2018 GINA Severe Asthma Pocket Guide: Diagnosis and Management of Difficult-to-treat and Severe Asthma in adolescent and adult patients

GINA has added an important addition to the resources that we offer to assist practitioners treating patients with asthma. A new Pocket Guide, “Diagnosis and Management of Difficult-to-treat and Severe Asthma in adolescent and adult patients” is now available on the GINA website, www.ginasthma.org. Embracing the issue of severe asthma was a critical goal for the GINA Board of Directors and Science Committee, as their mission remains focused on maximizing benefit for patients with asthma whilst minimizing healthcare provider burden.

Prof. Helen Reddel, Chair of the GINA Science Committee and a research leader at the Woolcock Institute of Medical Research in Sydney, Australia, stated “Difficult-to-treat and severe asthma are high priority issues because of the physical, emotional and financial burden for patients and their families, and the impact on primary and specialist healthcare systems. Clinicians in both low and high income countries need practical advice about how to assess and treat patients for whom conventional asthma therapies don’t seem to be working, and about how treatment strategies, including biologic therapies if available, can be implemented into patient care.”
The need for a practical resource addressing severe asthma was made apparent to the GINA Science Committee and Board of Directors from responses to a survey of members of the GINA Assembly, which is a group of physician volunteers around the world who actively disseminate GINA strategy in their respective countries. Two particular needs identified were (1) at what point should a patient be referred to a specialist, and (2) guidance for biologic therapies.

THE GOALS OF THE POCKET GUIDE ARE STATED ON PAGE 4:

The goal of this Pocket Guide is to provide a practical summary for health professionals about how to identify, assess and manage difficult-to-treat and severe asthma in adolescents and adults. It is intended for use by general practitioners (GPs, primary care physicians), pulmonary specialists and other health professionals involved in the management of people with asthma.

The recommendations in this Pocket Guide were based on evidence where good quality systematic reviews or randomized controlled trials or, lacking these, robust observational data, were available, and on consensus by expert clinicians and researchers, where not. Development of the Pocket Guide and decision tree included extensive collaboration with experts in human-centered design to enhance the utility of these resources for end-users. This means translating existing high level lowcharts and text-based information to a more detailed visual format, and applying information architecture and diagramming principles.

Its time to revise Asthma Guidelines? Single maintenance and reliever therapy (SMART) decrease asthma exacerbations

Importance  Combined use of inhaled corticosteroids and long-acting β-agonists (LABAs) as the controller and the quick relief therapy termed single maintenance and reliever therapy (SMART) is a potential therapeutic regimen for the management of persistent asthma.

Objective  To conduct a systematic review and meta-analysis of the effects of SMART in patients with persistent asthma.

Data Sources and Study Selection  The databases of MEDLINE via OVID, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were searched from database inception through August 2016 and updated through November 28, 2017. Two reviewers selected randomized clinical trials or observational studies evaluating SMART vs inhaled corticosteroids with or without a LABA used as the controller therapy and short-acting β-agonists as the relief therapy for patients aged 5 years or older with persistent asthma and reporting on an outcome of interest.

Data Extraction and Synthesis  Meta-analyses were conducted using a random-effects model to calculate risk ratios (RRs), risk differences (RDs), and mean differences with corresponding 95% CIs. Citation screening, data abstraction, risk assessment, and strength of evidence grading were completed by 2 independent reviewers.

Main Outcomes and Measures  Asthma exacerbations.

Results  The analyses included 16 randomized clinical trials (N = 22 748 patients), 15 of which evaluated SMART as a combination therapy with budesonide and formoterol in a dry-powder inhaler. Among patients aged 12 years or older (n = 22 524; mean age, 42 years; 14 634 [65%] were female), SMART was associated with a reduced risk of asthma exacerbations compared with the same dose of inhaled corticosteroids and LABA as the controller therapy (RR, 0.68 [95% CI, 0.58 to 0.80]; RD, −6.4% [95% CI, −10.2% to −2.6%]) and a higher dose of inhaled corticosteroids and LABA as the controller therapy (RR, 0.77 [95% CI, 0.60 to 0.98]; RD, −2.8% [95% CI, −5.2% to −0.3%]). Similar results were seen when SMART was compared with inhaled corticosteroids alone as the controller therapy. Among patients aged 4 to 11 years (n = 341; median age, 8 [range, 4-11] years; 69 [31%] were female), SMART was associated with a reduced risk of asthma exacerbations compared with a higher dose of inhaled corticosteroids as the controller therapy (RR, 0.55 [95% CI, 0.32 to 0.94]; RD, −12.0% [95% CI, −22.5% to −1.5%]) or the same dose of inhaled corticosteroids and LABA as the controller therapy (RR, 0.38 [95% CI, 0.23 to 0.63]; RD, −23.2% [95% CI, −33.6% to −12.1%]).

Conclusions and Relevance  In this meta-analysis of patients with persistent asthma, the use of single maintenance and reliever therapy compared with inhaled corticosteroids as the controller therapy (with or without a long-acting β-agonist) and short-acting β-agonists as the relief therapy was associated with a lower risk of asthma exacerbations. Evidence for patients aged 4 to 11 years was limited.

Full text:

https://jamanetwork.com/journals/jama/fullarticle/2675737

2018 New approach for the treatment of severe uncontrolled asthma

New updated approach to severe uncontrolled asthma was presented by Greek team in ERJ Open research!!!
Asthma is a common, chronic and heterogeneous disease, affecting people of all ages. It may be mild, barely noticed by the patient, or it may range all the way to very severe disease, causing constant symptoms greatly affecting the life of the patient, and may result in poor quality of life and severe, life-threatening attacks. 
A small subgroup of patients with asthma suffers from severe disease that is either partially controlled or uncontrolled despite intensive, guideline-based treatment. These patients have significantly impaired quality of life and although they constitute <5% of all asthma patients, they are responsible for more than half of asthma-related healthcare costs. Here, we review a definition for severe asthma and present all therapeutic options currently available for these severe asthma patients. Moreover, we suggest a specific algorithmic treatment approach for the management of severe, difficult-to-treat asthma based on specific phenotype characteristics and biomarkers. 

The diagnosis and management of severe asthma requires specialised experience, time and effort to comprehend the needs and expectations of each individual patient and incorporate those as well as his/her specific phenotype characteristics into the management planning. Although some new treatment options are currently available for these patients, there is still a need for further research into severe asthma and yet more treatment options.

Full text:

http://openres.ersjournals.com/content/4/1/00125-2017

New study contradicts Asthma Guidelines: How efficient is escalating inhaled glucocorticoids for prevention of asthma exacerbations?

Evidence indicates that substantial escalation of regularly used inhaled glucocorticoids, fails to prevent most asthma exacerbations. A small subgroup of adults and adolescents with asthma may have a response to an escalation strategy; however, their baseline and exacerbation characteristics remain to be defined.
New study was published in NEJM on Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations.

In children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth.
Full text

Ashtma-Chronic obstructive pulmonary disease overlap syndrome (ACOS): current evidence and future research directions (Free Full text from 2017 COPD Research and Practice)

Chronic obstructive pulmonary disease and asthma are the most frequent chronic respiratory diseases that affect the general population. For a long period of time these two conditions were considered to be separate diseases. However, it became evident that some patients share symptoms and clinical findings from both diseases. 

These patients are considered to represent a distinct phenotype, called asthma-COPD overlap syndrome (ACOS). However, since approximately the one third of the asthmatics smoke the ACOS may primarily define those patients. This is a relatively newly defined clinical syndrome whose underlying mechanisms and most appropriate management remain to be confirmed. In this review, we summarize current knowledge on this syndrome, aiming to update clinicians and help their daily practice.

Free full text:

https://copdrp.biomedcentral.com/articles/10.1186/s40749-017-0025-x

Oral Glucocorticoid–Sparing Effect of Benralizumab in Severe Asthma (free full text from 2017 NEJM)

Many patients with severe asthma rely on oral glucocorticoids to manage their disease. We investigated whether benralizumab, a monoclonal antibody directed against the alpha subunit of the interleukin-5 receptor that significantly reduces the incidence of asthma exacerbations, was also effective as an oral glucocorticoid–sparing therapy in patients relying on oral glucocorticoids to manage severe asthma associated with eosinophilia.

In a 28-week randomized, controlled trial, we assessed the effects of benralizumab (at a dose of 30 mg administered subcutaneously either every 4 weeks or every 8 weeks [with the first three doses administered every 4 weeks]) versus placebo on the reduction in the oral glucocorticoid dose while asthma control was maintained in adult patients with severe asthma. The primary end point was the percentage change in the oral glucocorticoid dose from baseline to week 28. Annual asthma exacerbation rates, lung function, symptoms, and safety were assessed.

Results

Of 369 patients enrolled, 220 underwent randomization and started receiving benralizumab or placebo. The two benralizumab dosing regimens significantly reduced the median final oral glucocorticoid doses from baseline by 75%, as compared with a reduction of 25% in the oral glucocorticoid doses in the placebo group (P<0.001 for both comparisons). The odds of a reduction in the oral glucocorticoid dose were more than 4 times as high with benralizumab as with placebo. Among the secondary outcomes, benralizumab administered every 4 weeks resulted in an annual exacerbation rate that was 55% lower than the rate with placebo (marginal rate, 0.83 vs. 1.83, P=0.003), and benralizumab administered every 8 weeks resulted in an annual exacerbation rate that was 70% lower than the rate with placebo (marginal rate, 0.54 vs. 1.83, P<0.001). At 28 weeks, there was no significant effect of either benralizumab regimen on the forced expiratory volume in 1 second (FEV₁), as compared with placebo. The effects on various measures of asthma symptoms were mixed, with some showing significant changes in favor of benralizumab and others not showing significant changes. Frequencies of adverse events were similar between each benralizumab group and the placebo group.

Conclusions

Benralizumab showed significant, clinically relevant benefits, as compared with placebo, on oral glucocorticoid use and exacerbation rates. These effects occurred without a sustained effect on the FEV₁.

Free full text:
http://www.nejm.org/doi/full/10.1056/NEJMoa1703501#Top

World Asthma Day 2017: read article on Asthma research in Europe from ERJ (Free full text)

Asthma is highly prevalent, often starting in infancy and persisting throughout life, and is associated with high morbidity and burden. It is a major global health challenge with growing impact, affecting more than 300 million people worldwide and at least 10% of all Europeans. Furthermore, it is the most prevalent long-term condition in children. Approximately 5–10% of asthma cases are so severe that current treatments do not work, and over five million people in the European Union (EU) fall into this category.

People with asthma live at risk of life-threatening asthma attacks, leading to at least 500 000 hospitalisations worldwide each year. A European study estimated that unscheduled care and rescue medication accounted for 47% of the total cost-per-patient in infants, 45% in children and 56% in adults. This results in high socio-economic impact, estimated at more than €70 billion annually. This includes the costs of direct primary and hospital healthcare (estimated to be close to €20 billion per annum), costs due to lost productivity (€14 billion), and the monetised value of disability-adjusted life-years (DALYs) lost (over €38 billion). Close to 1 million DALYs are lost due to asthma in Europe every year.

Despite the fact that the direct and indirect costs of asthma are substantial and continue to rise, asthma remains under-prioritised in the EU research agenda. Only 0.5% of the Seventh Framework Programme (FP7) health research budget was devoted to asthma and chronic obstructive pulmonary disease (COPD) (€30 million). In comparison, some 5.4 times this amount (over €163 million) was spent on cardiovascular conditions and some 20.6 times (over €618 million) on brain research.

Asthma, with its high global prevalence and an associated multi-billion global market for treatments, plus its historical underfunding and the demand for new treatments and diagnostics, represents an enormous opportunity to drive substantial economic growth. This paper sets out how the EU may capitalise on this via investment in research with high commercial potential that can radically improve the EUs research agenda and public health.

Free full text:

http://erj.ersjournals.com/content/49/5/1602294

ERS Guidelines 2017: exhaled biomarkers in lung disease

Breath tests cover the fraction of nitric oxide in expired gas (F_eNO), volatile organic compounds (VOCs), variables in exhaled breath condensate (EBC) and other measurements. For EBC and for F_eNO, official recommendations for standardised procedures are more than 10 years old and there is none for exhaled VOCs and particles. The aim of this document is to provide technical standards and recommendations for sample collection and analytic approaches and to highlight future research priorities in the field. For EBC and F_eNO, new developments and advances in technology have been evaluated in the current document. This report is not intended to provide clinical guidance on disease diagnosis and management.

Clinicians and researchers with expertise in exhaled biomarkers were invited to participate. Published studies regarding methodology of breath tests were selected, discussed and evaluated in a consensus-based manner by the Task Force members.

Recommendations for standardisation of sampling, analysing and reporting of data and suggestions for research to cover gaps in the evidence have been created and summarised.

Application of breath biomarker measurement in a standardised manner will provide comparable results, thereby facilitating the potential use of these biomarkers in clinical practice.

Full text:

http://erj.ersjournals.com/content/49/4/1600965

Relationship of Allergy with Asthma: There Are More Than the Allergy “Eggs” in the Asthma “Basket” (Free full text from 2017 Frontiers in Pediatrics)

Asthma and allergy share a similar and very close course, especially through childhood. Considerable research effort has been put in untangling these associations; however, it is now becoming obvious that this is an exceedingly difficult task. In fact, each research breakthrough further perplexes this picture, as we are steadily moving toward the era of personalized medicine and we begin to appreciate that what we thought to be a single disease, asthma, is in fact an accumulation of distinct entities. In the context of this “syndrome,” which is characterized by several, as of yet poorly defined endotypes and phenotypes, the question of the link of “asthma” with allergy probably becomes non-relevant. In this review, we will revisit this question while putting the emphasis on the multifaceted nature of asthma.

Free full text:

http://journal.frontiersin.org/article/10.3389/fped.2017.00092/full

Pauci-granulocytic stable asthma (Article from Allergy 2017)

Read new article on hot topic paucigranulocytic asthma in comparison with another inflammatory asthma phenotypes! The emergence and increasing availability of validated, feasible non-invasive methods of assessment of inflammation has led to a greater understanding of inflammatory phenotypes in asthma. Two distinct and apparently stable sputum inflammatory phenotypes have been described, eosinophilic and non-eosinophilic, which have a differential treatment response, particularly to glucocorticosteroids. The classification has been further revised:  eosinophilic, neutrophilic, mixed granulocytic (raised eosinophils and neutrophils) and paucigranulocytic (normal levels of eosinophils and neutrophils).

http://onlinelibrary.wiley.com/doi/10.1111/all.13184/abstract

Background

According to induced sputum cell count, four different asthma phenotypes have been recognised(eosinophilic, neutrophilic, mixed and pauci-granulocytic). The aim of the present study was to detect functional and inflammatory characteristics of patients with pauci-granulocytic asthma.

Methods

240 asthmatic patients were categorised in the four phenotypes according to cell counts in induced sputum. All patients underwent pulmonary function tests, and measurement of FeNO. The levels of IL-8, IL-13, and ECP were also measured in sputum supernatant. Treatment, asthma control and the presence of Severe Refractory Asthma(SRA) were also recorded.

Results

Patients were categorized in the four phenotypes as follows: eosinophilic (40%), mixed (6.7%), neutrophilic (5.4%) and pauci-granulocytic (47.9%). Although ACT did not differ between groups (p=0.288) patients with pauci-granulocytic asthma had better lung function (FEV₁%pred) (median (IQR):71.5(59.0-88.75) vs 69.0(59.0-77.6) vs 68.0(60.0-85.5) vs 80.5(69.7-95.0), p=0.009] for eosinophilic, mixed, neutrophilic and pauci-granulocytic asthma respectively, p=0.009). SRA occurred more frequently in the eosinophilic and mixed phenotype (41.6% and 43.7% respectively) and less frequently in the neutrophilic and pauci-granulocytic phenotype (25% and 21.7% respectively, p=0.01). FeNO, ECP and IL-8 were all low in the pauci-granulocytic, whereas as expected FeNO and ECP were higher in eosinophilic and mixed asthma, while IL-8 was higher in patients with neutrophilic and mixed asthma(p<0.001 for all comparisons). Interestingly, 14.8% of patients with pauci-granulocytic asthma had poor asthma control.

Conclusion

Pauci-granulocytic asthma most likely represents a “benign” asthma phenotype, related to a good response to treatment, rather than a “true” phenotype of asthma. However, pauci-granulocytic patients that remain not-well-controlled despite optimal treatment represent an asthmatic population that requires further study for potential novel targeted interventions.

Direct link to article:

http://onlinelibrary.wiley.com/doi/10.1111/all.13184/abstract

News alert: According to the last Pharma R&D 2017 Review, Respiratory Drugs the only group decreasing

Pharma R&D 2017 Review, presented recently new drugs by Therapy Groups. Cancer at the top increasing 20%, Respiratory Drugs the only group decreasing.
It is a huge paradox, in the time when we have the progressive increasing of prevalence and mortality of chronic respiratory diseases!!!

Respiratory diseases are STILL among the leading causes of death worldwide.  

Lung infections (mostly pneumonia and tuberculosis), lung cancer and chronic obstructive pulmonary disease (COPD) together accounted for 9.5 million deaths worldwide during 2008, one-sixth of the global total. The World Health Organization estimates that the same four diseases accounted for one-tenth of the disability-adjusted life-years (DALYs) lost worldwide in 2008.

The Global Burden of Disease (GBD) Study recently compared the contribution of major diseases to deaths and disability worldwide for 1990 and 2010. Among the leading causes of death, lower respiratory infections were ranked 3rd in 1990 and 4th in 2010, whereas COPD was ranked 4th in 1990 and 3rd in 2010. Lung cancer rose from 8th- to 5th- commonest cause of death, while tuberculosis fell from 6th to 10th position in the ranking.

The GBD Study also presented rankings for years lived with disability, among which asthma ranked 13th worldwide in 1990 and 14th in 2010, while COPD ranked 6th in 1990 and 5th in 2010. When premature deaths and disability were combined as DALYs  lost, lower respiratory infections were ranked the leading cause worldwide in 1990, and the 2nd most important cause of DALYs lost in 2010. Also among the 25 most important causes were COPD (ranked 6th in 1990 and 9th in 2010), tuberculosis (ranked 8th in 1990 and 13th in 2010) and lung cancer (ranked 24th in 1990 and 22nd in 2010).

Interventions to improve inhaler technique for people with asthma (Free fulltext from 2017 The Cochrane Library)

Background to the question

Many asthma drugs are taken by an inhaler, which deposits the drug directly into the lungs. It is important that the inhaler is taken properly, so the patient gets the most benefit. Taken properly, asthma drugs can improve symptoms and reduce attacks.

Lots of people do not use their devices correctly. This means that the drug is not delivered properly to the lungs, and as a result, asthma may not be as well controlled as it should be. People also tell us that they can have more than one type of inhaler, so it is confusing to know what to do.

We wanted to find out whether teaching people with asthma how to use their inhalers works, and whether this leads to better control of symptoms and fewer attacks. It may seem obvious, but it is important that doctors and nurses know how best to help people with asthma.

Study characteristics

We found 29 studies involving 2210 people with asthma. Studies lasted between 2 and 26 weeks. Studies reported inhaler technique on a range of different checklists.

We grouped studies into three types: studies testing enhanced face-to-face training session(s), studies using multi-media to deliver inhaler training (e.g. a video, computer app or game) and studies testing devices that give people visual or audio feedback about technique.

Studies tested different types of training and used different measures to gauge success, meaning that we could not bring data together. This was particularly true when we tried to assess effects on asthma attacks, adverse events, visits to a healthcare provider and absences from work or school.

Key results

Both face-to-face and multi-media inhaler training improved inhaler technique in most studies, although results varied depending on how and when each technique was assessed.

Some studies reported the number of people who had correct or 'good enough' technique. More people had correct or 'good enough' technique after face-to-face training and with feedback devices. But the benefit of multi-media training for adults was uncertain.

Interventions that provide inhaler training may bring some benefit for quality of life and asthma control among adults and children, but results were varied and studies were small.

Children may receive some benefit but results tended to be less clear for children because fewer and smaller studies have included children as participants.

Quality of the evidence

For studies like these, it is not possible to blind people to their assigned group. This may bias how people behave or respond to questionnaires, which reduced our confidence in the findings. We were uncertain about other results because studies did not provide enough data to show clear benefit.

Conclusions

We cannot say for sure what is the best way to help people learn how to use their inhaler properly. It is important that patients understand how their inhaler works, so they should ask their doctor or nurse for help.

We also use Cochrane Reviews to make suggestions for future research. We suggest that trials should last longer than six months and should report adherence information. The most useful information reported was the number of people who had 'good enough' inhaler technique, so we urge future trials to report this as well.

Free full text link is 

HERE

Severe asthma: anti-IgE or anti-IL-5? (full text article from European Clinical Respiratory Journal 2016)

Dear friends please read interesting article: Severe asthma: anti-IgE or anti-IL-5? from European Clinical Respiratory Journal 2016!

Severe asthma is a discrete clinical entity characterised by recurrent exacerbations, reduced quality of life and poor asthma control as ordinary treatment regimens remain inadequate. Difficulty in managing severe asthma derives partly from the multiple existing phenotypes and our inability to recognise them. Though the exact pathogenetic pathway of severe allergic asthma remains unclear, it is known that numerous inflammatory cells and cytokines are involved, and eosinophils represent a key inflammatory cell mediator. Anti-IgE (omalizumab) and anti-IL-5 (mepolizumab) antibodies are biological agents that interfere in different steps of the Th2 inflammatory cascade and are licensed in severe asthma. 

Both exhibit a favourable clinical outcome as they reduce exacerbation rate and improve asthma control and quality of life, while mepolizumab also induces an oral steroid sparing effect. Nevertheless, it is still questionable which agent is more suitable in the management of severe allergic asthma since no comparable studies have been conducted. Omalizumab’s established effectiveness in clinical practice over a long period is complemented by a beneficial effect on airway remodelling process mediated mainly through its impact on eosinophils and other parameters strongly related to eosinophilic inflammation. However, it is possible that mepolizumab through nearly depleting eosinophils could have a similar effect on airway remodelling. Moreover, to date, markers indicative of the patient population responding to each treatment are unavailable although baseline eosinophils and exacerbation rate in the previous year demonstrate a predictive value regarding anti-IL-5 therapy effectiveness. On the other hand, a better therapeutic response for omalizumab has been observed when low forced expiratory volume in 1 sec, high-dose inhaled corticosteroids and increased IgE concentrations are present. Consequently, conclusions are not yet safe to be drawn based on existing knowledge, and additional research is necessary to unravel the remaining issues for the severe asthmatic population.

Read more:

http://www.ecrj.net/index.php/ecrj/article/view/31813

Asthma 2016 Guidelines: The 2016 update by the British Thoracic Society (free full text)

Today was published an important update to British Thoracic Society guidance on the management of asthma!

Diagnosing asthma

The guideline, produced jointly by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) emphasises that there is still no single test that can definitively diagnose asthma and an individual’s asthma status can change over time.

It recommends that if a health professional suspects asthma, they should undertake a ‘structured clinical assessment’ using a combination of patient history, examination and tests to assess the probability of asthma. 

The history should include a review of the following:

• Symptoms of cough, breathlessness, wheeze and chest tightness that have varied over time
• Any history of recurrent attacks of symptoms
• Any wheeze previously recorded by a health professional
• A personal or family history of allergic conditions such as eczema and allergic rhinitis
• Objective evidence of variability over time in obstruction to a patient’s airflow (using the results of lung function tests)
• The absence of any pointers to an alternative diagnosis to asthma.

Quality assured spirometry is spotlighted as the key frontline breathing test to be performed in most situations with adults and children over 5 years of age.  It is important that spirometry is quality assured i.e. professionals are trained and experienced in preparing and delivering the test as well as analysing the results.

If the test shows obstruction to the patient’s airflow which reverses with treatment, this strongly supports a diagnosis of asthma.

But a normal spirometry result does not always exclude an asthma diagnosis – especially if a patient has no symptoms at the time. It may be necessary for healthcare professionals to repeat spirometry when a patient has symptoms, and/or use different breathing tests - and observe over time.

One, often secondary, breathing test that can be carried out, involves measuring an individual’s fractional exhaled nitric oxide (FeNO) - a gas found in slightly higher levels in people with asthma. An increase suggests inflammation of the airways, and supports, but doesn’t prove, a diagnosis of asthma.

The guideline helps health professionals to assign patients into 3 groups based on the probability they have asthma; either high, intermediate or low.  It then summarises the key treatment and management actions to be taken for each group.

If the probability of asthma is high, health professionals should start a carefully monitored trial of treatment. If patients respond well, according to lung function tests or symptom questionnaires, this will confirm the diagnosis.   Health professionals should code their records as ‘suspected asthma’ until a diagnosis is confirmed and should make a clear record on what basis the diagnosis was confirmed. If the probability is low, further tests or immediate referral to a lung specialist may be appropriate.

Treating asthma

The updated guideline also includes new or revised content in the following areas: asthma drug treatment (replacing the previous stepwise approach), non-drug treatments, supported self-management, and the role of telehealthcare.

Key highlights include: 

• Short acting beta2 agonists - a group of drugs that can provide quick relief of asthma symptoms - are the key ‘rescue therapy’ from symptoms or asthma attacks and can form part of all treatment plans, but should rarely be used on their own
• A key emphasis on medication to prevent future asthma attacks - inhaled corticosteroids remain the most effective ‘preventer’ drug for all adults and children
• Asthma inhalers should not be prescribed generically to avoid patients being given an unfamiliar device that they may not know how to use properly
• If a patient has poor control of their asthma, it is essential to check whether they are using their current drug treatment correctly and regularly, before stepping up treatment
• Weight loss initiatives – including dietary and exercise programmes – can be offered for overweight or obese adults and children with asthma and may improve their asthma control 
• Each patient should be offered a written asthma action plan as it is key to the effective management of their asthma
• The use of new electronic technologies can help in the delivery of asthma care, and evidence shows they can be at least as good as traditional methods, although outcomes do vary

Approaches include; games to encourage children to take their medication, remote consultations, automated treatment reminders, and computerised decision-support systems for health professionals. The guideline says they can be considered according to local need

• Women with asthma who are pregnant should be informed of the importance of continuing their asthma medication during pregnancy for the health of both mother and baby

Dr John White, British Thoracic Society member and Consultant Respiratory Physician, York NHS Foundation Trust, who co-chaired the group that delivered the updated BTS/SIGN Guideline, said:

‘Asthma is a complex disease and symptoms can vary over time.  In addition, evidence shows there’s still no single ‘magic bullet test’ for asthma. This all means that diagnosis isn’t always easy.

This update should be really valuable as it gives healthcare professionals an evidence-based but highly practical approach to suspecting and confirming a diagnosis of asthma, as well as giving the latest guidance on the most appropriate treatments and interventions to combat the disease.  

The guideline also reinforces previous messages that remain vital in the battle against asthma. It is critical, for example, that everyone with the condition is offered a written personalised action plan and review, and that inhalers are only prescribed after patients have received training in using them and demonstrate adequate technique.

We do hope that health, social care and education professionals can work together with people with asthma in using these guidelines to provide the best care possible.’   

SIGN is part of Healthcare Improvement Scotland.

Sara Twaddle, Director of Evidence for Healthcare Improvement Scotland, said:

“Over 5 million people are currently being treated for asthma in the UK and 1,468 people died from asthma attacks in the UK in 2015 – the highest level for 10 years. It’s important that we diagnose and treat people to the best of our ability, hence the reason we update this guideline for clinicians every two years using the most up-to-date evidence. This new updated guideline underlines that there is still no single diagnostic test for asthma, and emphasises the importance of preventive therapy. We urge clinicians across the UK to refer to this guideline for diagnosis and treatment. By doing so, they will help to improve the care that people with asthma receive.”

The BTS/SIGN asthma guideline is a ‘living guideline’ updated biennially.  Following a scoping exercise, key sections are selected for updating based on availability of new evidence. 

Free full text:

https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/

Effects of omalizumab in severe asthmatics across ages: A real life Italian experience (article from Respiratory Medicine 2016)

Dear friends, read new article from last issue of Respiratory Medicine on effects of Omalizumab in asthmatics!

Background

This retrospective study aimed at evaluating long-term effects of Omalizumab in elderly asthmatics in a real-life setting.

Methods

105 consecutive severe asthmatics (GINA step 4–5; mean FEV₁% predicted:66 ± 15.7) treated with Omalizumab for at least 1 year (treatment mean duration 35.1 ± 21.7 months) were divided into 3 groups according to their age at Omalizumab treatment onset: 18–39, 40–64 and ≥ 65 years.

Results

Comorbidities, number of overweight/obese subjects and patients with late-onset asthma were more frequent among older people. A similar reduction of inhaled corticosteroids dosage and SABA on-demand therapy was observed in all groups during Omalizumab treatment; a similar FEV₁ increased was also observed. Asthma Control Test (ACT) improved significantly (p < 0.001) in the three groups, increasing from 15 [IQR:12-18] to 24 [IQR:22-25] in younger subjects, from 14 [IQR:10-16] to 21 [IQR:20-23] in the 40-64-year-group and from 15 [IQR:12-16] to 20 [IQR:18-22] in elderly patients where improvement was lower (p = 0.039) compared to younger people. Asthma exacerbations decreased significantly after Omalizumab but the percentage of exacerbation-free patients was higher in younger people (76.9%) compared to middle aged patients (49.2%) and the elderly (29%) (p = 0.049).

After Omalizumab treatment, the risk for exacerbations was lower in subjects aged 40–64 (OR = 0.284 [CI95% = 0.098–0.826], p = 0.021) and 18–39 (OR = 0.133 [CI95% = 0.026–0.678], p = 0.015), compared to elderly asthmatics. Also, a significantly reduced ACT improvement (β = −1.070; p = 0.046) passing from each age class was observed.

Conclusion

Omalizumab improves all asthma outcomes independently of age, although the magnitude of the effects observed in the elderly seems to be lower than in the other age groups.

Fevipiprant, a prostaglandin D2 receptor 2 antagonist, in patients with persistent eosinophilic asthma (Lancet article)

The clinical trial of Fevipiprant, conducted by experts at Leicester University, found that it led to a big drop in the the symptoms of asthma, improved sufferers’ lung function, reduced inflammation of the lungs and also helped to repair the lining of patients’ airways.

Background

Eosinophilic airway inflammation is often present in asthma, and reduction of such inflammation results in improved clinical outcomes. We hypothesised that fevipiprant (QAW039), an antagonist of prostaglandin D₂ receptor 2, might reduce eosinophilic airway inflammation in patients with moderate-to-severe eosinophilic asthma.

Methods

We performed a single-centre, randomised, double-blind, parallel-group, placebo-controlled trial at Glenfield Hospital (Leicester, UK). We recruited patients with persistent, moderate-to-severe asthma and an elevated sputum eosinophil count (≥2%). After a 2-week single-blind placebo run-in period, patients were randomly assigned (1:1) by the trial pharmacist, using previously generated treatment allocation cards, to receive fevipiprant (225 mg twice per day orally) or placebo, stratified by the use of oral corticosteroid treatment and bronchoscopy. The 12-week treatment period was followed by a 6-week single-blind placebo washout period. The primary outcome was the change in sputum eosinophil percentage from baseline to 12 weeks after treatment, analysed in the intention-to-treat population. All patients who received at least one dose of study drug were included in the safety analyses. This trial is registered with ClinicalTrials.gov, number NCT01545726, and with EudraCT, number 2011-004966-13.

Findings

Between Feb 10, 2012, and Jan 30, 2013, 61 patients were randomly assigned to receive fevipiprant (n=30) or placebo (n=31). Three patients in the fevipiprant group and four patients in the placebo group withdrew because of asthma exacerbations. Two patients in the fevipiprant group were incorrectly given placebo (one at the mid-treatment visit and one throughout the course of the study). They were both included in the fevipiprant group for the primary analysis, but the patient who was incorrectly given placebo throughout was included in the placebo group for the safety analyses. Between baseline and 12 weeks after treatment, sputum eosinophil percentage decreased from a geometric mean of 5·4% (95% CI 3·1–9·6) to 1·1% (0·7–1·9) in the fevipiprant group and from 4·6% (2·5–8·7) to 3·9% (CI 2·3–6·7) in the placebo group. Compared with baseline, mean sputum eosinophil percentage was reduced by 4·5 times in the fevipiprant group and by 1·3 times in the placebo group (difference between groups 3·5 times, 95% CI 1·7–7·0; p=0·0014). Fevipiprant had a favourable safety profile, with no deaths or serious adverse events reported. No patient withdrawals were judged by the investigator to be related to the study drug.

Interpretation

Fevipiprant reduces eosinophilic airway inflammation and is well tolerated in patients with persistent moderate-to-severe asthma and raised sputum eosinophil counts despite inhaled corticosteroid treatment.

Full text:

http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(16)30179-5/abstract

Effects of body mass index, tobacco smoking, alcohol drinking and solid fuel use on the risk of asthma: meta-analysis from BMJ Open Resp Res 2016 (free full text)

Background We assessed the relationship of body mass index (BMI), smoking, drinking and solid fuel use (r; SFU), and the individual and combined effects of these factors on wheezing symptoms (WS) and on diagnosed asthma (DA).

Methods We analysed 175 000 individuals from 51 nationally representative surveys, using self-reports of WS and DA as the measures of asthma. The fixed-effects and random-effects estimates of the pooled ORs between asthma and underweight (BMI <18.5 kg/m²), obesity (BMI ≥30 kg/m²), smoking, drinking and SFU were reported.

Results The pooled risks of all individual risk factors were significantly associated with WS and DA (with the exception of current smoking with DA in women and SFU with DA in both genders). Stronger dose–response relationships were seen in women for smoking amounts and duration; BMI showed stronger quadratic relationships. The combined risks were generally larger in women than in men, with significant risks for underweight (OR=2.73) as well as obese (OR=2.00) smokers for WS (OR=2.13 and OR=1.58 for DA, respectively). The magnitude of the combined effects from low/high BMI, smoking and drinking were also consistently higher among women than among men in WS and DA. SFU among underweight smokers also had positive association with WS (men and women) and DA (women).

Conclusions BMI, smoking, drinking and SFU—in combination—are associated with double or triple the risk of development of asthma. These risk factors might help explain the wide variation in asthma burden across countries. 

Free full text:

http://bmjopenrespres.bmj.com/content/3/1/e000121.full

Why do so many elite athletes have asthma? (full text article from Austin Journal of Pulmonary & Respiratory Medicine)

British well known national daily newspaper the Guardian wrotes last week: "The idea of a supremely fit professional cyclist like Simon Yates having to occasionally reach for an inhaler to ward off a wheeze might seem anomalous. But asthma is surprisingly common among some elite athletes.

A handful have classic asthma, the usually allergy-triggered constriction of the bronchial tubes that tends to begin in childhood.

Much more common in sport is exercise-induced asthma, or EIA, in which rapid and heavy breathing causes the same symptoms. The effect can be exacerbated by atmospheric conditions, which means some sportspeople tend to suffer more than others.

John Dickinson from Kent University’s school of sport & exercise sciences, a world expert on asthma in sport, tested all 33 UK-based members of the British swimming squad and found 70% had some form of asthma, against a national asthma rate of about 8% to 10%. It is believed the chlorinated atmosphere of a pool could be a factor in this."

Read our article on Exercise-Induced Bronchoconstriction in Athletes (full text article from Austin Journal of Pulmonary & Respiratory Medicine):

https://www.researchgate.net/publication/297733949_Exercise-Induced_Bronchoconstriction_in_Athletes

 

Asthma 2016 Guidelines on World Asthma Day 2016: The 2016 update of the Global Strategy for Asthma Management and Prevention

World Asthma Day is a big event celebrated all over the world by the people to increase the awareness among public worldwide about the precautions and preventions of the asthma. This event is annually organized on international level by the GINA (Global Initiative for Asthma) in order to increase the asthma awareness all around the world. It is celebrated on annual basis at 1^st Tuesday of the May month. World Asthma Day celebration was first started celebrating in the year 1998 by the GINA in more than 35 countries after its first “World Asthma Meeting” in the Barcelona, Spain.

The 2016 update of the Global Strategy for Asthma Management and Prevention incorporates new scientific information about asthma based on a review of recent scientific literature by an international panel of experts on the GINA Science Committee. This comprehensive and practical resource about one of the most common chronic lung diseases worldwide contains extensive citations from the scientific literature and forms the basis for other GINA documents and programs.

Link for free download of the 2016 update of the Global Strategy for Asthma Management and Prevention:

http://ginasthma.org/2016-gina-report-global-strategy-for-asthma-management-and-prevention/

Roflumilast combined with montelukast in asthma (free full text)

Roflumilast, a selective phosphodiesterase 4 inhibitor, has been shown to provide modest improvements in lung function in patients with mild-to-moderate asthma, but its efficacy in patients with moderate-to-severe asthma has not been assessed. Authors hypothesized that this drug might provide benefit if combined with montelukast, a leukotriene receptor antagonist, in patients whose symptoms are uncontrolled by inhaled corticosteroids and long-acting β-agonists.

The combination of roflumilast with montelukast compared with montelukast alone improved lung function and asthma control in patients with moderate-to-severe asthma and deserves further study for this indication.

Free full text:

http://www.jacionline.org/action/showFullTextImages?pii=S0091-6749%2816%2900107-X