ronald L Sorkness
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Michael E Wechsler
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Ill
| | - Joe Zein
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amir A Zeki
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Md
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16
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Bush A, Fitzpatrick AM, Saglani S, Anderson WC, Szefler SJ. Difficult-to-Treat Asthma Management in School-Age Children. J Allergy Clin Immunol Pract 2022; 10:359-375. [PMID: 34838706 DOI: 10.1016/j.jaip.2021.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 12/13/2022]
Abstract
The World Health Organization divides severe asthma into three categories: untreated severe asthma; difficult-to-treat severe asthma; and severe, therapy-resistant asthma. The apparent frequency of severe asthma in the general population of asthmatic children is probably around 5%. Upon referral of these children, it is important to evaluate the diagnosis of asthma carefully before modifying management and applying a long-term monitoring plan. Identification of pathophysiologic phenotypes using objective biomarkers is essential in our routine assessments of severe asthma. Although conventional pharmacologic approaches should be attempted first, there is growing recognition that children with difficult-to-treat asthma may have unique clinical phenotypes that may necessitate alternative treatment approaches including asthma biologics. These new medications, especially those with effects on multiple pathologic features of asthma, raise the hope that new treatment strategies could induce remission. Besides introducing new medications, the opportunity for closer monitoring is feasible with advances in digital health. Therefore, we have the opportunity to improve response to medications, individualize treatment, and monitor response along with potential steps to prevent severe asthma.
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Affiliation(s)
- Andy Bush
- Director, Imperial Centre for Paediatrics and Child Health, Professor of Paediatrics and Paediatric Respirology, National Heart and Lung Institute, Imperial College, Consultant Paediatric Chest Physician, Royal Brompton Hospital, London, United Kingdom
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
| | - Sejal Saglani
- National Heart & Lung Institute, Imperial College London and Department of Respiratory Paediatrics, Royal Brompton Hospital, London, United Kingdom
| | - William C Anderson
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colo; Allergy and Immunology Section, Children's Hospital Colorado, Aurora, Colo
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colo; Breathing Institute, Children's Hospital Colorado, Aurora, Colo; University of Colorado Anschutz Medical Campus, Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, Colo.
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17
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Abrams EM, Jordan K, Szefler SJ. School Asthma Care During COVID-19: What We Have Learned and What We Are Learning. The Journal of Allergy and Clinical Immunology: In Practice 2022; 10:453-459. [PMID: 34848382 PMCID: PMC8626345 DOI: 10.1016/j.jaip.2021.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/15/2021] [Accepted: 11/19/2021] [Indexed: 02/07/2023]
Abstract
The focus of this article is to review school asthma care during coronavirus disease 2019 (COVID-19). Asthma is listed as a risk factor in some guidelines, although children with asthma appear to not be at increased risk of severe respiratory outcomes compared with children without asthma during the pandemic. Differentiating COVID-19 from allergic disease is very difficult in the school-aged children. For school management, there is firm evidence that masks do not exacerbate underlying lung conditions including asthma, and evidence to date supports that children with asthma can learn in-person at school because they do not appear to be at increased risk of COVID-19 morbidity or mortality. For children and adolescents, the COVID-19 vaccine has been demonstrated to be safe and well tolerated. School asthma management includes remaining on prescribed asthma medications. Asthma management, as with management of all pediatric conditions, must also factor in the impact of adverse social determinants and health disparities. Broadly, the pandemic has also served as a call to resource stewardship and innovation and allowed practitioners to consider how this may impact asthma care moving forward.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Man, Canada.
| | - Kamyron Jordan
- Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
| | - Stanley J Szefler
- Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
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18
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Ortega VE, Daya M, Szefler SJ, Bleecker ER, Chinchilli VM, Phipatanakul W, Mauger D, Martinez FD, Herrera-Luis E, Pino-Yanes M, Hawkins GA, Ampleford EJ, Kunselman SJ, Cox C, Bacharier LB, Cabana MD, Cardet JC, Castro M, Denlinger LC, Eng C, Fitzpatrick AM, Holguin F, Hu D, Jackson DJ, Jarjour N, Kraft M, Krishnan JA, Lazarus SC, Lemanske RF, Lima JJ, Lugogo N, Mak A, Moore WC, Naureckas ET, Peters SP, Pongracic JA, Sajuthi SP, Seibold MA, Smith LJ, Solway J, Sorkness CA, Wenzel S, White SR, Burchard EG, Barnes K, Meyers DA, Israel E, Wechsler ME. Pharmacogenetic studies of long-acting beta agonist and inhaled corticosteroid responsiveness in randomised controlled trials of individuals of African descent with asthma. Lancet Child Adolesc Health 2021; 5:862-872. [PMID: 34762840 DOI: 10.1016/s2352-4642(21)00268-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pharmacogenetic studies in asthma cohorts, primarily made up of White people of European descent, have identified loci associated with response to inhaled beta agonists and corticosteroids (ICSs). Differences exist in how individuals from different ancestral backgrounds respond to long-acting beta agonist (LABA) and ICSs. Therefore, we sought to understand the pharmacogenetic mechanisms regulating therapeutic responsiveness in individuals of African descent. METHODS We did ancestry-based pharmacogenetic studies of children (aged 5-11 years) and adolescents and adults (aged 12-69 years) from the Best African Response to Drug (BARD) trials, in which participants with asthma uncontrolled with low-dose ICS (fluticasone propionate 50 μg in children, 100 μg in adolescents and adults) received different step-up combination therapies. The hierarchal composite outcome of pairwise superior responsiveness in BARD was based on asthma exacerbations, a 31-day difference in annualised asthma-control days, or a 5% difference in percentage predicted FEV1. We did whole-genome admixture mapping of 15 159 ancestral segments within 312 independent regions, stratified by the two age groups. The two co-primary outcome comparisons were the step up from low-dose ICS to the quintuple dose of ICS (5 × ICS: 250 μg twice daily in children and 500 μg twice daily in adolescents and adults) versus double dose (2-2·5 × ICS: 100 μg twice daily in children, 250 μg twice daily in adolescents and adults), and 5 × ICS versus 100 μg fluticasone plus a LABA (salmeterol 50 μg twice daily). We used a genome-wide significance threshold of p<1·6 × 10-4, and tested for replication using independent cohorts of individuals of African descent with asthma. FINDINGS We included 249 unrelated children and 267 unrelated adolescents and adults in the BARD pharmacogenetic analysis. In children, we identified a significant admixture mapping peak for superior responsiveness to 5 × ICS versus 100 μg fluticasone plus salmeterol on chromosome 12 (odds ratio [ORlocal African] 3·95, 95% CI 2·02-7·72, p=6·1 × 10-5) fine mapped to a locus adjacent to RNFT2 and NOS1 (rs73399224, ORallele dose 0·17, 95% CI 0·07-0·42, p=8·4 × 10-5). In adolescents and adults, we identified a peak for superior responsiveness to 5 × ICS versus 2·5 × ICS on chromosome 22 (ORlocal African 3·35, 1·98-5·67, p=6·8 × 10-6) containing a locus adjacent to TPST2 (rs5752429, ORallele dose 0·21, 0·09-0·52, p=5·7 × 10-4). We replicated rs5752429 and nominally replicated rs73399224 in independent African American cohorts. INTERPRETATION BARD is the first genome-wide pharmacogenetic study of LABA and ICS response in clinical trials of individuals of African descent to detect and replicate genome-wide significant loci. Admixture mapping of the composite BARD trial outcome enabled the identification of novel pharmacogenetic variation accounting for differential therapeutic responses in people of African descent with asthma. FUNDING National Institutes of Health, National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Victor E Ortega
- Department of Internal Medicine, Section for Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Michelle Daya
- Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Eugene R Bleecker
- Department of Internal Medicine, Division of Genetics, Genomics, and Precision Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Wanda Phipatanakul
- Division of Pediatric Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dave Mauger
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Esther Herrera-Luis
- Department of Biochemistry, La Laguna, Tenerife, Spain; Microbiology, Cell Biology, and Genetics, La Laguna, Tenerife, Spain; Genomics and Health Group, La Laguna, Tenerife, Spain; Universidad de La Laguna, La Laguna, Tenerife, Spain
| | - Maria Pino-Yanes
- Department of Biochemistry, La Laguna, Tenerife, Spain; Microbiology, Cell Biology, and Genetics, La Laguna, Tenerife, Spain; Genomics and Health Group, La Laguna, Tenerife, Spain; Universidad de La Laguna, La Laguna, Tenerife, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Gregory A Hawkins
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Elizabeth J Ampleford
- Department of Internal Medicine, Section for Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Susan J Kunselman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Corey Cox
- Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Michael D Cabana
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Juan Carlos Cardet
- Department of Internal Medicine, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Mario Castro
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Loren C Denlinger
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Celeste Eng
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Fernando Holguin
- Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Donglei Hu
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
| | - Nizar Jarjour
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Monica Kraft
- Department of Internal Medicine, Division of Genetics, Genomics, and Precision Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Jerry A Krishnan
- Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois, Chicago, IL, USA
| | - Stephen C Lazarus
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Robert F Lemanske
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
| | - John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
| | - Njira Lugogo
- Department of Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Angel Mak
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Wendy C Moore
- Department of Internal Medicine, Section for Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Stephen P Peters
- Department of Internal Medicine, Section for Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jacqueline A Pongracic
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Satria P Sajuthi
- Center for Genes, Environment, and Health, Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Max A Seibold
- Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, USA; Center for Genes, Environment, and Health, Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Lewis J Smith
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Julian Solway
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Christine A Sorkness
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Sally Wenzel
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven R White
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Esteban G Burchard
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kathleen Barnes
- Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Deborah A Meyers
- Department of Internal Medicine, Division of Genetics, Genomics, and Precision Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Elliot Israel
- Department of Pulmonary and Critical Care Medicine and Allergy and Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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19
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Martin J, Pijnenburg MW, Roberts G, Pike KC, Petsky H, Chang AB, Szefler SJ, Gergen P, Vermeulen F, Vael R, Turner S. Does lung function change in the months after an asthma exacerbation in children? Pediatr Allergy Immunol 2021; 32:1208-1216. [PMID: 33721352 DOI: 10.1111/pai.13503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are limited data describing lung function changes in children after an asthma exacerbation. Our hypothesis was that lung function does not fully recover in children in the months following an asthma exacerbation. METHODS We used a data set of children with asthma where lung function (including FEV1 , FEV1 /FVC ratio and FEF25-75 ) was measured at 3-month intervals over a year. Mixed-level models compared spirometry measured on two occasions 3 months apart before a single exacerbation (assessments 1 and 2) with measurements made on two occasions after the exacerbation (assessments 3 and 4), with adjustment for covariates. Changes in spirometry over a year were also analysed across those with exacerbations in no, one or more than one 3-month periods. RESULTS For the 113 children who had a single exacerbation, spirometry measured at assessments 1 or 2 did not differ from measurements at assessments 3 or 4 when the whole population was considered. When stratified into tertiles by change in %FEV1 between assessments 2 and 3, those with the greater reduction were more likely to be treated with long-acting beta-agonist, but in this category, %FEV1 at assessment 4 had returned to the value at assessment 1. %FEV1 did not change over a 12-month period within and between the three exacerbation categories (n = 809). CONCLUSION One or more asthma exacerbation was not associated with a fall in lung function for the whole population. In a subset of individuals, lung function does fall after an exacerbation but returns to pre-exacerbation values after a period of months.
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Affiliation(s)
| | - Marielle W Pijnenburg
- Department of Paediatric Respiratory Medicine and Allergology, University Medical Centre Rotterdam, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Graham Roberts
- Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Helen Petsky
- School of Nursing and Midwifery, Griffith University, Menzies Health Institute Queensland, Brisbane, Qld, Australia
| | - Anne B Chang
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Queensland University of Technology, Brisbane, Qld, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Stanley J Szefler
- Department of Pediatrics, Breathing Institute, Children's Hospital Colorado, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Peter Gergen
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Francoise Vermeulen
- Department of Paediatrics, Hôpital Erasme, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Robin Vael
- Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Steve Turner
- Child Health, University of Aberdeen, Aberdeen, UK
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20
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Szefler SJ, Jerschow E, Yoo B, Janampally P, Pazwash H, Holweg CTJ, Hudes G. Response to Omalizumab in Black and White Patients with Allergic Asthma. J Allergy Clin Immunol Pract 2021; 9:4021-4028. [PMID: 34303017 DOI: 10.1016/j.jaip.2021.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/09/2021] [Accepted: 07/07/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Higher asthma burden is more likely to be experienced by Black than White patients. In clinical research, underrepresentation of minority populations is observed. OBJECTIVE To estimate response to omalizumab in Black and White patients in North America with moderate to severe asthma. METHODS Data from placebo-controlled (EXTRA) and single-armed (PROSPERO) omalizumab studies were used for this post hoc analysis. We used a Poisson regression model to examine exacerbation rates. An analysis of covariance model was used to estimate placebo-corrected change in FEV1 and Asthma Quality of Life Questionnaire (AQLQ) by racial group. RESULTS This analysis included 631 White and 176 Black patients from EXTRA and 567 White and 130 Black patients from PROSPERO. In EXTRA, placebo-corrected exacerbation rate reductions (relative rate change [95% confidence interval], 22.6% [2.0-38.9%] vs 22.0% [-18.0% to 48.4%]) and FEV1 improvements were similar for White and Black patients. There was a trend toward greater AQLQ improvements for Black versus White patients (least squares mean treatment differences: 0.0 vs 0.3, 0.6 vs 0.4, and 0.6 vs 0.2 at weeks 16, 32, and 48, respectively) throughout the study. In PROSPERO, on-study exacerbation rates (0.76 [0.65-0.88] vs 0.77 [0.56-1.10]) and AQLQ improvements (least squares mean change from baseline: 1.2 vs 1.2 and 1.3 vs 1.2 at month 6 and end of study, respectively) were similar for White versus Black patients. A trend toward greater FEV1 improvement was observed in White versus Black patients throughout the study. CONCLUSIONS This analysis of EXTRA and PROSPERO suggests that Black and White patients with moderate to severe asthma experience similar improvements in exacerbations, FEV1, and AQLQ with omalizumab.
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Affiliation(s)
- Stanley J Szefler
- Pediatric Asthma Research Program, Breathing Institute, Children's Hospital Colorado, and University of Colorado School of Medicine, Aurora, Colo
| | - Elina Jerschow
- Department of Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, NY
| | - Bongin Yoo
- Genentech, Inc., South San Francisco, Calif
| | | | | | | | - Golda Hudes
- Department of Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, NY
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21
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Udoko M, De Keyser H, Szefler SJ. Should children with asthma simply be treated as little adults? Ann Allergy Asthma Immunol 2021; 127:520-521. [PMID: 34260900 DOI: 10.1016/j.anai.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Mfonobong Udoko
- The Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Heather De Keyser
- The Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.
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22
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Federico MJ, Denlinger LC, Corren J, Szefler SJ, Fuhlbrigge AL. Exacerbation-Prone Asthma: A Biological Phenotype or a Social Construct. J Allergy Clin Immunol Pract 2021; 9:2627-2634. [PMID: 34051392 DOI: 10.1016/j.jaip.2021.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022]
Abstract
Asthma is a complex syndrome with multiple phenotypes and endotypes. Asthma exacerbations are not only the clearest indictor of the morbidity of asthma and of the risk for mortality due to asthma, but also comprise a significant amount of the cost to care for poorly controlled asthma. There continues to be significant disparity in the prevalence, mortality, and morbidity due to asthma. Patients with asthma who suffer recurrent exacerbations are considered to have exacerbation-prone asthma (EPA). Efforts to characterize patients with frequent exacerbations show that the etiology is likely multifactorial. Research to determine the intrinsic risk factors for EPA include studies of both genetic and inflammatory biomarkers. External factors contributing to exacerbations have been extensively reviewed and include viral infection, environmental exposures, air pollution, and psychosocial and economic barriers to optimizing health. It is likely that EPA occurs when patients who have an increased underlying intrinsic/biological risk are placed in a given exposome (environments with a variety of exposures and triggers including allergens, pollution, stress, barriers, and occupational exposures). It is the social construct combined with underlying biology that frequently drives an EPA phenotype.
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Affiliation(s)
- Monica J Federico
- The Breathing Institute, Children's Hospital Colorado, and Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo.
| | - Loren C Denlinger
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Jonathan Corren
- Departments of Medicine and Pediatrics, Divisions of Allergy and Clinical Immunology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, Calif
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, and Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - Anne L Fuhlbrigge
- Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
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23
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Izadi N, Baraghoshi D, Curran-Everett D, Zeiger RS, Szefler SJ, Covar RA. Factors Associated with Persistence of Severe Asthma from Late Adolescence to Early Adulthood. Am J Respir Crit Care Med 2021; 204:776-787. [PMID: 34029510 PMCID: PMC8528529 DOI: 10.1164/rccm.202010-3763oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 05/10/2021] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Asthma severity in children generally starts mild but may progress and stay severe for unknown reasons. OBJECTIVES Identify factors in childhood that predict persistence of severe asthma in late adolescence and early adulthood. METHODS The Childhood Asthma Management Program is the largest and longest asthma trial in 1041 children aged 5-12 years with mild to moderate asthma. We evaluated 682 participants from the program with analyzable data in late adolescence (age 17-19) and early adulthood (age 21-23). MEASUREMENTS Severe asthma was defined using criteria from the American Thoracic Society and the National Asthma Education and Prevention Program to best capture severe asthma. Logistic regression with stepwise elimination was used to analyze clinical features, biomarkers, and lung function predictive of persistence of severe asthma. MAIN RESULTS In late adolescence and early adulthood 12% and 19% of the patents had severe asthma, respectively; only 6% were severe at both time periods. For every 5% decrease in post bronchodilator FEV1/FVC in childhood, the odds of persistence of severe asthma increased 2.36-fold (95% CI: 1.70-3.28; p <0.0001), for participants with maternal smoking during pregnancy odds of persistence of severe asthma increased 3.17-fold (95% CI: 1.18-8.53, p=0.02). Reduced growth lung function trajectory was significantly associated with persistence of severe asthma compared to normal growth. CONCLUSIONS Lung function and maternal smoking during pregnancy were significant predictors of severe asthma from late adolescence to early adulthood. Interventions to preserve lung function early may prevent disease progression.
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Affiliation(s)
- Neema Izadi
- Children's Hospital Los Angeles Department of Pediatrics, 337885, Division of Clinical Immunology & Allergy, Los Angeles, California, United States;
| | | | | | | | - Stanley J Szefler
- University of Colorado Denver School of Medicine, 12225, Pediatrics, Aurora, Colorado, United States
| | - Ronina A Covar
- National Jewish Health, 2930, Pediatrics, Denver, Colorado, United States
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24
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Israel E, Denlinger LC, Bacharier LB, LaVange LM, Moore WC, Peters MC, Georas SN, Wright RJ, Mauger DT, Noel P, Akuthota P, Bach J, Bleecker ER, Cardet JC, Carr TF, Castro M, Cinelli A, Comhair SAA, Covar RA, Alexander LC, DiMango EA, Erzurum SC, Fahy JV, Fajt ML, Gaston BM, Hoffman EA, Holguin F, Jackson DJ, Jain S, Jarjour NN, Ji Y, Kenyon NJ, Kosorok MR, Kraft M, Krishnan JA, Kumar R, Liu AH, Liu MC, Ly NP, Marquis MA, Martinez FD, Moy JN, O'Neal WK, Ortega VE, Peden DB, Phipatanakul W, Ross K, Smith LJ, Szefler SJ, Teague WG, Tulchinsky AF, Vijayanand P, Wechsler ME, Wenzel SE, White SR, Zeki AA, Ivanova A. PrecISE: Precision Medicine in Severe Asthma: An adaptive platform trial with biomarker ascertainment. J Allergy Clin Immunol 2021; 147:1594-1601. [PMID: 33667479 PMCID: PMC8113113 DOI: 10.1016/j.jaci.2021.01.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 12/08/2020] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023]
Abstract
Severe asthma accounts for almost half the cost associated with asthma. Severe asthma is driven by heterogeneous molecular mechanisms. Conventional clinical trial design often lacks the power and efficiency to target subgroups with specific pathobiological mechanisms. Furthermore, the validation and approval of new asthma therapies is a lengthy process. A large proportion of that time is taken by clinical trials to validate asthma interventions. The National Institutes of Health Precision Medicine in Severe and/or Exacerbation Prone Asthma (PrecISE) program was established with the goal of designing and executing a trial that uses adaptive design techniques to rapidly evaluate novel interventions in biomarker-defined subgroups of severe asthma, while seeking to refine these biomarker subgroups, and to identify early markers of response to therapy. The novel trial design is an adaptive platform trial conducted under a single master protocol that incorporates precision medicine components. Furthermore, it includes innovative applications of futility analysis, cross-over design with use of shared placebo groups, and early futility analysis to permit more rapid identification of effective interventions. The development and rationale behind the study design are described. The interventions chosen for the initial investigation and the criteria used to identify these interventions are enumerated. The biomarker-based adaptive design and analytic scheme are detailed as well as special considerations involved in the final trial design.
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Affiliation(s)
- Elliot Israel
- Department of Medicine, Divisions of Pulmonary & Critical Care Medicine & Allergy & Immunology, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Lisa M LaVange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Wendy C Moore
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael C Peters
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Steve N Georas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - David T Mauger
- Pennsylvania State University School of Medicine, Hershey, Pa
| | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Praveen Akuthota
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Julia Bach
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Eugene R Bleecker
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | | | - Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Kan
| | | | | | | | - Laura Crotty Alexander
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | | | | | - John V Fahy
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Merritt L Fajt
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Benjamin M Gaston
- Wells Center for Pediatric Research, Indiana University, Indianapolis, Ind
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | - Daniel J Jackson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Sonia Jain
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Yuan Ji
- Department of Health Studies, University of Chicago, Chicago, Ill
| | - Nicholas J Kenyon
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Michael R Kosorok
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jerry A Krishnan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | | | - Andrew H Liu
- University of Colorado School of Medicine, Aurora, Colo; Children's Hospital Colorado, Aurora, Colo
| | - Mark C Liu
- Pulmonary and Critical Care Medicine, Department of Medicine, the Johns Hopkins University, Baltimore, Md
| | - Ngoc P Ly
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - M Alison Marquis
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - James N Moy
- Rush University Medical Center, Chicago, Ill
| | - Wanda K O'Neal
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | - Victor E Ortega
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - David B Peden
- Marsico Lung Institute, UNC CF Research Center, University of North Carolina, Chapel Hill, NC
| | | | - Kristie Ross
- UH Rainbow Babies and Children's Hospitals, Cleveland, Ohio
| | | | - Stanley J Szefler
- University of Colorado School of Medicine, Aurora, Colo; Children's Hospital Colorado, Aurora, Colo
| | - W Gerald Teague
- University of Virginia School of Medicine, Charlottesville, Va
| | | | | | - Michael E Wechsler
- National Jewish Health, Denver, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Ill
| | - Amir A Zeki
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Anastasia Ivanova
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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25
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Mosnaim G, Safioti G, Brown R, DePietro M, Szefler SJ, Lang DM, Portnoy JM, Bukstein DA, Bacharier LB, Merchant RK. Digital Health Technology in Asthma: A Comprehensive Scoping Review. J Allergy Clin Immunol Pract 2021; 9:2377-2398. [PMID: 33652136 DOI: 10.1016/j.jaip.2021.02.028] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND A variety of digital intervention approaches have been investigated for asthma therapy during the past decade, with different levels of interactivity and personalization and a range of impacts on different outcome measurements. OBJECTIVE To assess the effectiveness of digital interventions in asthma with regard to acceptability and outcomes and evaluate the potential of digital initiatives for monitoring or treating patients with asthma. METHODS We evaluated digital interventions using a scoping review methodology through a literature search and review. Of 871 articles identified, 121 were evaluated to explore intervention characteristics, the perception and acceptability of digital interventions to patients and physicians, and effects on asthma outcomes. Interventions were categorized by their level of interactivity with the patient. RESULTS Interventions featuring non-individualized content sent to patients appeared capable of promoting improved adherence to inhaled corticosteroids, but with no identified improvement in asthma burden; and data-gathering interventions appeared to have little effect on adherence or asthma burden. Evidence of improvement in both adherence and patients' impairment due to asthma were seen only with interactive interventions involving two-way responsive patient communication. Digital interventions were generally positively perceived by patients and physicians. Implementation was considered feasible, with certain preferences for design and features important to drive use. CONCLUSIONS Digital health interventions show substantial promise for asthma disease monitoring and personalization of treatment. To be successful, future interventions will need to include both inhaler device and software elements, combining accurate measurement of clinical parameters with careful consideration of ease of use, personalization, and patient engagement aspects.
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Affiliation(s)
- Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, North Shore University Health System, Evanston, Ill
| | | | - Randall Brown
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pa
| | - Michael DePietro
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pa.
| | - Stanley J Szefler
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jay M Portnoy
- Pediatric Allergy and Immunology, Children's Mercy Hospital, Kansas City School of Medicine, Kansas City, Mo
| | - Don A Bukstein
- Allergy, Asthma and Sinus Center, Milwaukee, Greenfield, Wis
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tenn
| | - Rajan K Merchant
- Woodland Clinic Medical Group, Allergy Department, Dignity Health, Woodland, Calif
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26
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Sheehan WJ, Paul IM, Mauger DT, Moy JN, Szefler SJ, Jackson DJ, Fitzpatrick AM, Cabana MD, Covar R, Robison RG, Phipatanakul W. Adherence rates during a randomized controlled trial evaluating the use of blinded acetaminophen and ibuprofen in children with asthma. Contemp Clin Trials 2021; 104:106334. [PMID: 33652129 DOI: 10.1016/j.cct.2021.106334] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND/AIMS When conducting clinical trials comparing over-the-counter (OTC) medications, the wide availability of these treatments are a potential challenge to maintaining study integrity. We seek to describe adherence to a study protocol involving widely available OTC medications. METHODS To prospectively evaluate associations between acetaminophen use and asthma in 300 children aged 1-5 years, we conducted a double blind, randomized, controlled trial where parents administered blinded forms of either acetaminophen or ibuprofen as needed to their children over a 48 week period. Written and verbal instructions encouraged the exclusive use of the blinded study medication and discouraged OTC use. Adherence was determined by evaluating the frequency of use of per-protocol blinded study medication compared to off-protocol use of OTC medications. RESULTS 4195 doses of acetaminophen or ibuprofen were received by children during the study which included 3664 doses (87.3%) of blinded study medication adhering to the protocol and 531 doses (12.7%) of OTC products deviating from the protocol with better adherence among those randomized to ibuprofen as compared to acetaminophen (89.5% vs. 85.5% of doses, p < 0.01). Individually, 227 participants (75.7%) remained fully adherent by not receiving any OTC medications. Pre-study preference for either acetaminophen or ibuprofen by the participants' families was not associated with differential rates of adherence to the blinded medication. CONCLUSION This parallel study demonstrated greater than 85% of acetaminophen or ibuprofen doses were blinded study medications adhering to the protocol while less than 15% were OTC deviations from the protocol. This successfully implemented study design provides a template to comparatively evaluate these and other OTC medications.
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Affiliation(s)
- William J Sheehan
- Boston Children's Hospital, Division of Allergy and Immunology, Harvard Medical School, Boston, MA, United States of America; Children's National Hospital, Division of Allergy and Immunology, George Washington University School of Medicine and Health Sciences, Washington DC, United States of America
| | - Ian M Paul
- Penn State College of Medicine, Department of Pediatrics, Hershey, PA, United States of America
| | - David T Mauger
- Penn State College of Medicine, Department of Public Health Sciences, Hershey, PA, United States of America
| | - James N Moy
- Stroger Hospital of Cook County, Department of Pediatrics, Rush University Medical Center, Chicago, IL, United States of America
| | - Stanley J Szefler
- Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Daniel J Jackson
- University of Wisconsin School of Medicine and Public Health, Section of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Madison, WI, United States of America
| | - Anne M Fitzpatrick
- Emory University, Department of Pediatrics, Atlanta, GA, United States of America
| | - Michael D Cabana
- University of California, San Francisco, Department of Pediatrics, San Francisco, CA, United States of America
| | - Ronina Covar
- National Jewish Health, Department of Pediatrics, Denver, CO, United States of America
| | - Rachel G Robison
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Allergy and Immunology, Chicago, IL, United States of America
| | - Wanda Phipatanakul
- Boston Children's Hospital, Division of Allergy and Immunology, Harvard Medical School, Boston, MA, United States of America.
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27
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Lee LA, Pedersen S, Pascoe SJ, Szefler SJ, Lenney W. No dose effect observed with chronic fluticasone propionate on growth velocity in children. Pediatr Allergy Immunol 2021; 32:377-381. [PMID: 32966707 PMCID: PMC7894339 DOI: 10.1111/pai.13378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Laurie A Lee
- Respiratory Clinical Development, GlaxoSmithKline, Collegeville, PA, USA
| | - Søren Pedersen
- Department of Pediatrics, Center Lillebaelt, Fredericia and Kolding Hospital, Odense, Denmark
| | - Steven J Pascoe
- Respiratory Clinical Development, GlaxoSmithKline, Collegeville, PA, USA
| | - Stanley J Szefler
- Department of Pediatrics, Breathing Institute, Pediatric Pulmonary Section, Children's Hospital Colorado, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Warren Lenney
- Respiratory Child Health, Keele University, Staffordshire, UK
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Anderson WC, Gondalia R, De Keyser HE, Kaye L, Szefler SJ, Stempel DA. Digital assessment of medication utilization by age and diagnosis of asthma or COPD. J Allergy Clin Immunol Pract 2020; 9:1723-1725. [PMID: 33212238 DOI: 10.1016/j.jaip.2020.10.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/27/2020] [Accepted: 10/31/2020] [Indexed: 01/20/2023]
Affiliation(s)
- William C Anderson
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | | | - Heather E De Keyser
- Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | | | - Stanley J Szefler
- Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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Ivanova A, Israel E, LaVange LM, Peters MC, Denlinger LC, Moore WC, Bacharier LB, Marquis MA, Gotman NM, Kosorok MR, Tomlinson C, Mauger DT, Georas SN, Wright RJ, Noel P, Rosner GL, Akuthota P, Billheimer D, Bleecker ER, Cardet JC, Castro M, DiMango EA, Erzurum SC, Fahy JV, Fajt ML, Gaston BM, Holguin F, Jain S, Kenyon NJ, Krishnan JA, Kraft M, Kumar R, Liu MC, Ly NP, Moy JN, Phipatanakul W, Ross K, Smith LJ, Szefler SJ, Teague WG, Wechsler ME, Wenzel SE, White SR. The precision interventions for severe and/or exacerbation-prone asthma (PrecISE) adaptive platform trial: statistical considerations. J Biopharm Stat 2020; 30:1026-1037. [PMID: 32941098 PMCID: PMC7954787 DOI: 10.1080/10543406.2020.1821705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 12/24/2022]
Abstract
The Precision Interventions for Severe and/or Exacerbation-prone Asthma (PrecISE) study is an adaptive platform trial designed to investigate novel interventions to severe asthma. The study is conducted under a master protocol and utilizes a crossover design with each participant receiving up to five interventions and at least one placebo. Treatment assignments are based on the patients' biomarker profiles and precision health methods are incorporated into the interim and final analyses. We describe key elements of the PrecISE study including the multistage adaptive enrichment strategy, early stopping of an intervention for futility, power calculations, and the primary analysis strategy.
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Affiliation(s)
| | - Elliot Israel
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD
| | | | - Praveen Akuthota
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | - Dean Billheimer
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | | | | | | | | | | | | | - Merritt L. Fajt
- Wells Center for Pediatric Research, Indiana University, Indianapolis
| | | | | | | | | | - Jerry A. Krishnan
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | | | | | | | - Ngoc P. Ly
- Rush University Medical Center, Chicago, IL
| | - James N. Moy
- Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Wanda Phipatanakul
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Kristie Ross
- UH Rainbow Babies and Children’s Hospitals, Cleveland, OH
| | | | - Stanley J. Szefler
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | | | | | - Sally E. Wenzel
- National Jewish Health, Denver, CO, and University of Colorado School of Medicine, Aurora, CO
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30
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Menzies-Gow A, Szefler SJ, Busse WW. The Relationship of Asthma Biologics to Remission for Asthma. J Allergy Clin Immunol Pract 2020; 9:1090-1098. [PMID: 33130146 DOI: 10.1016/j.jaip.2020.10.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/20/2022]
Abstract
Asthma treatments have evolved from bronchodilators to interventions directed toward the regulation of airway inflammation. From these advances has come greater disease control and reduced morbidity. The addition of biologics directed toward specific pathways of inflammation has advanced the efficacy of asthma control. With these treatment advances, a renewed interest in achieving a remission in asthma has arisen. Although asthma remission has been considered to reflect a "cure," new evaluations of this concept have proposed criteria for remission while on treatment. These criteria reflect a high level of disease control including absence of symptoms, optimization and stabilization of lung function, and absence of the use of systemic corticosteroids and have been proposed to indicate a remission of disease activity. Given the added efficacy found with biologics in asthma treatment for patients with moderate to severe disease, the question has arisen as to whether the use of biologics meets criteria for remission and may this change a component of underlying disease and risks. Biologics are highly effective in reducing exacerbations, diminishing symptoms, and improving lung function in well-defined asthma populations. At present, however, biologics achieve some, but in most cases not all criteria for a remission on treatment. However, the concept of promoting treatment efforts to achieve disease remission in asthma is important, potentially achievable, and merits consideration for future guideline-directed care approaches.
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Affiliation(s)
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - William W Busse
- Department of Medicine, Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, Wis.
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31
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Busse WW, Szefler SJ, Haselkorn T, Iqbal A, Ortiz B, Lanier BQ, Chipps BE. Possible Protective Effect of Omalizumab on Lung Function Decline in Patients Experiencing Asthma Exacerbations. J Allergy Clin Immunol Pract 2020; 9:1201-1211. [PMID: 33223095 DOI: 10.1016/j.jaip.2020.10.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Frequent exacerbations are associated with greater FEV1 decline in patients with asthma. The effect of omalizumab versus placebo on lung function in patients experiencing asthma exacerbations has not been previously examined. OBJECTIVE To evaluate the relationship between postbaseline (treatment phase) exacerbation status and lung function decline in children, adolescents, and adults treated with omalizumab versus placebo using data from 3 pediatric and adolescent/adult studies. METHODS Changes in percent predicted FEV1 (ppFEV1) and FEV1 by treatment (omalizumab/placebo) and postbaseline exacerbation status (exacerbators/nonexacerbators) were assessed in patients aged 6 to 11 years (IA05, n = 576) and 12 to 75 years (EXTRA/INNOVATE pooled, n = 1202). Pediatric patients were examined at treatment weeks 12, 24, 28, 40, and 52, and adolescent/adult data at weeks 4, 12, 20, and 28. RESULTS Omalizumab-treated patients experienced larger increases in ppFEV1 and FEV1 compared with placebo-treated patients in the pediatric and pooled adolescent/adult populations. The response was observed in pediatric exacerbators, with significantly larger increases in ppFEV1 and FEV1 at week 12 (mean difference [95% CI], 4.11% [0.93%-7.30%], P = .011 for ppFEV1; 80 [10-140] mL, P = .017 for FEV1) and week 28 (mean difference [95% CI], 3.65% [0.11%-7.19%], P = .043 for ppFEV1; 100 [30-170] mL, P = .007 for FEV1). In the adolescent/adult population, both exacerbators and nonexacerbators derived similar benefit with omalizumab compared with placebo. CONCLUSIONS Findings from this post hoc analysis suggest that omalizumab may confer some protection against lung function decline among patients who experienced exacerbations during treatment.
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Affiliation(s)
- William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Stanley J Szefler
- Children's Hospital Colorado, and University of Colorado School of Medicine, Aurora, Colo
| | | | | | | | - Bobby Q Lanier
- University of North Texas Health Science Center, Fort Worth, Texas
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32
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Navanandan N, Szefler SJ. Personalized asthma management in pediatric patients based on treatment response. Expert Review of Precision Medicine and Drug Development 2020. [DOI: 10.1080/23808993.2020.1834843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Nidhya Navanandan
- Pediatric Emergency Medicine, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stanley J. Szefler
- Pediatric Pulmonary and Sleep Medicine, Children’s Hospital Colorado, Breathing Institute, University of Colorado School of Medicine, Aurora, CO, USA
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33
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Abrams EM, Szefler SJ. Managing Asthma during Coronavirus Disease-2019: An Example for Other Chronic Conditions in Children and Adolescents. J Pediatr 2020; 222:221-226. [PMID: 32330469 PMCID: PMC7172836 DOI: 10.1016/j.jpeds.2020.04.049] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/17/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Winnipeg, Canada.
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, Aurora, CO; Section of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
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34
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Abrams EM, Szefler SJ. COVID-19 and the impact of social determinants of health. Lancet Respir Med 2020. [PMID: 32437646 DOI: 10.1016/s22132600(20)30234-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Elissa M Abrams
- Department of Paediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB R2A 5L9 Canada; Department of Paediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada.
| | - Stanley J Szefler
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
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35
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Cicutto L, Gleason M, Haas-Howard C, White M, Hollenbach JP, Williams S, McGinn M, Villarreal M, Mitchell H, Cloutier MM, Vinick C, Langton C, Shocks DJ, Stempel DA, Szefler SJ. Building Bridges for Asthma Care Program: A School-Centered Program Connecting Schools, Families, and Community Health-Care Providers. J Sch Nurs 2020; 36:168-180. [PMID: 30336726 PMCID: PMC7222283 DOI: 10.1177/1059840518805824] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Asthma imposes tremendous burden on children, families, and society. Successful management requires coordinated care among children, families, health providers, and schools. Building Bridges for Asthma Care Program, a school-centered program to coordinate care for successful asthma management, was developed, implemented, and evaluated. The program consists of five steps: (1) identify students with asthma; (2) assess asthma risk/control; (3) engage the family and student at risk; (4) provide case management and care coordination, including engagement of health-care providers; and (5) prepare for next school year. Implementation occurred in 28 schools from two large urban school districts in Colorado and Connecticut. Significant improvements were noted in the proportions of students with completed School Asthma Care Plans, a quick-relief inhaler at school, Home Asthma Action/Treatment Plans and inhaler technique (p < .01 for all variables). Building Bridges for Asthma Care was successfully implemented extending asthma care to at-risk children with asthma through engagement of schools, health providers, and families.
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Affiliation(s)
- Lisa Cicutto
- Community Outreach and Research, National Jewish Health, Denver, CO, USA
- Clinical Science Program, College of Nursing, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Melanie Gleason
- Building Bridges Asthma Program, Children's Hospital of Colorado, Aurora, CO, USA
- Department of Pediatrics, Section of Pediatric Pulmonary Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Christy Haas-Howard
- Nursing and Student Health Services, Denver Public Schools, Denver, CO, USA
- Asthma Grant Program, Colorado Department of Education, Denver, CO, USA
| | - Marty White
- Children's Hospital Colorado/Denver Public Schools, Denver, CO, USA
| | - Jessica P. Hollenbach
- Department of Pediatrics, School of Medicine, University of Connecticut, Hartford, CT, USA
- Asthma Center, Connecticut Children's Medical Center, Hartford, CT, USA
| | | | | | | | | | - Michelle M. Cloutier
- Asthma Center, Connecticut Children's Medical Center, Hartford, CT, USA
- Department of Pediatrics, UConn Health, Farmington, CT, USA
| | - Carol Vinick
- Asthma Center, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Christine Langton
- Asthma Center, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Donna J. Shocks
- Nursing and Student Health Services, Denver Public Schools, Denver, CO, USA
| | - David A. Stempel
- Propeller Health, San Francisco, CA, USA
- GlaxoSmithKline, Sacramento, CA, USA
| | - Stanley J. Szefler
- Pediatric Asthma Research Program, Breathing Institute, Section of Pediatric Pulmonary Medicine, Aurora, CO, USA
- Denver School of Medicine, University of Colorado, Aurora, CO, USA
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36
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Fielding SS, Pijnenburg M, de Jongste J, Pike K, Roberts G, Petsky H, Chang AB, Fritsch M, Frischer T, Szefler SJ, Gergen P, Vermeulen F, Vael R, Turner SS. Does treatment guided by exhaled nitric oxide fraction improve outcomes in subgroups of children with asthma? Eur Respir J 2020; 55:13993003.01879-2019. [PMID: 32165403 DOI: 10.1183/13993003.01879-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/17/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Exhaled nitric oxide fraction (F ENO), a biomarker of eosinophilic airway inflammation, may be useful to guide asthma treatment. F ENO-guided treatment may be more effective in certain subgroups for improving asthma outcomes compared to standard treatment. METHODS An individual patient data analysis was performed using data from seven randomised clinical trials (RCTs) which used F ENO to guide asthma treatment. The incidence of an asthma exacerbation and loss of control, and the time to first exacerbation and loss of control were described between five subgroups of RCT participants. RESULTS Data were available in 1112 RCT participants. Among those not treated with leukotriene receptor antagonists (LTRA), but not among those who were treated with LTRA, F ENO-guided treatment was associated with reduced exacerbation risk (OR 0.68, 95% CI 0.49-0.94), longer time to first exacerbation (hazard ratio (HR) 0.76, 95% CI 0.57-0.99) and borderline reduced risk for loss of control (OR 0.70, 95% CI 0.49-1.00). Nonobese children, compared to obese children, were less likely to lose asthma control when treatment was guided by F ENO (OR 0.69, 95% CI 0.48-0.99) and time to loss of control was longer (HR 0.77, 95% CI 0.61-0.99). CONCLUSIONS Asthma treatment guided by F ENO may be more effective in achieving better asthma outcomes for patients who are not treated with LTRA and who are not obese, compared to standard practice.
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Affiliation(s)
- Shona S Fielding
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Marielle Pijnenburg
- Dept of Paediatric Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johan de Jongste
- Dept of Paediatric Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Katherine Pike
- Clinical and Experimental Science Academic Unit, University of Southampton, Southampton, UK.,Respiratory Critical Care and Anaesthesia Group, Institute of Child Health, University College London, London, UK
| | - Graham Roberts
- Clinical and Experimental Science Academic Unit, University of Southampton, Southampton, UK
| | - Helen Petsky
- School of Nursing and Midwifery, Griffith University, Menzies Health Institute Queensland, Brisbane, Australia
| | - Anne B Chang
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Queensland University of Technology, Brisbane, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | | | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado, Dept of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter Gergen
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Francoise Vermeulen
- Pediatric Dept, Hôpital Erasme, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Robin Vael
- Dept of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
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Szefler SJ, Goldstein S, Vogelberg C, Bensch GW, Given J, Jugovic B, Engel M, Moroni-Zentgraf PM, Sigmund R, Hamelmann EH. Forced Expiratory Flow (FEF 25-75%) as a Clinical Endpoint in Children and Adolescents with Symptomatic Asthma Receiving Tiotropium: A Post Hoc Analysis. Pulm Ther 2020; 6:151-158. [PMID: 32399899 PMCID: PMC7672130 DOI: 10.1007/s41030-020-00117-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction In pediatric patients with asthma, measurements of forced expiratory volume in 1 s (FEV1) may be normal or may not correlate with symptom severity. Forced expiratory flow at 25–75% of the vital capacity (FEF25–75%) is a potentially more sensitive parameter for assessing peripheral airway function. This post hoc analysis compared FEF25–75% with FEV1 as an endpoint to assess bronchodilator responsiveness in children with asthma. Methods Change from baseline in trough FEF25–75% and trough FEV1 following treatment with either tiotropium (5 µg or 2.5 µg) or placebo Respimat® was analyzed in four phase III trials in children (aged 6–11 years) and adolescents (aged 12–17 years) with symptomatic moderate (VivaTinA-asthma® and PensieTinA-asthma®) and mild (CanoTinA-asthma® and RubaTinA-asthma®) asthma. Data from all treatment arms were pooled and correlations between FEF25–75% and FEV1 were calculated and analyzed. Results A total of 1590 patients were included in the analysis. Tiotropium Respimat® consistently improved FEF25–75% and FEV1 versus placebo, although in adolescents with severe asthma, the observed improvements were not statistically significant. Improvements in FEF25–75% response with tiotropium versus placebo were largely more pronounced than improvements in FEV1. Statistical assessment of the correlation of FEV1 and FEF25–75% showed moderate-to-high correlations (Pearson’s correlation coefficients 0.73–0.80). Conclusions In pediatric patients, FEF25–75% may be a more sensitive measure to detect treatment response, certainly to tiotropium, than FEV1 and should be evaluated as an additional lung function measurement. Electronic Supplementary Material The online version of this article (10.1007/s41030-020-00117-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stanley J Szefler
- Department of Pediatrics, The Breathing Institute, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | | | - Christian Vogelberg
- University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - George W Bensch
- Allergy, Immunology and Asthma Medical Group, Inc., Stockton, CA, USA
| | - John Given
- Allergy and Respiratory Center, Canton, OH, USA
| | - Branko Jugovic
- TA Respiratory Diseases/Biosimilars Medicine, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Michael Engel
- TA Respiratory Diseases/Biosimilars Medicine, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Ralf Sigmund
- Global Biometrics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG., Biberach an der Riss, Germany
| | - Eckard H Hamelmann
- Klinik für Kinder- Und Jugendmedizin, Kinderzentrum Bethel, Evangelisches Klinikum Bethel EvKB, Bielefeld, Germany
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38
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Mosnaim G, Stempel H, Szefler SJ, Stempel DA. Asthma Control-Time to Rethink Definitions and Criteria. J Allergy Clin Immunol Pract 2020; 7:1522-1523. [PMID: 31076062 DOI: 10.1016/j.jaip.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Giselle Mosnaim
- Research Institute, NorthShore University HealthSystem, Evanston, Ill
| | - Hilary Stempel
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Stanley J Szefler
- Department of Pediatrics, Section of Allergy and Immunology and Pulmonary and Sleep Medicine, University of Colorado School of Medicine and the Breathing Institute, Children's Hospital Colorado, Aurora, Colo
| | - David A Stempel
- Department of Medical and Clinical Affairs, Propeller Health, San Francisco, Calif.
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Szefler SJ, Fitzgerald DA, Adachi Y, Doull IJ, Fischer GB, Fletcher M, Hong J, García-Marcos L, Pedersen S, Østrem A, Sly PD, Williams S, Winders T, Zar HJ, Bush A, Lenney W. A worldwide charter for all children with asthma. Pediatr Pulmonol 2020; 55:1282-1292. [PMID: 32142219 PMCID: PMC7187318 DOI: 10.1002/ppul.24713] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/14/2020] [Indexed: 12/21/2022]
Abstract
Childhood asthma is a huge global health burden. The spectrum of disease, diagnosis, and management vary depending on where children live in the world and how their community can care for them. Global improvement in diagnosis and management has been unsatisfactory, despite ever more evidence-based guidelines. Guidelines alone are insufficient and need supplementing by government support, changes in policy, access to diagnosis and effective therapy for all children, with research to improve implementation. We propose a worldwide charter for all children with asthma, a roadmap to better education and training which can be adapted for local use. It includes access to effective basic asthma medications. It is not about new expensive medications and biologics as much can be achieved without these. If implemented carefully, the overall cost of care is likely to fall and the global future health and life chance of children with asthma will greatly improve. The key to success will be community involvement together with the local and national development of asthma champions. We call on governments, institutions, and healthcare services to support its implementation.
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Affiliation(s)
- Stanley J Szefler
- Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, Pediatric Asthma Research Program, Anschutz Medical Campus, Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Dominic A Fitzgerald
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Yuichi Adachi
- Department of Pediatrics, University of Toyama, Toyama, Japan
| | - Iolo J Doull
- Department of Paediatric Respiratory Medicine, Children's Hospital for Wales, Cardiff, UK
| | - Gilberto B Fischer
- Department of Paediatrics, Universidade Federal de Ciencias da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Monica Fletcher
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, UK
| | - Jianguo Hong
- Department of Paediatrics, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Luis García-Marcos
- Department of Paediatrics, "Virgen de la Arrixaca" University Children's Hospital, University of Murcia, Murcia, Spain
| | - Søren Pedersen
- Paediatric Research Unit, Kolding Hospital, University of Southern Denmark, Kolding, Denmark
| | | | - Peter D Sly
- Children's Health and Environment Program and World Health Organisation Collaborating Centre for Children's Health and Environment, Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - Siân Williams
- International Primary Care Respiratory Group, London, UK
| | - Tonya Winders
- Allergy & Asthma Network, Vienna, Virginia.,Global Allergy & Asthma Patient Platform, Vienna, Virginia
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Andy Bush
- Department of Paediatrics, National Heart and Lung Institute and Royal Brompton & Harefield NHS Foundation Trust, Imperial College, London, UK
| | - Warren Lenney
- Department of Child Health, Institute of Applied Clinical Science, Keele University, Keele, UK
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Szefler SJ, Casale TB, Haselkorn T, Yoo B, Ortiz B, Kattan M, Busse WW. Treatment Benefit with Omalizumab in Children by Indicators of Asthma Severity. J Allergy Clin Immunol Pract 2020; 8:2673-2680.e3. [PMID: 32298853 DOI: 10.1016/j.jaip.2020.03.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Greater severity in childhood asthma negatively impacts functioning and quality of life. Omalizumab is effective in children aged 6 years or older with moderate to severe persistent asthma, but predicting responsiveness in severe disease requires further study. OBJECTIVE To assess response to omalizumab treatment among children using indicators of asthma severity. METHODS Post hoc analyses of randomized placebo-controlled studies of omalizumab (Inner-City Anti-IgE Therapy for Asthma [ICATA], IA05, and Preventative Omalizumab or Step-up Therapy for Fall Exacerbations [PROSE]) stratified by body mass index, eosinophil count, fractional exhaled nitric oxide levels, and baseline severity indicators (baseline percent predicted FEV1, previous hospitalizations, asthma exacerbations). Poisson regression analysis examined exacerbation rate reductions for body mass index, biomarkers, and severity indicators. RESULTS Children aged 6 to 11 years in IA05 (N = 576; 56% white, 17% black, 26% other/missing), ICATA (N = 237; 55% black, 43% Hispanic), and PROSE (N = 342; 59% black, 35% Hispanic) were included. Trends indicative of greater exacerbation rate change ([omalizumab - placebo]/placebo) were observed for low baseline lung function (IA05 percent predicted FEV1: <90%, 36% reduction, 95% CI, -53.3 to -13.5; ≥90%, 22% reduction, 95% CI, -52.1 to 27.5), previous hospitalizations (ICATA: 46% reduction with, 95% CI, -69.7 to -3.9; 24% reduction without, 95% CI, -48.1 to 10.3), frequent baseline exacerbations (IA05: ≥3, 42% reduction, 95% CI, -60.4 to -14.1; <3, 20% reduction, 95% CI, -45.2 to -15.9), and high baseline eosinophil count (IA05: ≥300 cells/μL, 39% reduction, 95% CI, -56.4 to -14.7; <300 cells/μL, 5% reduction, 95% CI, -40.6 to 52.1). CONCLUSIONS Omalizumab reduces exacerbations in children with moderate to severe persistent allergic asthma, and may provide greater benefit in children with more severe asthma subtypes.
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Affiliation(s)
- Stanley J Szefler
- Pediatric Asthma Research Program, Breathing Institute, Children's Hospital Colorado, and University of Colorado School of Medicine, Aurora, Colo.
| | | | | | - Bongin Yoo
- Genentech, Inc, South San Francisco, Calif
| | | | - Meyer Kattan
- Columbia University College of Physicians and Surgeons, New York, NY
| | - William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
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41
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Federico MJ, McFarlane AE, Szefler SJ, Abrams EM. The Impact of Social Determinants of Health on Children with Asthma. J Allergy Clin Immunol Pract 2020; 8:1808-1814. [PMID: 32294541 DOI: 10.1016/j.jaip.2020.03.028] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/12/2020] [Accepted: 03/25/2020] [Indexed: 12/20/2022]
Abstract
SzAsthma is the most common chronic disease of childhood. Disparities in asthma outcomes have led to international attention on the biologic, social, economic, and other factors that impact the health of children with asthma. Studies indicate that social determinants of health such as housing, neighborhood safety, and access to care significantly impact the health of children with asthma. However, screening for socioeconomic and environmental factors that impact asthma can be difficult to integrate into clinical practice. In addition, it is not yet clear which interventions to address these factors are most effective. This article will review recent studies of determinants and social determinants of health and propose a framework for identifying and addressing them in the care of children with asthma in a clinical setting.
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Affiliation(s)
- Monica J Federico
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - Arthur E McFarlane
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - Stanley J Szefler
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada.
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42
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Hamelmann E, von Mutius E, Bush A, Szefler SJ. Addressing the risk domain in the long-term management of pediatric asthma. Pediatr Allergy Immunol 2020; 31:233-242. [PMID: 31732983 PMCID: PMC7217022 DOI: 10.1111/pai.13175] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 01/15/2023]
Abstract
There is growing concern regarding the long-term outcomes of early and poorly controlled childhood asthma, either of which can potentially lead to the development of severe asthma in adults and irrecoverable loss of lung function leading to chronic obstructive pulmonary disease. These outcomes of inadequately controlled asthma should prompt a change in practice to better and/or earlier identify children at risk of adverse respiratory outcomes of asthma, to monitor disease progression, and to design intervention strategies that could either prevent or reverse asthma progression in children. The careful follow-up of spirometry over time-in the form of lung function trajectories, the application of biomarkers to assist in the diagnosis of early asthma and medication selection for these patients, as well as methods to identify patients at risk of asthma attacks-can be used to develop individualized management strategies for children with asthma. It is now time for asthma specialists to communicate this information to patients, parents, and primary care physicians and to incorporate them into routine clinical assessments of children with asthma. In time, these concepts of risk management and prevention can be refined to provide a more comprehensive approach to asthma care so as to prevent adverse respiratory outcomes from poorly controlled childhood asthma.
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Affiliation(s)
- Eckard Hamelmann
- Department of Pediatrics, Children's Center Bethel, Evangelical Hospital Bethel, Bielefeld, Germany.,Allergy Center, Ruhr-University, Bochum, Germany
| | - Erika von Mutius
- Institute for Asthma and Allergy Prevention (IAP) at Helmholtz Zentrum München GmbH, Neuherberg, Germany.,Dr von Hauner Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Stanley J Szefler
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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43
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Haselkorn T, Szefler SJ, Chipps BE, Bleecker ER, Harkins MS, Paknis B, Kianifard F, Ortiz B, Zeiger RS. Disease Burden and Long-Term Risk of Persistent Very Poorly Controlled Asthma: TENOR II. J Allergy Clin Immunol Pract 2020; 8:2243-2253. [PMID: 32173511 DOI: 10.1016/j.jaip.2020.02.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 01/30/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe/difficult-to-treat disease occurs in 5% to 10% of patients with asthma, but accounts for more than 50% of related economic costs. Understanding factors associated with persistent very poorly controlled (VPC) asthma may improve outcomes. OBJECTIVE To characterize persistent VPC asthma after more than 10 years of standard of care. METHODS The Epidemiology and Natural history of asthma: Outcomes and treatment Regimens (TENOR) II (N = 341) was a multicenter, observational study of patients with severe/difficult-to-treat asthma with a single, cross-sectional visit more than 10 years after TENOR I. Persistent VPC asthma was defined as VPC asthma at TENOR I and TENOR II enrollment; without VPC asthma was defined as well- or not well-controlled asthma at either or both visits. Multivariable logistic regression assessed long-term predictors of persistent VPC asthma using TENOR I baseline variables. RESULTS Of 327 patients, nearly half (48.0%, n = 157) had persistent VPC asthma. Comorbidities and asthma triggers were more frequent in patients with persistent VPC asthma than in patients without VPC asthma. Total geometric mean IgE was higher in patients with persistent VPC asthma (89.3 IU/mL vs 55.7 IU/mL); there was no difference in eosinophil levels. Lung function was lower in patients with persistent VPC asthma (mean % predicted pre- and postbronchodilator FEV1, 63.0% vs 82.8% and 69.6% vs 87.2%, respectively). Exacerbations in the previous year were more likely in patients with persistent VPC asthma (29.7% vs 9.0%, respectively). Predictors of persistent VPC asthma were black versus white race/ethnicity, allergic trigger count (4 vs 0), systemic corticosteroid use, and postbronchodilator FEV1 (per 10% decrease). CONCLUSIONS The burden of persistent VPC asthma is high in severe/difficult-to-treat disease; management of modifiable risk factors, maximization of lung function, and trigger avoidance may improve outcomes.
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Affiliation(s)
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colo
| | - Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Eugene R Bleecker
- Department of Medicine, Division of Pharmacogenomics, Center for Applied Genetics and Genomics Medicine, University of Arizona Health Sciences, Tucson, Ariz
| | - Michelle S Harkins
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico, Albuquerque, NM
| | | | | | | | - Robert S Zeiger
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif
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Fitzpatrick AM, Bacharier LB, Jackson DJ, Szefler SJ, Beigelman A, Cabana M, Covar R, Guilbert T, Holguin F, Lemanske RF, Martinez FD, Morgan W, Phipatanakul W, Pongracic JA, Raissy HH, Zeiger RS, Mauger DT. Heterogeneity of Mild to Moderate Persistent Asthma in Children: Confirmation by Latent Class Analysis and Association with 1-Year Outcomes. J Allergy Clin Immunol Pract 2020; 8:2617-2627.e4. [PMID: 32156610 DOI: 10.1016/j.jaip.2020.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Compared with adults, phenotypic characterization of children with asthma is still limited and it remains difficult to predict which children with asthma are at highest risk for poor outcomes. OBJECTIVE To identify latent classes in a large population of treatment-adherent children with mild to moderate asthma enrolled in clinical trials and determine whether latent class assignment predicts future lung function abnormalities and exacerbation rate. METHODS Latent class analysis was performed on 2593 children with mild to moderate asthma aged 5 18 years, with 19 variables encompassing demographic characteristics, medical history, symptoms, lung function, allergic sensitization, and type 2 inflammation. Outcomes included lung function and the annualized exacerbation rate at 12 months of follow-up. RESULTS Five latent classes were identified with differing demographic features, asthma control, sensitization, type 2 inflammatory markers, and lung function. Exacerbation rates were 1.30 ± 0.12 for class 1 (multiple sensitization with partially reversible airflow limitation), 0.90 ± 0.05 for class 2 (multiple sensitization with reversible airflow limitation), 0.87 ± 0.08 for class 3 (lesser sensitization with reversible airflow limitation), 0.87 ± 0.05 for class 4 (multiple sensitization with normal lung function), and 0.71 ± 0.06 for class 5 (lesser sensitization with normal lung function). Lung function abnormalities persisted in class 1 at 12 months. CONCLUSIONS Children with mild to moderate asthma are a heterogeneous group. Allergic sensitization and lung function may be particularly useful in identifying children at the greatest risk for future exacerbation. Additional studies are needed to determine whether latent classes correspond to meaningful phenotypes for the purpose of personalized treatment.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Daniel J Jackson
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stanley J Szefler
- Children's Hospital Colorado and Department of Pediatrics, University of Colorado, Aurora, Colo
| | - Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Michael Cabana
- Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York, NY
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Theresa Guilbert
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | | | - Robert F Lemanske
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Wayne Morgan
- Department of Pediatrics, The University of Arizona, Tucson, Ariz
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital and Harvard Medical School Department of Pediatrics, Boston, Mass
| | | | | | - Robert S Zeiger
- Kaiser Permanente, Southern California Region and Department of Pediatrics, University of California San Diego, San Diego, Calif
| | - David T Mauger
- Department of Public Health Sciences, Penn State University, Hershey, Pa
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45
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Hoch H, Kattan M, Szefler SJ. Challenges in managing difficult-to-treat asthma in children: Stop, look, and listen. Pediatr Pulmonol 2020; 55:791-794. [PMID: 31710161 DOI: 10.1002/ppul.24554] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/15/2019] [Indexed: 02/06/2023]
Abstract
It is recognized that asthma places a significant economic burden on the United States, with a total cost of $81.9 billion total costs including costs incurred by absenteeism and mortality. Severe asthma places a large burden of morbidity on children and their caregivers, including severe exacerbations, medication side effects, increased missed school days leading to impaired school performance, and lower caregiver quality of life. Therefore, we need to take a careful look at how we can make asthma care more efficient and cost effective, especially for those children with severe asthma. The 2019 American Thoracic Society symposium reported in this theme issue presented four aspects of managing severe asthma in children that merit attention including patient variables that affect severe asthma, understanding patient behaviors around medications, the appropriate use of bronchoscopy in diagnosis and management of severe asthma, and also the rational use of biologic therapy. This editorial will summarize key points in each of these reviews and prompt a more careful reading of each contribution.
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Affiliation(s)
- Heather Hoch
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Meyer Kattan
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Stanley J Szefler
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado
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46
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Szefler SJ. Legends of allergy and immunology: Donald Y. M. Leung. Allergy 2020; 75:724-726. [PMID: 31465550 DOI: 10.1111/all.14031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 08/02/2019] [Accepted: 08/04/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
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47
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Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan B Becker
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stanley J Szefler
- The Breathing Institute, Pulmonary Medicine Section, Children's Hospital Colorado, Aurora.,University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
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48
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Ross KR, Szefler SJ. Introducing telehealth and adherence monitoring to school-centered asthma management. Pediatr Pulmonol 2020; 55:565-567. [PMID: 31977164 DOI: 10.1002/ppul.24663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Kristie R Ross
- UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stanley J Szefler
- The Breathing Institute and Section for Pediatric Pulmonary and Sleep Medicine, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, Colorado
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49
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Menzies-Gow A, Bafadhel M, Busse WW, Casale TB, Kocks JWH, Pavord ID, Szefler SJ, Woodruff PG, de Giorgio-Miller A, Trudo F, Fageras M, Ambrose CS. An expert consensus framework for asthma remission as a treatment goal. J Allergy Clin Immunol 2019; 145:757-765. [PMID: 31866436 DOI: 10.1016/j.jaci.2019.12.006] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/23/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Abstract
With novel therapies in development, there is an opportunity to consider asthma remission as a treatment goal. In this Rostrum, we present a generalized framework for clinical and complete remission in asthma, on and off treatment, developed on the basis of medical literature and expert consensus. A modified Delphi survey approach was used to ascertain expert consensus on core components of asthma remission as a treatment target. Phase 1 identified other chronic inflammatory diseases with remission definitions. Phase 2 evaluated components of those definitions as well as published definitions of spontaneous asthma remission. Phase 3 evaluated a remission framework created using consensus findings. Clinical remission comprised 12 or more months with (1) absence of significant symptoms by validated instrument, (2) lung function optimization/stabilization, (3) patient/provider agreement regarding remission, and (4) no use of systemic corticosteroids. Complete remission was defined as clinical remission plus objective resolution of asthma-related inflammation and, if appropriate, negative bronchial hyperresponsiveness. Remission off treatment required no asthma treatment for 12 or more months. The proposed framework is a first step toward developing asthma remission as a treatment target and should be refined through future research, patient input, and clinical study.
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Affiliation(s)
| | - Mona Bafadhel
- Respiratory Medicine Unit and Oxford Biomedical Research Centre, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - William W Busse
- Department of Medicine, Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, Wis
| | - Thomas B Casale
- Department of Internal Medicine, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, The Netherlands; Observational and Pragmatic Research Institute, Singapore; Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, The Netherlands
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Biomedical Research Centre, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Prescott G Woodruff
- UCSF, Division of Pulmonary and Critical Care Medicine, Department of Medicine and CVRI, San Francisco, Calif
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50
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Federico MJ, Szefler SJ. High-risk asthma: Never give up. Ann Allergy Asthma Immunol 2019; 122:441-442. [PMID: 31054649 DOI: 10.1016/j.anai.2019.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/14/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Monica J Federico
- Breathing Institute, Children's Hospital Colorado, Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado, Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado.
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