Persistent Airflow Obstruction: A Marker of a Severe Asthma Cohort – Inflammatory, Functional and Pathological Features

In our previous severe asthma cohort, 82% had fixed obstruction. Although they had greater airway smooth muscle area with decreased periostin, inflammation and remodeling weren’t associated with symptom control. High-resolution computed tomography (HRCT) and measures of small airways could be important tools for exploring asthma severity. Our aim was to describe characteristics associated to airflow obstruction in our non-controlled severe asthmatics according to obstruction profile. Persistent obstruction subgroups were also evaluated comparing disease severity. Methods: Patients were evaluated using asthma control questionnaire, induced sputum, spirometry, plethysmography, and Single Breath N2 washout test, at baseline, after oral corticosteroid (OC) and at the end of the treatment. They also underwent thorax HRCT and bronchoscopy with endobronchial biopsy.Results: Sixty-two were included and 77.4% classified as having persistent obstruction; 75% and 25% with moderate and severe obstruction, respectively. Pulmonary function values (FEV1) improved in both subgroups, except in severe. Patients with bronchial thickening, according to RB1 WA% and pi10, had significantly higher airway smooth muscle area.Conclusion: Patients with severe obstruction had greater lung function impairment, no response to OC or bronchodilator. This could be explained by airway remodeling characterized by higher airway smooth muscle area and bronchial thickness assessed by thorax HRCT.

Global airways – a novel Standard Tests for Asthma, allergic Rhinitis, and chronic Rhinosinusitis (STARR-15)

Background: Global airway disease, with symptoms from both upper and lower airways, is a challenging problem for clinicians. Our goal is to design one single standard test for the awareness of global airway diseases to be used in clinical setting. Material and Methods: During 2019, rhinologists and pulmonologists generated a pool of items based on literature, patient-reported outcome measures and clinical experience. The items were administered to 206 patients with known asthma, CRS, allergic rhinitis, or a combination thereof. The patients also completed the Asthma Control Questionnaire (ACQ-5) and the Sino-Nasal Outcome Test (SNOT-22). Using a mix of clinical knowledge and data-driven methods a global airways questionnaire was developed. Results: Mean ACQ score was highest in patients with all three, whereas the highest SNOT-22 score was observed in patients with CRS and asthma. After the development process, analysis of responses from 206 patients to 44 items on a new global airway’s questionnaire led to identification of 15 items that form the STARR-15 questionnaire with three underlying domains (an allergic rhinitis sub-factor, a CRS sub-factor and an asthma sub-factor). Conclusion: STARR-15 represents the first global airways questionnaire, to be used when examining patients with upper and lower airways symptoms. Future analyses are warranted to evaluate the clinical and psychometric properties of STARR-15.

Quality of life and asthma control in pregnant women with asthma

Background Asthma is the most commonly occurring respiratory illness during pregnancy. Associations with complications of pregnancy and adverse perinatal outcome have been established. However, little is known about quality of life (QoL) in pregnant women with asthma and how it relates to asthma control particularly for Iran. Objective To determine the relationship between asthma related QoL and asthma control and severity. Methods We conducted a prospective study in pregnant women with asthma. We used the Asthma Control Questionnaire and the Asthma Quality of Life Questionnaire (AQLQ) and the guidelines of the Global Initiative for Asthma for assessment of asthma severity. Results Among 1603 pregnant women, 34 were diagnosed with asthma. Of these 13 had intermittent, 10 mild, 8 moderate and 3 severe persistent asthma. There was a significant decrease of QoL with poorer asthma control (p = 0.014). This decline could be due to limitations of activity in those with poorer asthma control, which is underlined by the significant decline of QoL with increasing asthma severity (p = 0.024). Conclusion Although the majority of pregnant women with asthma had a favorable score in AQLQ, reduced QoL was related to increased asthma severity and poor asthma control. This underlines the importance of controlling asthma during pregnancy not only for the prevention of adverse pregnancy outcomes but also for the preservation of QoL.

The effectiveness of benralizumab in the treatment of the eosinophilic phenotype of severe asthma in real clinical practice

To evaluate the effectiveness of benralizumab in patients with the eosinophilic phenotype of severe asthma in real clinical practice after a year of therapy.Methods. During Benralizumab therapy, 13 patients with severe eosinophilic asthma (average age – 55.44 ± 7.18 years old) were examined twice: before the treatment and after 1 year of benralizumab therapy. The assessment included collection of complaints, medical history, current therapy, Asthma Control Questionnaire (ACQ-5) test, absolute blood count of eosinophils, spirometry.Results. All patients initially had pronounced eosinophilia of 577.5 ± 356.4 cells/μl. After 1 year of using benralizumab, the eosinophil count decreased by 96.15%. During therapy, the ACQ-5 index decreased from 1.63 ± 0.62 to 0.73 ± 0.41 in the study patients, which corresponded to the achievement of asthma control. The forced expiratory volume in 1 second (FEV1) increased by 23 %. The number of exacerbations decreased by 58.09%. 12 (92.31%) patients were on oral corticosteroids (OCS) (10 ± 2.17 mg of prednisolone daily) before benralizumab therapy. All subjects noted a decrease in night and day symptoms over time and were able to reduce the use of OCS. 5 (38.46%) patients achieved complete elimination of daily OCS use, 7 (53.84%) patients were able to reduce their daily OCS dose.Conclusion. Benralizumab therapy as an add-on maintenance treatment in patients with eosinophilic phenotype of severe asthma contributes to a significant decrease in peripheral blood eosinophils, which mediates an improvement in asthma control, an increase in FEV1, a reduction in the number of exacerbations, and a decrease in the need for the OCS usage. Careful monitoring of long-term adverse events is necessary during treatment with benralizumab.

Real world effectiveness of benralizumab on respiratory function and asthma control

Background: Biological drugs have been recognized as a breakthrough in the treatment of severe refractory asthma. This retrospective real-life observational study aims to evaluate the effect of add-on benralizumab on lung function, exacerbation rate, oral corticosteroids (OCS) reduction and asthma control questionnaire (ACQ) score after 52 weeks.Methods: In this observational study, a cohort of 18 patients with severe eosinophilic asthma (SEA) according to the ERS / ATS and GINA 2020 classifications, with reference to the Pulmonology Unit of the Azienda USL - IRCCS, Reggio Emilia, Italy, were enrolled from 1 September 2019 to 31 August 2020. For each patient, the following data were collected: demographic data (age, sex, age of onset of asthma, history of smoking and atopy); comorbidity; clinical data (lung function, exacerbations, emergency room visits and hospitalizations); asthma control questionnaire (ACQ); biomarkers (blood eosinophil count and total serum IgE); asthma control drugs as high-dose inhaled corticosteroids / long-acting beta-adrenoceptor agonists (ICS / LABA), long-acting muscarinic antagonists (LAMA), leukotriene receptor antagonists (LTRA), theophylline, OCS. The benralizumab 30 mg treatment schedule was based on the currently recommended dosing regimen.Results: After end-of-treatment (EOT), a complete weaning of all patients from OCS was confirmed. After 26 weeks, the number of exacerbations decreased from 2.90 to 0.05 (p<0.0001), hospitalizations and ACQ score decreased from 3.37 to 0.97 (p<0.0001). At EOT, the number of exacerbations was unchanged, while no hospitalizations had occurred. Overall, lung function markedly improved over the study period. After 52 weeks, the increase in FEV1 from baseline was 26.8% (p=0.0002). The subset of patients with nasal polyposis (NP) had an increase of nearly 50% (1008 ml) and patients with blood eosinophils count (BEC) greater than 500 cells/μl showed an increase of 68% (1081 ml) in FEV1 at EOT.Conclusions: The notable improvement in respiratory function is a significant result in this study and it is much higher than what has emerged to date. This result, together with the OCS sparing effect and the excellent clinical control of asthma, makes benralizumab a reliable and safe therapeutic option for SEA.

Barriers and determinants of asthma control in children and adolescents in Africa: a systematic review

ObjectiveTo identify reasons for poor asthma control in African children and adolescents.DesignSystematic reviewData sourcesPubMed, Scopus, CINHAL, PsycINFO, MEDLINE and Web of Science databases were systematically searched up to 31 May 2020. Hand searching was done on Sabinet, African Journal online and Google Scholar.Eligibility criteriaStudies identifying barriers to asthma control, where asthma control was assessed by the validated Asthma Control Test/Child Asthma Control Test and/or Asthma Control Questionnaire were included.Data extraction and synthesisTwo reviewers independently selected studies for inclusion with disagreements resolved by a research team discussion, including a third reviewer. Data were extracted using the Cochrane Effective Practice and Organization of Care data collection form. The quality of the included studies was assessed using the modified Newcastle-Ottawa quality assessment scale. Identified barriers were reported in a thematic narrative synthesis.Primary outcomesPoorly controlled asthma and associated factors.ResultsFrom 914 records, three studies conducted between 2014 and 2019 in Nigeria, Uganda and South Africa met the inclusion criteria. A total of 883 children aged 4–19 years were analysed. Older age, concurrent allergy and city-dwelling significantly impacted asthma control. Few children with asthma symptoms in the community had ever used inhaled corticosteroids (6.7%) and identified reasons included lack of asthma diagnosis (38.8%) and no prescribed treatment (47.6%).ConclusionAsthma control in African children is impacted by age, allergy, urbanisation and lack of access to asthma diagnosis and treatment. More studies focusing on identifying barriers to asthma control in Africa are needed.PROSPERORegistration no: CRD42020196755)

Allergic Rhinitis Improvement in Asthmatic Children After Using Acaricidal Bait: A Randomized, Double-Blind, Cross-Placebo Study

Objective: This study aimed to evaluate the effects of acaricidal bait use on the house dust mite (HDM) allergen concentration and occurrence of allergic rhinitis (AR) and asthma symptoms in children sensitized to HDMs.Study Design: Sixty-six children (3–12 years old) with AR and asthma sensitized to HDMs were randomly assigned to receive an acaricidal bait intervention for 8 weeks and a placebo intervention for 8 weeks separated by a 4-week washout period. The visual analog scale (VAS) score, rhinitis control assessment test (RCAT) score, rhinoconjunctivitis quality of life questionnaire (RQLQ) score, asthma control questionnaire-5 (ACQ-5) score and HDM allergen levels were monitored.Results: HDM allergen levels were significantly decreased after 8 weeks (Δder p2+f2 2.282 (3.516) μg/g vs. 0.147 (0.25) μg/g, P &lt; 0.05) in the acaricidal bait group compared with the placebo group. The VAS, RCAT and RQLQ scores in the acaricidal bait group were also significantly improved (ΔVAS 7.5 (16) vs. 3 (18), P &lt; 0.05; ΔRCAT−3 (5) vs. 0 (7), P &lt; 0.05; ΔRQLQ 4.5 (8) vs. 1 (8), P &lt; 0.05), but the ACQ-5 score did not improve (ΔACQ-5 0.2 (0.4) vs. 0 (0.65), P &gt; 0.05).Conclusion: Acaricidal bait reduced HDM exposure and improved rhinitis symptoms. This trial is registered at www.chictr.org.cn.

Inhaled corticosteroid response in smoker versus non-smoker asthmatic patients: a cross-sectional study

Background Asthmatic smokers are a distinct phenotype of asthma. There is a lack of specific information about the treatment of asthma in smokers. The purpose of this study was to compare the effects of inhaled corticosteroid (ICS) on asthmatic smokers and non-smokers. Results The present observational, cross-sectional study was conducted at the Chest Department in Assiut University Hospital, during the period from August 2018 to January 2020. Hundred and seventeen asthmatic patients (42 smokers, 30 ex-smokers, and 45 non-smokers) were assessed using an asthma control questionnaire (ACQ), spirometry, sputum cytology, and serum periostin and eotaxin-2 to compare between a patient on inhaled corticosteroid for at least 3 months and patients who do not receive any form of corticosteroid. Asthmatic smokers had poor response to ICS and had insignificant improvement as regard all parameters. However, asthmatic ex-smokers had a partial response to ICS. They had higher post-bronchodilator FEV1 in comparison to those who did not receive ICS. Asthmatic non-smokers on ICS showed the best response as they were well controlled as regard ACQ. Moreover, they had higher post-bronchodilator FEV1/FVC, post-bronchodilator FEV1, and post-bronchodilator FEF25-75, and lower sputum eosinophils and neutrophils. Conclusion Smoking adversely affects the course and response to ICS therapy in asthma. Trial registration Interrelation between bronchial asthma and smoking: ClinicalTrials.gov ID: NCT03207620. Registered 27 June 2017.

One time a day mometasone/indacaterol fixed-dose combination versus two times a day fluticasone/salmeterol in patients with inadequately controlled asthma: pooled analysis from PALLADIUM and IRIDIUM studies

BackgroundDespite currently available standard-of-care inhaled corticosteroid (ICS)/long-acting β2-agonist therapies, a substantial proportion of patients with asthma remain inadequately controlled. This pooled analysis evaluated efficacy and safety of mometasone furoate/indacaterol acetate (MF/IND) versus fluticasone propionate/salmeterol xinafoate (FLU/SAL) in patients with inadequately controlled asthma.MethodsThis analysis included patients from PALLADIUM (NCT02554786) and IRIDIUM (NCT02571777) studies who received high-dose MF/IND (320/150 µg) or medium-dose MF/IND (160/150 µg) one time a day or high-dose FLU/SAL (500/50 µg) two times a day for 52 weeks. Reduction in asthma exacerbations, improvement in lung function, asthma control, and safety were evaluated for 52 weeks.ResultsIn total, 3154 patients (high-dose MF/IND, n=1054; medium-dose MF/IND, n=1044; high-dose FLU/SAL, n=1056) were included. High-dose MF/IND showed 26%, 22% and 19% reductions in rate of severe, moderate or severe, and all (mild, moderate and severe) exacerbations versus high-dose FLU/SAL, respectively, over 52 weeks (all, p<0.05). High-dose MF/IND improved trough FEV1 versus high-dose FLU/SAL at weeks 26 (Δ, 43 mL, p=0.001) and 52 (Δ, 51 mL, p<0.001). Reductions in asthma exacerbation rate and improvement in trough FEV1 with medium-dose MF/IND were comparable with high-dose FLU/SAL over 52 weeks. All treatments improved Asthma Control Questionnaire-7 score from baseline to 52 weeks with no difference between treatments. Safety was comparable between high-dose MF/IND and high-dose FLU/SAL.ConclusionsOne time a day, single-inhaler, high-dose MF/IND reduced asthma exacerbations and improved lung function versus two times a day, high-dose FLU/SAL in patients with inadequately controlled asthma. Similarly, improved outcomes were seen with one time a day, medium-dose MF/IND and two times a day, high-dose FLU/SAL, but at a lower ICS dose.

Assessment of asthma control in users of oral anti-asthma medications

BACKGROUND: Despite guidelines recommending inhalation therapy as the preferred choice, oral therapy is still widely used in the treatment of asthma in India. However, data about the level of asthma control and healthcare use in patients on oral anti-asthma medications are scarce.METHODS: A retrospective study was conducted to assess the level of asthma control and healthcare use in patients taking oral anti-asthma medications.RESULTS: The study population consisted of 381 adults randomly selected from health screening programmes. All subjects were already receiving oral anti-asthma medications; however, up to 72% had not been diagnosed with asthma by their treating doctors prior to the screening programmes. The cohort had a mean age of 48.26 ± 13.83 years (70% males) and mean peak expiratory flow of 245 ± 78.93 mL/sec. The mean Asthma Control Questionnaire 5 (ACQ-5) score was 2.53 ± 1.15, with respectively 33%, 49.3% and 32.6% reporting at least one episode of breathlessness, one emergency doctor visit and one hospitalisation due to asthma or its symptoms in the past year.CONCLUSION: Underdiagnosis and inappropriate management, as indicated by the poor asthma control and increased hospitalisations seen in this study, is probably a key contributor to the increased burden of the disease in India.