Asthma

Use of asthma medication by pregnant women was not associated with an increased risk of autism, attention-deficit/hyperactivity disorder, or Tourette syndrome for their children, a new study shows.

The drugs included in the study were leukotriene-receptor antagonists (LTRAs), which are often used to treat allergic airway diseases, including asthma and allergic rhinitis.

“Over the years, the U.S. Food and Drug Administration has monitored post-marketing data about the potential harm of neuropsychiatric events (NEs) associated with montelukast, the first type of LTRAs, and issued boxed warnings about serious mental health side effects for montelukast in 2020,” said corresponding author Tsung-Chieh Yao, MD, of Chang Gung Memorial Hospital, Taiwan, in an interview.

However, evidence of a link between NEs and LTRA use has been inconsistent, according to Dr. Yao and colleagues.

“To date, it remains totally unknown whether the exposure to LTRAs during pregnancy is associated with the risk of neuropsychiatric events in offspring,” said Dr. Yao.

To address this question, the researchers used data from National Health Insurance Research Database in Taiwan to identify pregnant women and their offspring from 2009 to 2019. The initial study population included 576,157 mother-offspring pairs, including 1,995 LTRA-exposed and 574,162 nonexposed children.

The women had a diagnosis of asthma or allergic rhinitis; multiple births and children with congenital malformations were excluded. LTRA exposure was defined as any dispensed prescription for LTRAs during pregnancy. Approximately two-thirds of the mothers were aged 30-40 years at the time of delivery.

The findings were published in a research letter in JAMA Network Open.

In the study population at large, the incidence of the three neurodevelopmental disorders ADHD, autism spectrum disorder (ASD), and Tourette syndrome was not significantly different between those children exposed to LTRAs and those not exposed to LTRAs in utero (1.25% vs. 1.32%; 3.31% vs. 4.36%; and 0.45% vs. 0.83%, respectively).

After propensity score matching, the study population included 1,988 LTRA-exposed children and 19,863 nonexposed children. In this group, no significant associations appeared between prenatal LTRA exposure and the risk of attention-deficit/hyperactivity disorder (adjusted hazard ratio, 1.03), autism spectrum disorder (AHR, 1.01), and Tourette syndrome (AHR, 0.63).

Neither duration nor cumulative dose of LTRA use during pregnancy showed an association with ADHD, ASD, or Tourette syndrome in offspring. Duration of LTRA use was categorized as shorter or longer periods of 1-4 weeks vs. more than 4 weeks; cumulative dose was categorized as 1-170 mg vs. 170 mg or higher.

The findings were limited by the lack of randomization, inability to detect long-term risk, and potential lack of generalizability to non-Asian populations, and more research is needed to replicate the results, the researchers noted. However, the current findings were strengthened by the large study population, and suggest that LTRA use in pregnancy does not present a significant risk for NEs in children, which should be reassuring to clinicians and patients, they concluded.

The current study is the first to use the whole of Taiwan population data and extends previous studies by examining the association between LTRA use during pregnancy and risk of neuropsychiatric events in offspring, Dr. Yao said in an interview. “The possibly surprising, but reassuring, finding is that prenatal LTRA exposure did not increase risk of ADHD, ASD, and Tourette syndrome in offspring,” he said.

“Clinicians prescribing LTRAs such as montelukast (Singulair and generics) to pregnant women with asthma or allergic rhinitis may be reassured by our findings,” Dr. Yao added. The results offer real-world evidence to help inform decision-making about the use of LTRAs during pregnancy, although additional research is needed to replicate the study findings in other populations, he said.

The study was supported by the National Health Research Institutes, Taiwan, the Ministry of Science and Technology of Taiwan, the National Science and Technology Council of Taiwan, and the Chang Gung Medical Foundation. The researchers had no financial conflicts to disclose.

Use of asthma medication by pregnant women was not associated with an increased risk of autism, attention-deficit/hyperactivity disorder, or Tourette syndrome for their children, a new study shows.

The drugs included in the study were leukotriene-receptor antagonists (LTRAs), which are often used to treat allergic airway diseases, including asthma and allergic rhinitis.

“Over the years, the U.S. Food and Drug Administration has monitored post-marketing data about the potential harm of neuropsychiatric events (NEs) associated with montelukast, the first type of LTRAs, and issued boxed warnings about serious mental health side effects for montelukast in 2020,” said corresponding author Tsung-Chieh Yao, MD, of Chang Gung Memorial Hospital, Taiwan, in an interview.

However, evidence of a link between NEs and LTRA use has been inconsistent, according to Dr. Yao and colleagues.

“To date, it remains totally unknown whether the exposure to LTRAs during pregnancy is associated with the risk of neuropsychiatric events in offspring,” said Dr. Yao.

To address this question, the researchers used data from National Health Insurance Research Database in Taiwan to identify pregnant women and their offspring from 2009 to 2019. The initial study population included 576,157 mother-offspring pairs, including 1,995 LTRA-exposed and 574,162 nonexposed children.

The women had a diagnosis of asthma or allergic rhinitis; multiple births and children with congenital malformations were excluded. LTRA exposure was defined as any dispensed prescription for LTRAs during pregnancy. Approximately two-thirds of the mothers were aged 30-40 years at the time of delivery.

The findings were published in a research letter in JAMA Network Open.

In the study population at large, the incidence of the three neurodevelopmental disorders ADHD, autism spectrum disorder (ASD), and Tourette syndrome was not significantly different between those children exposed to LTRAs and those not exposed to LTRAs in utero (1.25% vs. 1.32%; 3.31% vs. 4.36%; and 0.45% vs. 0.83%, respectively).

After propensity score matching, the study population included 1,988 LTRA-exposed children and 19,863 nonexposed children. In this group, no significant associations appeared between prenatal LTRA exposure and the risk of attention-deficit/hyperactivity disorder (adjusted hazard ratio, 1.03), autism spectrum disorder (AHR, 1.01), and Tourette syndrome (AHR, 0.63).

Neither duration nor cumulative dose of LTRA use during pregnancy showed an association with ADHD, ASD, or Tourette syndrome in offspring. Duration of LTRA use was categorized as shorter or longer periods of 1-4 weeks vs. more than 4 weeks; cumulative dose was categorized as 1-170 mg vs. 170 mg or higher.

The findings were limited by the lack of randomization, inability to detect long-term risk, and potential lack of generalizability to non-Asian populations, and more research is needed to replicate the results, the researchers noted. However, the current findings were strengthened by the large study population, and suggest that LTRA use in pregnancy does not present a significant risk for NEs in children, which should be reassuring to clinicians and patients, they concluded.

The current study is the first to use the whole of Taiwan population data and extends previous studies by examining the association between LTRA use during pregnancy and risk of neuropsychiatric events in offspring, Dr. Yao said in an interview. “The possibly surprising, but reassuring, finding is that prenatal LTRA exposure did not increase risk of ADHD, ASD, and Tourette syndrome in offspring,” he said.

“Clinicians prescribing LTRAs such as montelukast (Singulair and generics) to pregnant women with asthma or allergic rhinitis may be reassured by our findings,” Dr. Yao added. The results offer real-world evidence to help inform decision-making about the use of LTRAs during pregnancy, although additional research is needed to replicate the study findings in other populations, he said.

The study was supported by the National Health Research Institutes, Taiwan, the Ministry of Science and Technology of Taiwan, the National Science and Technology Council of Taiwan, and the Chang Gung Medical Foundation. The researchers had no financial conflicts to disclose.

Use of asthma medication by pregnant women was not associated with an increased risk of autism, attention-deficit/hyperactivity disorder, or Tourette syndrome for their children, a new study shows.

The drugs included in the study were leukotriene-receptor antagonists (LTRAs), which are often used to treat allergic airway diseases, including asthma and allergic rhinitis.

“Over the years, the U.S. Food and Drug Administration has monitored post-marketing data about the potential harm of neuropsychiatric events (NEs) associated with montelukast, the first type of LTRAs, and issued boxed warnings about serious mental health side effects for montelukast in 2020,” said corresponding author Tsung-Chieh Yao, MD, of Chang Gung Memorial Hospital, Taiwan, in an interview.

However, evidence of a link between NEs and LTRA use has been inconsistent, according to Dr. Yao and colleagues.

“To date, it remains totally unknown whether the exposure to LTRAs during pregnancy is associated with the risk of neuropsychiatric events in offspring,” said Dr. Yao.

To address this question, the researchers used data from National Health Insurance Research Database in Taiwan to identify pregnant women and their offspring from 2009 to 2019. The initial study population included 576,157 mother-offspring pairs, including 1,995 LTRA-exposed and 574,162 nonexposed children.

The women had a diagnosis of asthma or allergic rhinitis; multiple births and children with congenital malformations were excluded. LTRA exposure was defined as any dispensed prescription for LTRAs during pregnancy. Approximately two-thirds of the mothers were aged 30-40 years at the time of delivery.

The findings were published in a research letter in JAMA Network Open.

In the study population at large, the incidence of the three neurodevelopmental disorders ADHD, autism spectrum disorder (ASD), and Tourette syndrome was not significantly different between those children exposed to LTRAs and those not exposed to LTRAs in utero (1.25% vs. 1.32%; 3.31% vs. 4.36%; and 0.45% vs. 0.83%, respectively).

After propensity score matching, the study population included 1,988 LTRA-exposed children and 19,863 nonexposed children. In this group, no significant associations appeared between prenatal LTRA exposure and the risk of attention-deficit/hyperactivity disorder (adjusted hazard ratio, 1.03), autism spectrum disorder (AHR, 1.01), and Tourette syndrome (AHR, 0.63).

Neither duration nor cumulative dose of LTRA use during pregnancy showed an association with ADHD, ASD, or Tourette syndrome in offspring. Duration of LTRA use was categorized as shorter or longer periods of 1-4 weeks vs. more than 4 weeks; cumulative dose was categorized as 1-170 mg vs. 170 mg or higher.

The findings were limited by the lack of randomization, inability to detect long-term risk, and potential lack of generalizability to non-Asian populations, and more research is needed to replicate the results, the researchers noted. However, the current findings were strengthened by the large study population, and suggest that LTRA use in pregnancy does not present a significant risk for NEs in children, which should be reassuring to clinicians and patients, they concluded.

The current study is the first to use the whole of Taiwan population data and extends previous studies by examining the association between LTRA use during pregnancy and risk of neuropsychiatric events in offspring, Dr. Yao said in an interview. “The possibly surprising, but reassuring, finding is that prenatal LTRA exposure did not increase risk of ADHD, ASD, and Tourette syndrome in offspring,” he said.

“Clinicians prescribing LTRAs such as montelukast (Singulair and generics) to pregnant women with asthma or allergic rhinitis may be reassured by our findings,” Dr. Yao added. The results offer real-world evidence to help inform decision-making about the use of LTRAs during pregnancy, although additional research is needed to replicate the study findings in other populations, he said.

The study was supported by the National Health Research Institutes, Taiwan, the Ministry of Science and Technology of Taiwan, the National Science and Technology Council of Taiwan, and the Chang Gung Medical Foundation. The researchers had no financial conflicts to disclose.

If budesonide-formoterol were to become available over the counter (OTC) and used as-needed for mild asthma, it would save lives and cut health care costs, according to a computer modeling study presented at the American Academy of Allergy, Asthma, and Immunology 2023 annual meeting in San Antonio.

Asthma affects 25 million people, about 1 in 13, in the United States. About 28% are uninsured or underinsured, and 70% have mild asthma. Many are using a $30 inhaled epinephrine product (Primatene Mist) – the only FDA-approved asthma inhaler available without a prescription, said Marcus Shaker, MD, MS, professor of pediatrics and medicine at Geisel School of Medicine at Dartmouth, and clinician at Dartmouth Health Children’s, N.H.

A new version of Primatene Mist was reintroduced on the market in 2018 after the product was pulled for containing chlorofluorocarbons in 2011, but it is not recommended by professional medical societies because of safety concerns over epinephrine’s adverse effects, such as increased heart rate and blood pressure.

Drugs in its class (bronchodilators) have long been associated with a higher risk for death or near-death.

Meanwhile, research more than 2 decades ago linked regular use of low-dose inhaled corticosteroids with reduced risk for asthma death.

More recently, two large studies (SYGMA 1 and SYGMA 2) compared maintenance therapy with a low-dose inhaled corticosteroid (budesonide) vs. on-demand treatment with an inhaler containing both a corticosteroid (budesonide) and a long-acting bronchodilator (formoterol).

“Using as-needed budesonide-formoterol led to outcomes that are almost as good as taking a maintenance budesonide dose every day,” said Dr. Shaker.

The Global Initiative for Asthma guidelines now recommend this approach – as-needed inhaled corticosteroids (ICS) plus long-acting bronchodilators – for adults with mild asthma. In the United States, however, the National Heart, Lung, and Blood Institute still suggests daily ICS plus quick-relief therapy as needed.

Dr. Shaker and colleagues used computer modeling to compare the cost-effectiveness of as-needed budesonide-formoterol vs. over-the-counter inhaled epinephrine in underinsured U.S. adults who were self-managing their mild asthma. The study randomly assigned these individuals into three groups: OTC inhaled epinephrine (current reality), OTC budesonide-formoterol (not yet available), or no OTC option. The model assumed that patients treated for an exacerbation were referred to a health care provider and started a regimen of ICS plus as-needed rescue therapy.

In this analysis, which has been submitted for publication, the OTC budesonide-formoterol strategy was associated with 12,495 fewer deaths, prevented nearly 14 million severe asthma exacerbations, and saved more than $68 billion. And “when we looked at OTC budesonide-formoterol vs. having no OTC option at all, budesonide-formoterol was similarly cost-effective,” said Dr. Shaker, who presented the results at an AAAAI oral abstract session.

The cost savings emerged even though in the United States asthma controller therapies (for example, fluticasone) cost about 10 times more than rescue therapies (for instance, salbutamol, OTC epinephrine).

Nevertheless, the results make sense. “If you’re using Primatene Mist, your health costs are predicted to be much greater because you’re going to be in the hospital more. Your asthma is not going to be well-controlled,” Thanai Pongdee, MD, an allergist-immunologist with the Mayo Clinic in Rochester, Minn., told this news organization. “It’s not only the cost of your ER visit but also the cost of loss of work or school, and loss of daily productivity. There are all these associated costs.”

The analysis “is certainly something policy makers could take a look at,” he said.

He noted that current use of budesonide-formoterol is stymied by difficulties with insurance coverage. The difficulties stem from a mismatch between the updated recommendation for as-needed use and the description printed on the brand-name product (Symbicort).

“On the product label, it says Symbicort should be used on a daily basis,” Dr. Pongdee said. “But if a prescription comes through and says you’re going to use this ‘as needed,’ the health plan may say that’s not appropriate because that’s not on the product label.”

Given these access challenges with the all-in-one inhaler, other researchers have developed a workaround – asking patients to continue their usual care (that is, using a rescue inhaler as needed) but to also administer a controller medication after each rescue. When tested in Black and Latino patients with moderate to severe asthma, this easy strategy (patient activated reliever-triggered inhaled corticosteroid, or PARTICS) reduced severe asthma exacerbations about as well as the all-in-one inhaler.

If the all-in-one budesonide-formoterol does become available OTC, Dr. Shaker stressed that it “would not be a substitute for seeing an allergist and getting appropriate medical care and an evaluation and all the rest. But it’s better than the status quo. It’s the sort of thing where the perfect is not the enemy of the good,” he said.

Dr. Shaker is the AAAAI cochair of the Joint Task Force on Practice Parameters and serves as an editorial board member of the Journal of Allergy and Clinical Immunology in Practice. He is also an associate editor of the Annals of Allergy, Asthma, and Immunology. Dr. Pongdee serves as an at-large director on the AAAAI board of directors. He receives grant funding from GlaxoSmithKline, and Mayo Clinic is a trial site for GlaxoSmithKline and AstraZeneca.

A version of this article first appeared on Medscape.com.

If budesonide-formoterol were to become available over the counter (OTC) and used as-needed for mild asthma, it would save lives and cut health care costs, according to a computer modeling study presented at the American Academy of Allergy, Asthma, and Immunology 2023 annual meeting in San Antonio.

Asthma affects 25 million people, about 1 in 13, in the United States. About 28% are uninsured or underinsured, and 70% have mild asthma. Many are using a $30 inhaled epinephrine product (Primatene Mist) – the only FDA-approved asthma inhaler available without a prescription, said Marcus Shaker, MD, MS, professor of pediatrics and medicine at Geisel School of Medicine at Dartmouth, and clinician at Dartmouth Health Children’s, N.H.

A new version of Primatene Mist was reintroduced on the market in 2018 after the product was pulled for containing chlorofluorocarbons in 2011, but it is not recommended by professional medical societies because of safety concerns over epinephrine’s adverse effects, such as increased heart rate and blood pressure.

Drugs in its class (bronchodilators) have long been associated with a higher risk for death or near-death.

Meanwhile, research more than 2 decades ago linked regular use of low-dose inhaled corticosteroids with reduced risk for asthma death.

More recently, two large studies (SYGMA 1 and SYGMA 2) compared maintenance therapy with a low-dose inhaled corticosteroid (budesonide) vs. on-demand treatment with an inhaler containing both a corticosteroid (budesonide) and a long-acting bronchodilator (formoterol).

“Using as-needed budesonide-formoterol led to outcomes that are almost as good as taking a maintenance budesonide dose every day,” said Dr. Shaker.

The Global Initiative for Asthma guidelines now recommend this approach – as-needed inhaled corticosteroids (ICS) plus long-acting bronchodilators – for adults with mild asthma. In the United States, however, the National Heart, Lung, and Blood Institute still suggests daily ICS plus quick-relief therapy as needed.

Dr. Shaker and colleagues used computer modeling to compare the cost-effectiveness of as-needed budesonide-formoterol vs. over-the-counter inhaled epinephrine in underinsured U.S. adults who were self-managing their mild asthma. The study randomly assigned these individuals into three groups: OTC inhaled epinephrine (current reality), OTC budesonide-formoterol (not yet available), or no OTC option. The model assumed that patients treated for an exacerbation were referred to a health care provider and started a regimen of ICS plus as-needed rescue therapy.

In this analysis, which has been submitted for publication, the OTC budesonide-formoterol strategy was associated with 12,495 fewer deaths, prevented nearly 14 million severe asthma exacerbations, and saved more than $68 billion. And “when we looked at OTC budesonide-formoterol vs. having no OTC option at all, budesonide-formoterol was similarly cost-effective,” said Dr. Shaker, who presented the results at an AAAAI oral abstract session.

The cost savings emerged even though in the United States asthma controller therapies (for example, fluticasone) cost about 10 times more than rescue therapies (for instance, salbutamol, OTC epinephrine).

Nevertheless, the results make sense. “If you’re using Primatene Mist, your health costs are predicted to be much greater because you’re going to be in the hospital more. Your asthma is not going to be well-controlled,” Thanai Pongdee, MD, an allergist-immunologist with the Mayo Clinic in Rochester, Minn., told this news organization. “It’s not only the cost of your ER visit but also the cost of loss of work or school, and loss of daily productivity. There are all these associated costs.”

The analysis “is certainly something policy makers could take a look at,” he said.

He noted that current use of budesonide-formoterol is stymied by difficulties with insurance coverage. The difficulties stem from a mismatch between the updated recommendation for as-needed use and the description printed on the brand-name product (Symbicort).

“On the product label, it says Symbicort should be used on a daily basis,” Dr. Pongdee said. “But if a prescription comes through and says you’re going to use this ‘as needed,’ the health plan may say that’s not appropriate because that’s not on the product label.”

Given these access challenges with the all-in-one inhaler, other researchers have developed a workaround – asking patients to continue their usual care (that is, using a rescue inhaler as needed) but to also administer a controller medication after each rescue. When tested in Black and Latino patients with moderate to severe asthma, this easy strategy (patient activated reliever-triggered inhaled corticosteroid, or PARTICS) reduced severe asthma exacerbations about as well as the all-in-one inhaler.

If the all-in-one budesonide-formoterol does become available OTC, Dr. Shaker stressed that it “would not be a substitute for seeing an allergist and getting appropriate medical care and an evaluation and all the rest. But it’s better than the status quo. It’s the sort of thing where the perfect is not the enemy of the good,” he said.

Dr. Shaker is the AAAAI cochair of the Joint Task Force on Practice Parameters and serves as an editorial board member of the Journal of Allergy and Clinical Immunology in Practice. He is also an associate editor of the Annals of Allergy, Asthma, and Immunology. Dr. Pongdee serves as an at-large director on the AAAAI board of directors. He receives grant funding from GlaxoSmithKline, and Mayo Clinic is a trial site for GlaxoSmithKline and AstraZeneca.

A version of this article first appeared on Medscape.com.

If budesonide-formoterol were to become available over the counter (OTC) and used as-needed for mild asthma, it would save lives and cut health care costs, according to a computer modeling study presented at the American Academy of Allergy, Asthma, and Immunology 2023 annual meeting in San Antonio.

Asthma affects 25 million people, about 1 in 13, in the United States. About 28% are uninsured or underinsured, and 70% have mild asthma. Many are using a $30 inhaled epinephrine product (Primatene Mist) – the only FDA-approved asthma inhaler available without a prescription, said Marcus Shaker, MD, MS, professor of pediatrics and medicine at Geisel School of Medicine at Dartmouth, and clinician at Dartmouth Health Children’s, N.H.

A new version of Primatene Mist was reintroduced on the market in 2018 after the product was pulled for containing chlorofluorocarbons in 2011, but it is not recommended by professional medical societies because of safety concerns over epinephrine’s adverse effects, such as increased heart rate and blood pressure.

Drugs in its class (bronchodilators) have long been associated with a higher risk for death or near-death.

Meanwhile, research more than 2 decades ago linked regular use of low-dose inhaled corticosteroids with reduced risk for asthma death.

More recently, two large studies (SYGMA 1 and SYGMA 2) compared maintenance therapy with a low-dose inhaled corticosteroid (budesonide) vs. on-demand treatment with an inhaler containing both a corticosteroid (budesonide) and a long-acting bronchodilator (formoterol).

“Using as-needed budesonide-formoterol led to outcomes that are almost as good as taking a maintenance budesonide dose every day,” said Dr. Shaker.

The Global Initiative for Asthma guidelines now recommend this approach – as-needed inhaled corticosteroids (ICS) plus long-acting bronchodilators – for adults with mild asthma. In the United States, however, the National Heart, Lung, and Blood Institute still suggests daily ICS plus quick-relief therapy as needed.

Dr. Shaker and colleagues used computer modeling to compare the cost-effectiveness of as-needed budesonide-formoterol vs. over-the-counter inhaled epinephrine in underinsured U.S. adults who were self-managing their mild asthma. The study randomly assigned these individuals into three groups: OTC inhaled epinephrine (current reality), OTC budesonide-formoterol (not yet available), or no OTC option. The model assumed that patients treated for an exacerbation were referred to a health care provider and started a regimen of ICS plus as-needed rescue therapy.

In this analysis, which has been submitted for publication, the OTC budesonide-formoterol strategy was associated with 12,495 fewer deaths, prevented nearly 14 million severe asthma exacerbations, and saved more than $68 billion. And “when we looked at OTC budesonide-formoterol vs. having no OTC option at all, budesonide-formoterol was similarly cost-effective,” said Dr. Shaker, who presented the results at an AAAAI oral abstract session.

The cost savings emerged even though in the United States asthma controller therapies (for example, fluticasone) cost about 10 times more than rescue therapies (for instance, salbutamol, OTC epinephrine).

Nevertheless, the results make sense. “If you’re using Primatene Mist, your health costs are predicted to be much greater because you’re going to be in the hospital more. Your asthma is not going to be well-controlled,” Thanai Pongdee, MD, an allergist-immunologist with the Mayo Clinic in Rochester, Minn., told this news organization. “It’s not only the cost of your ER visit but also the cost of loss of work or school, and loss of daily productivity. There are all these associated costs.”

The analysis “is certainly something policy makers could take a look at,” he said.

He noted that current use of budesonide-formoterol is stymied by difficulties with insurance coverage. The difficulties stem from a mismatch between the updated recommendation for as-needed use and the description printed on the brand-name product (Symbicort).

“On the product label, it says Symbicort should be used on a daily basis,” Dr. Pongdee said. “But if a prescription comes through and says you’re going to use this ‘as needed,’ the health plan may say that’s not appropriate because that’s not on the product label.”

Given these access challenges with the all-in-one inhaler, other researchers have developed a workaround – asking patients to continue their usual care (that is, using a rescue inhaler as needed) but to also administer a controller medication after each rescue. When tested in Black and Latino patients with moderate to severe asthma, this easy strategy (patient activated reliever-triggered inhaled corticosteroid, or PARTICS) reduced severe asthma exacerbations about as well as the all-in-one inhaler.

If the all-in-one budesonide-formoterol does become available OTC, Dr. Shaker stressed that it “would not be a substitute for seeing an allergist and getting appropriate medical care and an evaluation and all the rest. But it’s better than the status quo. It’s the sort of thing where the perfect is not the enemy of the good,” he said.

Dr. Shaker is the AAAAI cochair of the Joint Task Force on Practice Parameters and serves as an editorial board member of the Journal of Allergy and Clinical Immunology in Practice. He is also an associate editor of the Annals of Allergy, Asthma, and Immunology. Dr. Pongdee serves as an at-large director on the AAAAI board of directors. He receives grant funding from GlaxoSmithKline, and Mayo Clinic is a trial site for GlaxoSmithKline and AstraZeneca.

A version of this article first appeared on Medscape.com.

Specific sputum markers, including higher sputum eosinophils, macrophages, and lymphocyte counts, were associated with remission after interleukin-5 (IL-5)–targeted therapy for patients with severe eosinophilic asthma. The finding was based on data from 52 individuals.

Although IL-5 therapies have been shown to be effective for improving asthma, patients’ responses vary, write Catherine Moermans, PhD, of Liège University, Belgium, and colleagues.

Biotherapies targeting IL-5 allow a tangible improvement of asthma. However, all patients do not respond the same way to these treatments, and reliable biomarkers for predicting treatment response are lacking, they say.

In an observational study published in the journal Chest, the researchers recruited 52 adults with severe asthma who began anti–IL-5 treatment at a single center. The primary outcome was remission of asthma.

Remission was defined as meeting all of the following criteria 1 year after therapy: no chronic treatment with oral corticosteroids; no exacerbation; asthma control questionnaire scores lower than 1.5 and/or asthma test greater than 19; forced expiratory volume in 1 second (FEV₁) of at least 80% predicted; and/or improvement of FEV₁ equal to or larger than 10%, and a blood eosinophil count lower than 300 cells/mL.

Prior to treatment, the researchers measured eosinophil peroxidase (EPX), immunoglobulin E (IgE), IL-3, IL-4, IL-5, IL-13, IL-25, IL-33, granulocyte-macrophage colony-stimulating factor (GM-CSF), thymic stromal lymphopoietin (TSLP), and eotaxin-1 levels in the sputum of each patient.

At follow-up, 11 patients met the criteria for remission. These patients had significantly higher sputum eosinophil counts, sputum macrophage counts, and lymphocyte counts at baseline, compared with those not in remission (P = .006, P = .02, and P = .04, respectively). Sputum neutrophil percentage levels were significantly lower in patients whose asthma was in remission, compared with those whose asthma was not in remission (P = .007).

At the protein level, remission patients also showed higher baseline levels of sputum eotaxin-1, TSLP, IL-5, EPX, and IgE protein, compared with patients who did not achieve remission (P = .046, P = .04, P = .002, P = .001, and P = .006, respectively).

Overall, EPX and IL-5 measures showed the best combination of sensitivity and specificity, as well as the best area under the curve, the researchers write.

Patients in remission were significantly more likely to be men (8 of 11 patients), a finding that reflected previous studies, the researchers write. The finding of eosinophilic inflammation associated with stronger response to anti–IL-5 therapy also reflected previous studies, but the current study showed that “with a comparable blood eosinophil level at baseline before biotherapy, the response can be highly variable.”

The study findings were limited by several factors, including the small sample size and the lack of a formal definition of remission. Other research needs include an analysis based on nonresponse or suboptimal response predictors, the researchers note.

The results suggest that sputum type 2 markers are potential predictors of remission after anti–IL-5 treatment in adults with severe eosinophilic asthma, although the results must be validated in a larger, multicenter cohort, they conclude.

The study was supported by GlaxoSmithKline and AstraZeneca. Several coauthors have relationships with these companies. Dr. Moermans has disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Specific sputum markers, including higher sputum eosinophils, macrophages, and lymphocyte counts, were associated with remission after interleukin-5 (IL-5)–targeted therapy for patients with severe eosinophilic asthma. The finding was based on data from 52 individuals.

Although IL-5 therapies have been shown to be effective for improving asthma, patients’ responses vary, write Catherine Moermans, PhD, of Liège University, Belgium, and colleagues.

Biotherapies targeting IL-5 allow a tangible improvement of asthma. However, all patients do not respond the same way to these treatments, and reliable biomarkers for predicting treatment response are lacking, they say.

In an observational study published in the journal Chest, the researchers recruited 52 adults with severe asthma who began anti–IL-5 treatment at a single center. The primary outcome was remission of asthma.

Remission was defined as meeting all of the following criteria 1 year after therapy: no chronic treatment with oral corticosteroids; no exacerbation; asthma control questionnaire scores lower than 1.5 and/or asthma test greater than 19; forced expiratory volume in 1 second (FEV₁) of at least 80% predicted; and/or improvement of FEV₁ equal to or larger than 10%, and a blood eosinophil count lower than 300 cells/mL.

Prior to treatment, the researchers measured eosinophil peroxidase (EPX), immunoglobulin E (IgE), IL-3, IL-4, IL-5, IL-13, IL-25, IL-33, granulocyte-macrophage colony-stimulating factor (GM-CSF), thymic stromal lymphopoietin (TSLP), and eotaxin-1 levels in the sputum of each patient.

At follow-up, 11 patients met the criteria for remission. These patients had significantly higher sputum eosinophil counts, sputum macrophage counts, and lymphocyte counts at baseline, compared with those not in remission (P = .006, P = .02, and P = .04, respectively). Sputum neutrophil percentage levels were significantly lower in patients whose asthma was in remission, compared with those whose asthma was not in remission (P = .007).

At the protein level, remission patients also showed higher baseline levels of sputum eotaxin-1, TSLP, IL-5, EPX, and IgE protein, compared with patients who did not achieve remission (P = .046, P = .04, P = .002, P = .001, and P = .006, respectively).

Overall, EPX and IL-5 measures showed the best combination of sensitivity and specificity, as well as the best area under the curve, the researchers write.

Patients in remission were significantly more likely to be men (8 of 11 patients), a finding that reflected previous studies, the researchers write. The finding of eosinophilic inflammation associated with stronger response to anti–IL-5 therapy also reflected previous studies, but the current study showed that “with a comparable blood eosinophil level at baseline before biotherapy, the response can be highly variable.”

The study findings were limited by several factors, including the small sample size and the lack of a formal definition of remission. Other research needs include an analysis based on nonresponse or suboptimal response predictors, the researchers note.

The results suggest that sputum type 2 markers are potential predictors of remission after anti–IL-5 treatment in adults with severe eosinophilic asthma, although the results must be validated in a larger, multicenter cohort, they conclude.

The study was supported by GlaxoSmithKline and AstraZeneca. Several coauthors have relationships with these companies. Dr. Moermans has disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Specific sputum markers, including higher sputum eosinophils, macrophages, and lymphocyte counts, were associated with remission after interleukin-5 (IL-5)–targeted therapy for patients with severe eosinophilic asthma. The finding was based on data from 52 individuals.

Although IL-5 therapies have been shown to be effective for improving asthma, patients’ responses vary, write Catherine Moermans, PhD, of Liège University, Belgium, and colleagues.

Biotherapies targeting IL-5 allow a tangible improvement of asthma. However, all patients do not respond the same way to these treatments, and reliable biomarkers for predicting treatment response are lacking, they say.

In an observational study published in the journal Chest, the researchers recruited 52 adults with severe asthma who began anti–IL-5 treatment at a single center. The primary outcome was remission of asthma.

Remission was defined as meeting all of the following criteria 1 year after therapy: no chronic treatment with oral corticosteroids; no exacerbation; asthma control questionnaire scores lower than 1.5 and/or asthma test greater than 19; forced expiratory volume in 1 second (FEV₁) of at least 80% predicted; and/or improvement of FEV₁ equal to or larger than 10%, and a blood eosinophil count lower than 300 cells/mL.

Prior to treatment, the researchers measured eosinophil peroxidase (EPX), immunoglobulin E (IgE), IL-3, IL-4, IL-5, IL-13, IL-25, IL-33, granulocyte-macrophage colony-stimulating factor (GM-CSF), thymic stromal lymphopoietin (TSLP), and eotaxin-1 levels in the sputum of each patient.

At follow-up, 11 patients met the criteria for remission. These patients had significantly higher sputum eosinophil counts, sputum macrophage counts, and lymphocyte counts at baseline, compared with those not in remission (P = .006, P = .02, and P = .04, respectively). Sputum neutrophil percentage levels were significantly lower in patients whose asthma was in remission, compared with those whose asthma was not in remission (P = .007).

At the protein level, remission patients also showed higher baseline levels of sputum eotaxin-1, TSLP, IL-5, EPX, and IgE protein, compared with patients who did not achieve remission (P = .046, P = .04, P = .002, P = .001, and P = .006, respectively).

Overall, EPX and IL-5 measures showed the best combination of sensitivity and specificity, as well as the best area under the curve, the researchers write.

Patients in remission were significantly more likely to be men (8 of 11 patients), a finding that reflected previous studies, the researchers write. The finding of eosinophilic inflammation associated with stronger response to anti–IL-5 therapy also reflected previous studies, but the current study showed that “with a comparable blood eosinophil level at baseline before biotherapy, the response can be highly variable.”

The study findings were limited by several factors, including the small sample size and the lack of a formal definition of remission. Other research needs include an analysis based on nonresponse or suboptimal response predictors, the researchers note.

The results suggest that sputum type 2 markers are potential predictors of remission after anti–IL-5 treatment in adults with severe eosinophilic asthma, although the results must be validated in a larger, multicenter cohort, they conclude.

The study was supported by GlaxoSmithKline and AstraZeneca. Several coauthors have relationships with these companies. Dr. Moermans has disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Both asthma and chronic obstructive pulmonary disease can be challenging to diagnose, and medication-driven episodes of sedation or hypoventilation are often overlooked as causes of acute exacerbations in these conditions, according to a letter published in The Lancet Respiratory Medicine.

“We are concerned about the number of patients we have seen with asthma or chronic obstructive pulmonary disease (COPD) exacerbations who have been prescribed sedative medications,” write Christos V. Chalitsios, PhD, of the University of Nottingham, England, and colleagues.

The authors note that exacerbations are the main complications of both asthma and COPD, and stress the importance of identifying causes and preventive strategies.

Sedatives such as opioids have been shown to depress respiratory drive, reduce muscle tone, and increase the risk of pneumonia, they write. The authors also propose that the risk of sedative-induced aspiration or hypoventilation would be associated with medications including pregabalin, gabapentin, and amitriptyline.

Other mechanisms may be involved in the association between sedatives and exacerbations in asthma and COPD. For example, sedative medications can suppress coughing, which may promote airway mucous compaction and possible infection, the authors write.

Most research involving prevention of asthma and COPD exacerbations has not addressed the potential impact of sedatives taken for reasons outside of obstructive lung disease, the authors say.

“Although the risk of sedation and hypoventilation events are known to be increased by opioids and antipsychotic drugs, there has not been a systematic assessment of commonly prescribed medications with potential respiratory side-effects, including gabapentin, amitriptyline, and pregabalin,” they write.

Polypharmacy is increasingly common and results in many patients with asthma or COPD presenting for treatment of acute exacerbations while on a combination of gabapentin, pregabalin, amitriptyline, and opioids, the authors note; “however, there is little data or disease-specific guidance on how best to manage this problem, which often starts with a prescription in primary care,” they write. Simply stopping sedatives is not an option for many patients given the addictive nature of these drugs and the unlikely resolution of the condition for which the drugs were prescribed, the authors say. However, “cautious dose reduction” of sedatives is possible once patients understand the reason, they add.

Clinicians may be able to suggest reduced doses and alternative treatments to patients with asthma and COPD while highlighting the risk of respiratory depression and polypharmacy – “potentially reducing the number of exacerbations of obstructive lung disease,” the authors conclude.

The study received no outside funding. The authors have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Both asthma and chronic obstructive pulmonary disease can be challenging to diagnose, and medication-driven episodes of sedation or hypoventilation are often overlooked as causes of acute exacerbations in these conditions, according to a letter published in The Lancet Respiratory Medicine.

“We are concerned about the number of patients we have seen with asthma or chronic obstructive pulmonary disease (COPD) exacerbations who have been prescribed sedative medications,” write Christos V. Chalitsios, PhD, of the University of Nottingham, England, and colleagues.

The authors note that exacerbations are the main complications of both asthma and COPD, and stress the importance of identifying causes and preventive strategies.

Sedatives such as opioids have been shown to depress respiratory drive, reduce muscle tone, and increase the risk of pneumonia, they write. The authors also propose that the risk of sedative-induced aspiration or hypoventilation would be associated with medications including pregabalin, gabapentin, and amitriptyline.

Other mechanisms may be involved in the association between sedatives and exacerbations in asthma and COPD. For example, sedative medications can suppress coughing, which may promote airway mucous compaction and possible infection, the authors write.

Most research involving prevention of asthma and COPD exacerbations has not addressed the potential impact of sedatives taken for reasons outside of obstructive lung disease, the authors say.

“Although the risk of sedation and hypoventilation events are known to be increased by opioids and antipsychotic drugs, there has not been a systematic assessment of commonly prescribed medications with potential respiratory side-effects, including gabapentin, amitriptyline, and pregabalin,” they write.

Polypharmacy is increasingly common and results in many patients with asthma or COPD presenting for treatment of acute exacerbations while on a combination of gabapentin, pregabalin, amitriptyline, and opioids, the authors note; “however, there is little data or disease-specific guidance on how best to manage this problem, which often starts with a prescription in primary care,” they write. Simply stopping sedatives is not an option for many patients given the addictive nature of these drugs and the unlikely resolution of the condition for which the drugs were prescribed, the authors say. However, “cautious dose reduction” of sedatives is possible once patients understand the reason, they add.

Clinicians may be able to suggest reduced doses and alternative treatments to patients with asthma and COPD while highlighting the risk of respiratory depression and polypharmacy – “potentially reducing the number of exacerbations of obstructive lung disease,” the authors conclude.

The study received no outside funding. The authors have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Both asthma and chronic obstructive pulmonary disease can be challenging to diagnose, and medication-driven episodes of sedation or hypoventilation are often overlooked as causes of acute exacerbations in these conditions, according to a letter published in The Lancet Respiratory Medicine.

“We are concerned about the number of patients we have seen with asthma or chronic obstructive pulmonary disease (COPD) exacerbations who have been prescribed sedative medications,” write Christos V. Chalitsios, PhD, of the University of Nottingham, England, and colleagues.

The authors note that exacerbations are the main complications of both asthma and COPD, and stress the importance of identifying causes and preventive strategies.

Sedatives such as opioids have been shown to depress respiratory drive, reduce muscle tone, and increase the risk of pneumonia, they write. The authors also propose that the risk of sedative-induced aspiration or hypoventilation would be associated with medications including pregabalin, gabapentin, and amitriptyline.

Other mechanisms may be involved in the association between sedatives and exacerbations in asthma and COPD. For example, sedative medications can suppress coughing, which may promote airway mucous compaction and possible infection, the authors write.

Most research involving prevention of asthma and COPD exacerbations has not addressed the potential impact of sedatives taken for reasons outside of obstructive lung disease, the authors say.

“Although the risk of sedation and hypoventilation events are known to be increased by opioids and antipsychotic drugs, there has not been a systematic assessment of commonly prescribed medications with potential respiratory side-effects, including gabapentin, amitriptyline, and pregabalin,” they write.

Polypharmacy is increasingly common and results in many patients with asthma or COPD presenting for treatment of acute exacerbations while on a combination of gabapentin, pregabalin, amitriptyline, and opioids, the authors note; “however, there is little data or disease-specific guidance on how best to manage this problem, which often starts with a prescription in primary care,” they write. Simply stopping sedatives is not an option for many patients given the addictive nature of these drugs and the unlikely resolution of the condition for which the drugs were prescribed, the authors say. However, “cautious dose reduction” of sedatives is possible once patients understand the reason, they add.

Clinicians may be able to suggest reduced doses and alternative treatments to patients with asthma and COPD while highlighting the risk of respiratory depression and polypharmacy – “potentially reducing the number of exacerbations of obstructive lung disease,” the authors conclude.

The study received no outside funding. The authors have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

In a proof-of-concept feasibility study among adults with difficult-to-treat asthma and body mass index ≥ 30kg/m², an evidence-based, dietitian-led program resulted in clinically important improvements in asthma control and quality of life over 16 weeks compared to usual care.

The Counterweight-Plus weight management program (CWP) used in the study includes 12 weeks of total diet replacement (TDR), stepwise food reintroduction in weeks 13-18, and weight loss maintenance up to 1 year, according to a report by Varun Sharma, MBChB, and fellow researchers at University of Glasgow.

Difficult-to-treat asthma, found among about 17% of asthma-affected patients, may be attributed to factors such as poor inhaler technique, treatment nonadherence, and comorbidities such as obesity. Obesity is frequently associated with difficult-to-treat, uncontrolled asthma and increased morbidity and mortality. Among multifactorial effects of obesity on asthma are direct ones on thoracic wall mechanics, increased airway closure, airway hyper-responsiveness and airway inflammation. Prior research showing that weight loss may improve asthma outcomes has been conducted among heterogeneous asthma populations, with no clear consensus regarding optimal methods of weight management, according to the authors.

They tested whether use of the CWP compared to usual care (1:1) would improve asthma control and quality of life in this population of patients with obesity. The TDR phase comprised a low-energy liquid diet consisting of 825-853 kcal/day (approximately 59% carbohydrate, 13% fat, 26% protein, 2% fiber), with meals supplied dried in sachets by the dietitian team and reconstituted with water by the participants. A review by the dietitian team at 1 week was followed by reviews every other week.

The primary outcome was difference in change in Asthma Control Questionnaire (ACQ6) from baseline (visit 1) to 16 weeks (visit 2), between CWP and usual care.

The single-center trial included 33 evaluable adult patients (75 years or younger; mean age 53 years; 63% women) with asthma (as per Global Initiative for Asthma guidelines) that was difficult to treat (as per Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines). The study population consisted of patients with frequent exacerbations with uncontrolled disease as reflected by the median interquartile range (IQR) for oral corticosteroid courses in the previous 12 months of 3 (2 to 5) and mean ACQ6 of 2.8 (2.4 to 3.1). Mean overall Asthma Quality of Life Questionnaire (AQLQ) was 3.8 (3.4 to 4.2). Median weight was 101.7 (91.4 to 118.7) kg, with a median BMI of 37.5 (35.0 to 42.3) kg/m². Recruitment was discontinued before the target of 40 patients because the CWP dropout rate (n = 2) was lower than expected.

The researchers reported that the mean change in ACQ6 over 16 weeks was –0.45 for CWP and 0.23 for usual care with a mean difference of –0.69 (P = .048) between groups. The secondary outcome of mean change in overall AQLQ was 0.81 for CWP and 0.08 for usual care with a mean difference of 0.76 (P = .013) between groups.

No unexpected serious adverse events or intervention-related adverse events were observed during the trial.

“In this pragmatic open label, randomized, controlled trial we showed that delivery of a supported low-calorie total diet replacement program (Counterweight-Plus) to patients with difficult-to treat asthma and obesity, was safe and led to significant improvements in asthma control and quality of life compared to usual care over 16 weeks,” the authors wrote.

“Findings from the study are a welcome addition to this field of study,” Diego J. Maselli, MD, associate professor of medicine and interim chief, division of pulmonary diseases and critical care, UT Health at San Antonio, said in an interview. “Over the past years there has been an increase in the focus of comorbid conditions that may influence asthma control, particularly in severe disease.  Obesity is an important comorbid condition because, although by itself it may have an effect on asthma patients, it is also associated with other comorbidities such as gastroesophageal reflux disease, obstructive sleep apnea, anxiety, depression, and others that in turn can affect asthmatics. Also, obesity may influence pulmonary physiology and it’s considered a proinflammatory state by many, and this can favor uncontrolled disease.”  

While underscoring the clinically relevant weight loss and improvements in ACQ6 and AQLQ, Dr. Maselli said that the study did not follow the patients long enough to determine if weight loss was associated with a reduction in exacerbations and other long-term outcomes in asthma such as resource utilization and changes in maintenance medications, which may be explored in future studies.

“It remains to be seen if the weight loss of these types of programs can be sustained over longer periods of time, given the considerable caloric restriction in the initial stages of the weight reduction program. Interestingly, the majority of the patients in the study did not exhibit features of type 2 inflammation and had low-T2 endotype with low eosinophil count and low FeNO [fractional exhaled nitric oxide],” Dr. Maselli added. “Although obesity has been linked to this phenotype, the vast majority of [people with asthma], about 80%, have high T2 phenotype. Future studies are still need with larger and more representative samples and with longer follow-up times to determine the effects of weight loss on asthma outcomes, especially in severe asthma,” he concluded.

The trial was funded by an NHS Greater Glasgow and Clyde Endowment Fund grant. Several of the authors reported having received travel awards to attend conferences and funding from Cambridge Weight Plan and one author is an employee of and another a medical adviser for Counterweight Ltd., the developer of the program used. Other authors reported receiving funding from a variety of pharmaceutical companies. Dr. Maselli reported no relevant conflicts.

In a proof-of-concept feasibility study among adults with difficult-to-treat asthma and body mass index ≥ 30kg/m², an evidence-based, dietitian-led program resulted in clinically important improvements in asthma control and quality of life over 16 weeks compared to usual care.

The Counterweight-Plus weight management program (CWP) used in the study includes 12 weeks of total diet replacement (TDR), stepwise food reintroduction in weeks 13-18, and weight loss maintenance up to 1 year, according to a report by Varun Sharma, MBChB, and fellow researchers at University of Glasgow.

Difficult-to-treat asthma, found among about 17% of asthma-affected patients, may be attributed to factors such as poor inhaler technique, treatment nonadherence, and comorbidities such as obesity. Obesity is frequently associated with difficult-to-treat, uncontrolled asthma and increased morbidity and mortality. Among multifactorial effects of obesity on asthma are direct ones on thoracic wall mechanics, increased airway closure, airway hyper-responsiveness and airway inflammation. Prior research showing that weight loss may improve asthma outcomes has been conducted among heterogeneous asthma populations, with no clear consensus regarding optimal methods of weight management, according to the authors.

They tested whether use of the CWP compared to usual care (1:1) would improve asthma control and quality of life in this population of patients with obesity. The TDR phase comprised a low-energy liquid diet consisting of 825-853 kcal/day (approximately 59% carbohydrate, 13% fat, 26% protein, 2% fiber), with meals supplied dried in sachets by the dietitian team and reconstituted with water by the participants. A review by the dietitian team at 1 week was followed by reviews every other week.

The primary outcome was difference in change in Asthma Control Questionnaire (ACQ6) from baseline (visit 1) to 16 weeks (visit 2), between CWP and usual care.

The single-center trial included 33 evaluable adult patients (75 years or younger; mean age 53 years; 63% women) with asthma (as per Global Initiative for Asthma guidelines) that was difficult to treat (as per Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines). The study population consisted of patients with frequent exacerbations with uncontrolled disease as reflected by the median interquartile range (IQR) for oral corticosteroid courses in the previous 12 months of 3 (2 to 5) and mean ACQ6 of 2.8 (2.4 to 3.1). Mean overall Asthma Quality of Life Questionnaire (AQLQ) was 3.8 (3.4 to 4.2). Median weight was 101.7 (91.4 to 118.7) kg, with a median BMI of 37.5 (35.0 to 42.3) kg/m². Recruitment was discontinued before the target of 40 patients because the CWP dropout rate (n = 2) was lower than expected.

The researchers reported that the mean change in ACQ6 over 16 weeks was –0.45 for CWP and 0.23 for usual care with a mean difference of –0.69 (P = .048) between groups. The secondary outcome of mean change in overall AQLQ was 0.81 for CWP and 0.08 for usual care with a mean difference of 0.76 (P = .013) between groups.

No unexpected serious adverse events or intervention-related adverse events were observed during the trial.

“In this pragmatic open label, randomized, controlled trial we showed that delivery of a supported low-calorie total diet replacement program (Counterweight-Plus) to patients with difficult-to treat asthma and obesity, was safe and led to significant improvements in asthma control and quality of life compared to usual care over 16 weeks,” the authors wrote.

“Findings from the study are a welcome addition to this field of study,” Diego J. Maselli, MD, associate professor of medicine and interim chief, division of pulmonary diseases and critical care, UT Health at San Antonio, said in an interview. “Over the past years there has been an increase in the focus of comorbid conditions that may influence asthma control, particularly in severe disease.  Obesity is an important comorbid condition because, although by itself it may have an effect on asthma patients, it is also associated with other comorbidities such as gastroesophageal reflux disease, obstructive sleep apnea, anxiety, depression, and others that in turn can affect asthmatics. Also, obesity may influence pulmonary physiology and it’s considered a proinflammatory state by many, and this can favor uncontrolled disease.”  

While underscoring the clinically relevant weight loss and improvements in ACQ6 and AQLQ, Dr. Maselli said that the study did not follow the patients long enough to determine if weight loss was associated with a reduction in exacerbations and other long-term outcomes in asthma such as resource utilization and changes in maintenance medications, which may be explored in future studies.

“It remains to be seen if the weight loss of these types of programs can be sustained over longer periods of time, given the considerable caloric restriction in the initial stages of the weight reduction program. Interestingly, the majority of the patients in the study did not exhibit features of type 2 inflammation and had low-T2 endotype with low eosinophil count and low FeNO [fractional exhaled nitric oxide],” Dr. Maselli added. “Although obesity has been linked to this phenotype, the vast majority of [people with asthma], about 80%, have high T2 phenotype. Future studies are still need with larger and more representative samples and with longer follow-up times to determine the effects of weight loss on asthma outcomes, especially in severe asthma,” he concluded.

The trial was funded by an NHS Greater Glasgow and Clyde Endowment Fund grant. Several of the authors reported having received travel awards to attend conferences and funding from Cambridge Weight Plan and one author is an employee of and another a medical adviser for Counterweight Ltd., the developer of the program used. Other authors reported receiving funding from a variety of pharmaceutical companies. Dr. Maselli reported no relevant conflicts.

In a proof-of-concept feasibility study among adults with difficult-to-treat asthma and body mass index ≥ 30kg/m², an evidence-based, dietitian-led program resulted in clinically important improvements in asthma control and quality of life over 16 weeks compared to usual care.

The Counterweight-Plus weight management program (CWP) used in the study includes 12 weeks of total diet replacement (TDR), stepwise food reintroduction in weeks 13-18, and weight loss maintenance up to 1 year, according to a report by Varun Sharma, MBChB, and fellow researchers at University of Glasgow.

Difficult-to-treat asthma, found among about 17% of asthma-affected patients, may be attributed to factors such as poor inhaler technique, treatment nonadherence, and comorbidities such as obesity. Obesity is frequently associated with difficult-to-treat, uncontrolled asthma and increased morbidity and mortality. Among multifactorial effects of obesity on asthma are direct ones on thoracic wall mechanics, increased airway closure, airway hyper-responsiveness and airway inflammation. Prior research showing that weight loss may improve asthma outcomes has been conducted among heterogeneous asthma populations, with no clear consensus regarding optimal methods of weight management, according to the authors.

They tested whether use of the CWP compared to usual care (1:1) would improve asthma control and quality of life in this population of patients with obesity. The TDR phase comprised a low-energy liquid diet consisting of 825-853 kcal/day (approximately 59% carbohydrate, 13% fat, 26% protein, 2% fiber), with meals supplied dried in sachets by the dietitian team and reconstituted with water by the participants. A review by the dietitian team at 1 week was followed by reviews every other week.

The primary outcome was difference in change in Asthma Control Questionnaire (ACQ6) from baseline (visit 1) to 16 weeks (visit 2), between CWP and usual care.

The single-center trial included 33 evaluable adult patients (75 years or younger; mean age 53 years; 63% women) with asthma (as per Global Initiative for Asthma guidelines) that was difficult to treat (as per Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines). The study population consisted of patients with frequent exacerbations with uncontrolled disease as reflected by the median interquartile range (IQR) for oral corticosteroid courses in the previous 12 months of 3 (2 to 5) and mean ACQ6 of 2.8 (2.4 to 3.1). Mean overall Asthma Quality of Life Questionnaire (AQLQ) was 3.8 (3.4 to 4.2). Median weight was 101.7 (91.4 to 118.7) kg, with a median BMI of 37.5 (35.0 to 42.3) kg/m². Recruitment was discontinued before the target of 40 patients because the CWP dropout rate (n = 2) was lower than expected.

The researchers reported that the mean change in ACQ6 over 16 weeks was –0.45 for CWP and 0.23 for usual care with a mean difference of –0.69 (P = .048) between groups. The secondary outcome of mean change in overall AQLQ was 0.81 for CWP and 0.08 for usual care with a mean difference of 0.76 (P = .013) between groups.

No unexpected serious adverse events or intervention-related adverse events were observed during the trial.

“In this pragmatic open label, randomized, controlled trial we showed that delivery of a supported low-calorie total diet replacement program (Counterweight-Plus) to patients with difficult-to treat asthma and obesity, was safe and led to significant improvements in asthma control and quality of life compared to usual care over 16 weeks,” the authors wrote.

“Findings from the study are a welcome addition to this field of study,” Diego J. Maselli, MD, associate professor of medicine and interim chief, division of pulmonary diseases and critical care, UT Health at San Antonio, said in an interview. “Over the past years there has been an increase in the focus of comorbid conditions that may influence asthma control, particularly in severe disease.  Obesity is an important comorbid condition because, although by itself it may have an effect on asthma patients, it is also associated with other comorbidities such as gastroesophageal reflux disease, obstructive sleep apnea, anxiety, depression, and others that in turn can affect asthmatics. Also, obesity may influence pulmonary physiology and it’s considered a proinflammatory state by many, and this can favor uncontrolled disease.”  

While underscoring the clinically relevant weight loss and improvements in ACQ6 and AQLQ, Dr. Maselli said that the study did not follow the patients long enough to determine if weight loss was associated with a reduction in exacerbations and other long-term outcomes in asthma such as resource utilization and changes in maintenance medications, which may be explored in future studies.

“It remains to be seen if the weight loss of these types of programs can be sustained over longer periods of time, given the considerable caloric restriction in the initial stages of the weight reduction program. Interestingly, the majority of the patients in the study did not exhibit features of type 2 inflammation and had low-T2 endotype with low eosinophil count and low FeNO [fractional exhaled nitric oxide],” Dr. Maselli added. “Although obesity has been linked to this phenotype, the vast majority of [people with asthma], about 80%, have high T2 phenotype. Future studies are still need with larger and more representative samples and with longer follow-up times to determine the effects of weight loss on asthma outcomes, especially in severe asthma,” he concluded.

The trial was funded by an NHS Greater Glasgow and Clyde Endowment Fund grant. Several of the authors reported having received travel awards to attend conferences and funding from Cambridge Weight Plan and one author is an employee of and another a medical adviser for Counterweight Ltd., the developer of the program used. Other authors reported receiving funding from a variety of pharmaceutical companies. Dr. Maselli reported no relevant conflicts.

Frequent visits to green spaces such as parks and community gardens are associated with a reduced use of certain prescription medications among city dwellers, a new analysis suggests.

In a cross-sectional cohort study, frequent green space visits were associated with less frequent use of psychotropic, antihypertensive, and asthma medications in urban environments.

Viewing green or so called “blue” spaces (views of lakes, rivers, or other water views) from the home was not associated with reduced medication use.

Flickr-Rickr [CC BY-SA 2.0](http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

Nature exposure a timely topic

Exposure to natural environments is thought to be beneficial for human health, but the evidence is inconsistent, Dr. Turunen said.

“The potential health benefits of nature exposure is a very timely topic in environmental epidemiology. Scientific evidence indicates that residential exposure to greenery and water bodies might be beneficial, especially for mental, cardiovascular, and respiratory health, but the findings are partly inconsistent and thus, more detailed information is needed,” she said.

In the current cross-sectional study, the investigators surveyed 16,000 residents of three urban areas in Finland – Helsinki, Espoo, and Vantaa – over the period of 12 months from 2015 to 2016, about their exposure to green and blue spaces.

Of this number, 43% responded, resulting in 7,321 participants.

In the questionnaire, green areas were defined as forests, parks, fields, meadows, boglands, and rocks, as well as any playgrounds or playing fields within those areas, and blue areas were defined as sea, lakes, and rivers. 

Residents were asked about their use of anxiolytics, hypnotics, antidepressants, antihypertensives, and asthma medication within the past 7 to 52 weeks.

They were also asked if they had any green and blue views from any of the windows of their home, and if so, how often did they look out of those windows, selecting “seldom” to “often.”

They were also asked about how much time they spent outdoors in green spaces during the months of May and September. If so, did they spend any of that time exercising? Options ranged from never to five or more times a week.

In addition, amounts of residential green and blue spaces located within a 1 km radius of the respondents’ homes were assessed from land use and land cover data.

Covariates included health behaviors, outdoor air pollution and noise, and socioeconomic status, including household income and educational attainment.

Results showed that the presence of green and blue spaces at home, and the amount of time spent viewing them, had no association with the use of the prescribed medicines.

However, greater frequency of green space visits was associated with lower odds of using the medications surveyed.

For psychotropic medications, the odds ratios were 0.67 (95% confidence interval, 0.55-0.82) for 3-4 times per week and 0.78 (95% CI, 0.63-0.96) for 5 or more times per week.

For antihypertensive meds, the ORs were 0.64 (95% CI, 0.52-0.78) for 3-4 times per week and 0.59 (95% CI, 0.48-0.74) for 5 or more times per week.

For asthma medications, the ORs were 0.74 (95% CI, 0.58-0.94) for 3-4 times per week and 0.76 (95% CI, 0.59-0.99) for 5 or more times per week.

The observed associations were attenuated by body mass index.

“We observed that those who reported visiting green spaces often had a slightly lower BMI than those who visited green spaces less often,” Dr. Turunen said. However, no consistent interactions with socioeconomic status indicators were observed.

“We are hoping to see new results from different countries and different settings,” she noted. “Longitudinal studies, especially, are needed. In epidemiology, a large body of consistent evidence is needed to draw strong conclusions and to make recommendations.”
 

Evidence mounts on the benefits of nature

There is growing evidence that exposure to nature could benefit human health, especially mental and cardiovascular health, says Jochem Klompmaker, PhD, a postdoctoral researcher in the department of environmental health at the Harvard T.H. Chan School of Public Health, Boston.

Dr. Klompmaker has researched the association between exposure to green spaces and health outcomes related to neurological diseases.

In a study recently published in JAMA Network Open, and reported by this news organization, Dr. Klompmaker and his team found that among a large cohort of about 6.7 million fee-for-service Medicare beneficiaries in the United States aged 65 or older, living in areas rich with greenery, parks, and waterways was associated with fewer hospitalizations for certain neurological disorders, including Parkinson’s disease, Alzheimer’s disease, and related dementias.

Commenting on the current study, Dr. Klompmaker noted its strengths.

“A particular strength of this study is that they used data about the amount of green and blue spaces around the residential addresses of the participants, data about green space visit frequency, and data about green and blue views from home. Most other studies only have data about the amount of green and blue spaces in general,” he said.

“The strong protective associations of frequency of green space visits make sense to me and indicate the importance of one’s actual nature exposure,” he added. “Like the results of our study, these results provide clinicians with more evidence of the importance of being close to nature and of encouraging patients to take more walks. If they live near a park, that could be a good place to be more physically active and reduce stress levels.”

The study was supported by the Academy of Finland and the Ministry of the Environment. Dr. Turunen and Dr. Klompmaker report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Frequent visits to green spaces such as parks and community gardens are associated with a reduced use of certain prescription medications among city dwellers, a new analysis suggests.

In a cross-sectional cohort study, frequent green space visits were associated with less frequent use of psychotropic, antihypertensive, and asthma medications in urban environments.

Viewing green or so called “blue” spaces (views of lakes, rivers, or other water views) from the home was not associated with reduced medication use.

Flickr-Rickr [CC BY-SA 2.0](http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

Nature exposure a timely topic

Exposure to natural environments is thought to be beneficial for human health, but the evidence is inconsistent, Dr. Turunen said.

“The potential health benefits of nature exposure is a very timely topic in environmental epidemiology. Scientific evidence indicates that residential exposure to greenery and water bodies might be beneficial, especially for mental, cardiovascular, and respiratory health, but the findings are partly inconsistent and thus, more detailed information is needed,” she said.

In the current cross-sectional study, the investigators surveyed 16,000 residents of three urban areas in Finland – Helsinki, Espoo, and Vantaa – over the period of 12 months from 2015 to 2016, about their exposure to green and blue spaces.

Of this number, 43% responded, resulting in 7,321 participants.

In the questionnaire, green areas were defined as forests, parks, fields, meadows, boglands, and rocks, as well as any playgrounds or playing fields within those areas, and blue areas were defined as sea, lakes, and rivers. 

Residents were asked about their use of anxiolytics, hypnotics, antidepressants, antihypertensives, and asthma medication within the past 7 to 52 weeks.

They were also asked if they had any green and blue views from any of the windows of their home, and if so, how often did they look out of those windows, selecting “seldom” to “often.”

They were also asked about how much time they spent outdoors in green spaces during the months of May and September. If so, did they spend any of that time exercising? Options ranged from never to five or more times a week.

In addition, amounts of residential green and blue spaces located within a 1 km radius of the respondents’ homes were assessed from land use and land cover data.

Covariates included health behaviors, outdoor air pollution and noise, and socioeconomic status, including household income and educational attainment.

Results showed that the presence of green and blue spaces at home, and the amount of time spent viewing them, had no association with the use of the prescribed medicines.

However, greater frequency of green space visits was associated with lower odds of using the medications surveyed.

For psychotropic medications, the odds ratios were 0.67 (95% confidence interval, 0.55-0.82) for 3-4 times per week and 0.78 (95% CI, 0.63-0.96) for 5 or more times per week.

For antihypertensive meds, the ORs were 0.64 (95% CI, 0.52-0.78) for 3-4 times per week and 0.59 (95% CI, 0.48-0.74) for 5 or more times per week.

For asthma medications, the ORs were 0.74 (95% CI, 0.58-0.94) for 3-4 times per week and 0.76 (95% CI, 0.59-0.99) for 5 or more times per week.

The observed associations were attenuated by body mass index.

“We observed that those who reported visiting green spaces often had a slightly lower BMI than those who visited green spaces less often,” Dr. Turunen said. However, no consistent interactions with socioeconomic status indicators were observed.

“We are hoping to see new results from different countries and different settings,” she noted. “Longitudinal studies, especially, are needed. In epidemiology, a large body of consistent evidence is needed to draw strong conclusions and to make recommendations.”
 

Evidence mounts on the benefits of nature

There is growing evidence that exposure to nature could benefit human health, especially mental and cardiovascular health, says Jochem Klompmaker, PhD, a postdoctoral researcher in the department of environmental health at the Harvard T.H. Chan School of Public Health, Boston.

Dr. Klompmaker has researched the association between exposure to green spaces and health outcomes related to neurological diseases.

In a study recently published in JAMA Network Open, and reported by this news organization, Dr. Klompmaker and his team found that among a large cohort of about 6.7 million fee-for-service Medicare beneficiaries in the United States aged 65 or older, living in areas rich with greenery, parks, and waterways was associated with fewer hospitalizations for certain neurological disorders, including Parkinson’s disease, Alzheimer’s disease, and related dementias.

Commenting on the current study, Dr. Klompmaker noted its strengths.

“A particular strength of this study is that they used data about the amount of green and blue spaces around the residential addresses of the participants, data about green space visit frequency, and data about green and blue views from home. Most other studies only have data about the amount of green and blue spaces in general,” he said.

“The strong protective associations of frequency of green space visits make sense to me and indicate the importance of one’s actual nature exposure,” he added. “Like the results of our study, these results provide clinicians with more evidence of the importance of being close to nature and of encouraging patients to take more walks. If they live near a park, that could be a good place to be more physically active and reduce stress levels.”

The study was supported by the Academy of Finland and the Ministry of the Environment. Dr. Turunen and Dr. Klompmaker report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Frequent visits to green spaces such as parks and community gardens are associated with a reduced use of certain prescription medications among city dwellers, a new analysis suggests.

In a cross-sectional cohort study, frequent green space visits were associated with less frequent use of psychotropic, antihypertensive, and asthma medications in urban environments.

Viewing green or so called “blue” spaces (views of lakes, rivers, or other water views) from the home was not associated with reduced medication use.

Flickr-Rickr [CC BY-SA 2.0](http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

Nature exposure a timely topic

Exposure to natural environments is thought to be beneficial for human health, but the evidence is inconsistent, Dr. Turunen said.

“The potential health benefits of nature exposure is a very timely topic in environmental epidemiology. Scientific evidence indicates that residential exposure to greenery and water bodies might be beneficial, especially for mental, cardiovascular, and respiratory health, but the findings are partly inconsistent and thus, more detailed information is needed,” she said.

In the current cross-sectional study, the investigators surveyed 16,000 residents of three urban areas in Finland – Helsinki, Espoo, and Vantaa – over the period of 12 months from 2015 to 2016, about their exposure to green and blue spaces.

Of this number, 43% responded, resulting in 7,321 participants.

In the questionnaire, green areas were defined as forests, parks, fields, meadows, boglands, and rocks, as well as any playgrounds or playing fields within those areas, and blue areas were defined as sea, lakes, and rivers. 

Residents were asked about their use of anxiolytics, hypnotics, antidepressants, antihypertensives, and asthma medication within the past 7 to 52 weeks.

They were also asked if they had any green and blue views from any of the windows of their home, and if so, how often did they look out of those windows, selecting “seldom” to “often.”

They were also asked about how much time they spent outdoors in green spaces during the months of May and September. If so, did they spend any of that time exercising? Options ranged from never to five or more times a week.

In addition, amounts of residential green and blue spaces located within a 1 km radius of the respondents’ homes were assessed from land use and land cover data.

Covariates included health behaviors, outdoor air pollution and noise, and socioeconomic status, including household income and educational attainment.

Results showed that the presence of green and blue spaces at home, and the amount of time spent viewing them, had no association with the use of the prescribed medicines.

However, greater frequency of green space visits was associated with lower odds of using the medications surveyed.

For psychotropic medications, the odds ratios were 0.67 (95% confidence interval, 0.55-0.82) for 3-4 times per week and 0.78 (95% CI, 0.63-0.96) for 5 or more times per week.

For antihypertensive meds, the ORs were 0.64 (95% CI, 0.52-0.78) for 3-4 times per week and 0.59 (95% CI, 0.48-0.74) for 5 or more times per week.

For asthma medications, the ORs were 0.74 (95% CI, 0.58-0.94) for 3-4 times per week and 0.76 (95% CI, 0.59-0.99) for 5 or more times per week.

The observed associations were attenuated by body mass index.

“We observed that those who reported visiting green spaces often had a slightly lower BMI than those who visited green spaces less often,” Dr. Turunen said. However, no consistent interactions with socioeconomic status indicators were observed.

“We are hoping to see new results from different countries and different settings,” she noted. “Longitudinal studies, especially, are needed. In epidemiology, a large body of consistent evidence is needed to draw strong conclusions and to make recommendations.”
 

Evidence mounts on the benefits of nature

There is growing evidence that exposure to nature could benefit human health, especially mental and cardiovascular health, says Jochem Klompmaker, PhD, a postdoctoral researcher in the department of environmental health at the Harvard T.H. Chan School of Public Health, Boston.

Dr. Klompmaker has researched the association between exposure to green spaces and health outcomes related to neurological diseases.

In a study recently published in JAMA Network Open, and reported by this news organization, Dr. Klompmaker and his team found that among a large cohort of about 6.7 million fee-for-service Medicare beneficiaries in the United States aged 65 or older, living in areas rich with greenery, parks, and waterways was associated with fewer hospitalizations for certain neurological disorders, including Parkinson’s disease, Alzheimer’s disease, and related dementias.

Commenting on the current study, Dr. Klompmaker noted its strengths.

“A particular strength of this study is that they used data about the amount of green and blue spaces around the residential addresses of the participants, data about green space visit frequency, and data about green and blue views from home. Most other studies only have data about the amount of green and blue spaces in general,” he said.

“The strong protective associations of frequency of green space visits make sense to me and indicate the importance of one’s actual nature exposure,” he added. “Like the results of our study, these results provide clinicians with more evidence of the importance of being close to nature and of encouraging patients to take more walks. If they live near a park, that could be a good place to be more physically active and reduce stress levels.”

The study was supported by the Academy of Finland and the Ministry of the Environment. Dr. Turunen and Dr. Klompmaker report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Lower muscle mass was significantly associated with more airway obstruction and reduced functional exercise capacity in adults with asthma, based on data from 114 individuals.

Previous studies have shown reduced muscle mass in asthma patients, but the impact on clinical and functional outcomes has not been well studied, wrote Edith Visser, MSc, of Medical Centre Leeuwarden (the Netherlands) and colleagues.

“Many asthma patients, especially those with severe disease, report exercise intolerance and limitations in daily activities, severely affecting their quality of life,” they said. Research into the clinical consequences of low muscle mass and low muscle strength for patients with asthma and the role of inflammation could make muscle function a potential treatment target for those with asthma, they said.

In a study published in the Journal of Allergy and Clinical Immunology: In Practice, the researchers recruited 114 consecutive adults aged 18 years and older with a diagnosis of moderate to severe asthma who were seen at a single center between Jun. 2019 and Oct. 2022. The mean age of the patients was 51.9 years, 36% were men, 70% were overweight or obese, and 34 were diagnosed with severe asthma.

Participants underwent clinical, functional, and laboratory assessments at one or two visits within a 2-week period. Assessment tools included the Asthma Quality of Life Questionnaire (AQLQ), the Asthma Control Questionnaire (ACQ-6), a questionnaire on health care use (HCU), and the ‘short questionnaire to assess health-enhancing physical activity’ (SQUASH).

Functional activity was based on the 6-minute walking distance (6MWD), and lung function tests included spirometry and fractional inhaled nitric oxide (FeNO). Muscle mass was based on fat-free mass index (FFMI) and urinary creatinine excretion rate (CER). Muscle strength was measured using hand-grip strength (HGS).

The researchers examined levels of muscle mass and strength and their relation to functional and clinical outcomes.

Overall, the mean measures of muscle mass and strength were higher in males, who had average FFMI, CER, and HGS measures of 20.1 kg/m², 15.3 mmol/day, and 48.8 kg, respectively. These measures in women were 17.3 kg/m², 10.8 mmol/day, and 29.3 kg, respectively.

After adjusting for confounding factors, patients in the lowest tertile for muscle mass based on FFMI had significantly more severe asthma based on postbronchodilator forced expiratory volume in 1 second and FEV₁/forced vital capacity, as well as lower functional exercise capacity based on the 6MWD compared to those in the highest tertile. A similar association appeared between CER and FEV₁, but not FEV₁/FVC.

However, no significant associations appeared between the muscle mass measures of FFMI or CER and scores on the ACQ, AQLQ, emergency department visits, or asthma exacerbations, the researchers noted.

No relationship appeared between muscle strength and functional outcomes. However, patients in the lowest tertile of HGS had worse asthma control, worse quality of life, and a higher probability of at least one visit to the emergency department compared to patients in the highest HGS tertile.

Higher leukocyte levels were significantly associated with lower muscle mass after adjusting for age, sex, weight, and physical activity, but no other inflammatory markers were significantly associated with FFMI.

The association between lower muscle strength and poorer asthma control, lower quality of life, and greater odds of emergency department visits reflect findings from previous studies, the researchers said. The mechanisms behind the loss of muscle strength in asthma remain unclear, but physical inactivity and daily oral corticosteroid use may play a role, they added.

The study findings were limited by the cross-sectional design and the possibility that muscle weakness may instead stem from reduced physical activity associated with poor lung function and asthma control, the researchers noted. Other limitations included the potential overestimation of FFMI and the lack of statistical power to show a relationship between FFMI and emergency department visits and asthma exacerbations, they said.

However, the current study is the first known to explore the relationship between lower muscle mass and strength and a range of both functional and clinical outcomes in patients with moderate to severe asthma, they said.

“Our findings encourage longitudinal studies into muscle function as a potential target for treatment to improve asthma outcomes,” they concluded.

The study was supported by unrestricted grants from Medical Centre Leeuwarden research fund. Ms. Visser had no financial conflicts to disclose.

Lower muscle mass was significantly associated with more airway obstruction and reduced functional exercise capacity in adults with asthma, based on data from 114 individuals.

Previous studies have shown reduced muscle mass in asthma patients, but the impact on clinical and functional outcomes has not been well studied, wrote Edith Visser, MSc, of Medical Centre Leeuwarden (the Netherlands) and colleagues.

“Many asthma patients, especially those with severe disease, report exercise intolerance and limitations in daily activities, severely affecting their quality of life,” they said. Research into the clinical consequences of low muscle mass and low muscle strength for patients with asthma and the role of inflammation could make muscle function a potential treatment target for those with asthma, they said.

In a study published in the Journal of Allergy and Clinical Immunology: In Practice, the researchers recruited 114 consecutive adults aged 18 years and older with a diagnosis of moderate to severe asthma who were seen at a single center between Jun. 2019 and Oct. 2022. The mean age of the patients was 51.9 years, 36% were men, 70% were overweight or obese, and 34 were diagnosed with severe asthma.

Participants underwent clinical, functional, and laboratory assessments at one or two visits within a 2-week period. Assessment tools included the Asthma Quality of Life Questionnaire (AQLQ), the Asthma Control Questionnaire (ACQ-6), a questionnaire on health care use (HCU), and the ‘short questionnaire to assess health-enhancing physical activity’ (SQUASH).

Functional activity was based on the 6-minute walking distance (6MWD), and lung function tests included spirometry and fractional inhaled nitric oxide (FeNO). Muscle mass was based on fat-free mass index (FFMI) and urinary creatinine excretion rate (CER). Muscle strength was measured using hand-grip strength (HGS).

The researchers examined levels of muscle mass and strength and their relation to functional and clinical outcomes.

Overall, the mean measures of muscle mass and strength were higher in males, who had average FFMI, CER, and HGS measures of 20.1 kg/m², 15.3 mmol/day, and 48.8 kg, respectively. These measures in women were 17.3 kg/m², 10.8 mmol/day, and 29.3 kg, respectively.

After adjusting for confounding factors, patients in the lowest tertile for muscle mass based on FFMI had significantly more severe asthma based on postbronchodilator forced expiratory volume in 1 second and FEV₁/forced vital capacity, as well as lower functional exercise capacity based on the 6MWD compared to those in the highest tertile. A similar association appeared between CER and FEV₁, but not FEV₁/FVC.

However, no significant associations appeared between the muscle mass measures of FFMI or CER and scores on the ACQ, AQLQ, emergency department visits, or asthma exacerbations, the researchers noted.

No relationship appeared between muscle strength and functional outcomes. However, patients in the lowest tertile of HGS had worse asthma control, worse quality of life, and a higher probability of at least one visit to the emergency department compared to patients in the highest HGS tertile.

Higher leukocyte levels were significantly associated with lower muscle mass after adjusting for age, sex, weight, and physical activity, but no other inflammatory markers were significantly associated with FFMI.

The association between lower muscle strength and poorer asthma control, lower quality of life, and greater odds of emergency department visits reflect findings from previous studies, the researchers said. The mechanisms behind the loss of muscle strength in asthma remain unclear, but physical inactivity and daily oral corticosteroid use may play a role, they added.

The study findings were limited by the cross-sectional design and the possibility that muscle weakness may instead stem from reduced physical activity associated with poor lung function and asthma control, the researchers noted. Other limitations included the potential overestimation of FFMI and the lack of statistical power to show a relationship between FFMI and emergency department visits and asthma exacerbations, they said.

However, the current study is the first known to explore the relationship between lower muscle mass and strength and a range of both functional and clinical outcomes in patients with moderate to severe asthma, they said.

“Our findings encourage longitudinal studies into muscle function as a potential target for treatment to improve asthma outcomes,” they concluded.

The study was supported by unrestricted grants from Medical Centre Leeuwarden research fund. Ms. Visser had no financial conflicts to disclose.

Lower muscle mass was significantly associated with more airway obstruction and reduced functional exercise capacity in adults with asthma, based on data from 114 individuals.

Previous studies have shown reduced muscle mass in asthma patients, but the impact on clinical and functional outcomes has not been well studied, wrote Edith Visser, MSc, of Medical Centre Leeuwarden (the Netherlands) and colleagues.

“Many asthma patients, especially those with severe disease, report exercise intolerance and limitations in daily activities, severely affecting their quality of life,” they said. Research into the clinical consequences of low muscle mass and low muscle strength for patients with asthma and the role of inflammation could make muscle function a potential treatment target for those with asthma, they said.

In a study published in the Journal of Allergy and Clinical Immunology: In Practice, the researchers recruited 114 consecutive adults aged 18 years and older with a diagnosis of moderate to severe asthma who were seen at a single center between Jun. 2019 and Oct. 2022. The mean age of the patients was 51.9 years, 36% were men, 70% were overweight or obese, and 34 were diagnosed with severe asthma.

Participants underwent clinical, functional, and laboratory assessments at one or two visits within a 2-week period. Assessment tools included the Asthma Quality of Life Questionnaire (AQLQ), the Asthma Control Questionnaire (ACQ-6), a questionnaire on health care use (HCU), and the ‘short questionnaire to assess health-enhancing physical activity’ (SQUASH).

Functional activity was based on the 6-minute walking distance (6MWD), and lung function tests included spirometry and fractional inhaled nitric oxide (FeNO). Muscle mass was based on fat-free mass index (FFMI) and urinary creatinine excretion rate (CER). Muscle strength was measured using hand-grip strength (HGS).

The researchers examined levels of muscle mass and strength and their relation to functional and clinical outcomes.

Overall, the mean measures of muscle mass and strength were higher in males, who had average FFMI, CER, and HGS measures of 20.1 kg/m², 15.3 mmol/day, and 48.8 kg, respectively. These measures in women were 17.3 kg/m², 10.8 mmol/day, and 29.3 kg, respectively.

After adjusting for confounding factors, patients in the lowest tertile for muscle mass based on FFMI had significantly more severe asthma based on postbronchodilator forced expiratory volume in 1 second and FEV₁/forced vital capacity, as well as lower functional exercise capacity based on the 6MWD compared to those in the highest tertile. A similar association appeared between CER and FEV₁, but not FEV₁/FVC.

However, no significant associations appeared between the muscle mass measures of FFMI or CER and scores on the ACQ, AQLQ, emergency department visits, or asthma exacerbations, the researchers noted.

No relationship appeared between muscle strength and functional outcomes. However, patients in the lowest tertile of HGS had worse asthma control, worse quality of life, and a higher probability of at least one visit to the emergency department compared to patients in the highest HGS tertile.

Higher leukocyte levels were significantly associated with lower muscle mass after adjusting for age, sex, weight, and physical activity, but no other inflammatory markers were significantly associated with FFMI.

The association between lower muscle strength and poorer asthma control, lower quality of life, and greater odds of emergency department visits reflect findings from previous studies, the researchers said. The mechanisms behind the loss of muscle strength in asthma remain unclear, but physical inactivity and daily oral corticosteroid use may play a role, they added.

The study findings were limited by the cross-sectional design and the possibility that muscle weakness may instead stem from reduced physical activity associated with poor lung function and asthma control, the researchers noted. Other limitations included the potential overestimation of FFMI and the lack of statistical power to show a relationship between FFMI and emergency department visits and asthma exacerbations, they said.

However, the current study is the first known to explore the relationship between lower muscle mass and strength and a range of both functional and clinical outcomes in patients with moderate to severe asthma, they said.

“Our findings encourage longitudinal studies into muscle function as a potential target for treatment to improve asthma outcomes,” they concluded.

The study was supported by unrestricted grants from Medical Centre Leeuwarden research fund. Ms. Visser had no financial conflicts to disclose.

The clinical features and inflammatory mediators of adult-onset asthma were associated with distinct endotype groups defined by eosinophil and neutrophil levels, based on data from a real-life long term study of 203 patients.

Asthma is a chronic condition from lower respiratory tract inflammation composed of complex, heterogeneous endotypes with T2 helper cells being one way to distinguish between them. Endotypes have previously been suggested to have differing risks for asthma exacerbations and severity. However, clinical and biomarker information used for recognizing and targeting treatment is largely lacking in those subgroups other than eosinophilic asthma, according to Ella Flinkman, faculty of medicine and health technology, of Tampere University (Finland), and colleagues.

In a study published in The Journal of Allergy and Clinical Immunology: In Practice the researchers reported on their single-center 12-year follow-up phase II Seinäjoki Adult Asthma Study (SAAS). The included cohort of 203 patients had a median age of 58 years and 58% were women; all participants were originally diagnosed by a respiratory specialist physician as having new adult-onset asthma during the years 1999-2000 using asthma symptoms and objective lung function measurements.

To evaluate the association between clinical features and inflammation mediators to venous blood granulocytes this cohort was divided into paucigranulocytic (n = 108), neutrophilic (n = 60), eosinophilic (n = 21), and mixed granulocytic (n = 14) endotype subgroups based on eosinophil and neutrophil levels. Objective comparisons between groups were made using measurements from forced expiratory volume in 1 second (FEV₁), fraction of exhaled nitric oxide (FeNO), immunoglobin E (IgE), high-sensitivity C-reactive protein (hsCRP), IL-6, resistin, MMP-9, plasma soluble urokinase plasminogen activator receptor (suPAR), leptin, HMW adiponectin, and periostin tests. Asthma-related medications and disease exacerbation data were collected from medical records accumulated over the 12-year study period.

The neutrophilic group was defined by high (≥ 4.4×10^9/L) neutrophil but low (< 0.30×10⁹/L) eosinophil counts and conversely the eosinophilic group had low (< 4.4×10⁹/L) neutrophil but high (≥ 0.30×10⁹/L) eosinophil counts. The paucigranulocytic was low and the mixed granulocytic group was high for both eosinophil and neutrophil levels, respectively. Each group was associated with a unique profile of features related to asthma prognosis and treatment. The paucigranulocytic endotype was used as the base comparison group in regression analysis as it was the least likely to meet the definition of severe asthma. This was indicated by the lowest use of inhaled corticosteroid (ICS), antibiotics, and occurrence of unplanned respiratory visits. The other three groups were more likely to fulfill a severe asthma classification.

Negative binomial regression analysis showed significant association of increased incidence rate ratio (IRR) of unplanned respiratory visits, highest body mass index (BMI), and highest dispensed doses of ICS with neutrophilic asthma. Additional significantly associated factors included smoking history and gender. Adjustment for dispensed ICS 2 years prior to the 12-year follow-up visit resulted in a change from borderline to significant association of increased IRR for the eosinophilic group. Both the eosinophilic and neutrophilic groups were associated with the most antibiotic use over the 12-year follow-up period. The authors suggested their data may indicate that antibiotics are overprescribed for asthma and further investigation is required.

Multiple linear regression analysis showed a decline in lung function associated with the eosinophilic but not the neutrophilic group. Connections between specific blood endotypes and molecular features were also identified. Highest periostin and FeNO levels found in the eosinophilic group were consistent with other studies on patients specifically diagnosed with eosinophilic asthma.

The neutrophilic group was distinguished by the highest hsCRP, MMP-9, IL-6, leptin, and suPAR levels. Highest resistin levels were found in both the mixed granulocyte and neutrophilic groups.

This study was strengthened by its real life long-term nature and method for cohort selection, according to the authors, though the value of a larger population to raise numbers particularly in the smaller sized groups was noted.

The authors concluded: “Our study indicates that assays of blood eosinophil and neutrophil counts provide useful information for assessing and treating patients with adult-onset asthma. These granulocyte counts reflect the underlying inflammatory pattern and reveal important differences in asthma clinical features and outcomes.” Additional research “regarding biomarkers used to identify different endotypes of asthma” is needed.

The study was sponsored by a number of research foundations in Finland as well as hospital research center funds. Several of the authors disclosed associations with pharmaceutical companies, including Astra Zeneca, Boehringer-Ingelheim, GSK, Novartis, and Sanofi.

The clinical features and inflammatory mediators of adult-onset asthma were associated with distinct endotype groups defined by eosinophil and neutrophil levels, based on data from a real-life long term study of 203 patients.

Asthma is a chronic condition from lower respiratory tract inflammation composed of complex, heterogeneous endotypes with T2 helper cells being one way to distinguish between them. Endotypes have previously been suggested to have differing risks for asthma exacerbations and severity. However, clinical and biomarker information used for recognizing and targeting treatment is largely lacking in those subgroups other than eosinophilic asthma, according to Ella Flinkman, faculty of medicine and health technology, of Tampere University (Finland), and colleagues.

In a study published in The Journal of Allergy and Clinical Immunology: In Practice the researchers reported on their single-center 12-year follow-up phase II Seinäjoki Adult Asthma Study (SAAS). The included cohort of 203 patients had a median age of 58 years and 58% were women; all participants were originally diagnosed by a respiratory specialist physician as having new adult-onset asthma during the years 1999-2000 using asthma symptoms and objective lung function measurements.

To evaluate the association between clinical features and inflammation mediators to venous blood granulocytes this cohort was divided into paucigranulocytic (n = 108), neutrophilic (n = 60), eosinophilic (n = 21), and mixed granulocytic (n = 14) endotype subgroups based on eosinophil and neutrophil levels. Objective comparisons between groups were made using measurements from forced expiratory volume in 1 second (FEV₁), fraction of exhaled nitric oxide (FeNO), immunoglobin E (IgE), high-sensitivity C-reactive protein (hsCRP), IL-6, resistin, MMP-9, plasma soluble urokinase plasminogen activator receptor (suPAR), leptin, HMW adiponectin, and periostin tests. Asthma-related medications and disease exacerbation data were collected from medical records accumulated over the 12-year study period.

The neutrophilic group was defined by high (≥ 4.4×10^9/L) neutrophil but low (< 0.30×10⁹/L) eosinophil counts and conversely the eosinophilic group had low (< 4.4×10⁹/L) neutrophil but high (≥ 0.30×10⁹/L) eosinophil counts. The paucigranulocytic was low and the mixed granulocytic group was high for both eosinophil and neutrophil levels, respectively. Each group was associated with a unique profile of features related to asthma prognosis and treatment. The paucigranulocytic endotype was used as the base comparison group in regression analysis as it was the least likely to meet the definition of severe asthma. This was indicated by the lowest use of inhaled corticosteroid (ICS), antibiotics, and occurrence of unplanned respiratory visits. The other three groups were more likely to fulfill a severe asthma classification.

Negative binomial regression analysis showed significant association of increased incidence rate ratio (IRR) of unplanned respiratory visits, highest body mass index (BMI), and highest dispensed doses of ICS with neutrophilic asthma. Additional significantly associated factors included smoking history and gender. Adjustment for dispensed ICS 2 years prior to the 12-year follow-up visit resulted in a change from borderline to significant association of increased IRR for the eosinophilic group. Both the eosinophilic and neutrophilic groups were associated with the most antibiotic use over the 12-year follow-up period. The authors suggested their data may indicate that antibiotics are overprescribed for asthma and further investigation is required.

Multiple linear regression analysis showed a decline in lung function associated with the eosinophilic but not the neutrophilic group. Connections between specific blood endotypes and molecular features were also identified. Highest periostin and FeNO levels found in the eosinophilic group were consistent with other studies on patients specifically diagnosed with eosinophilic asthma.

The neutrophilic group was distinguished by the highest hsCRP, MMP-9, IL-6, leptin, and suPAR levels. Highest resistin levels were found in both the mixed granulocyte and neutrophilic groups.

This study was strengthened by its real life long-term nature and method for cohort selection, according to the authors, though the value of a larger population to raise numbers particularly in the smaller sized groups was noted.

The authors concluded: “Our study indicates that assays of blood eosinophil and neutrophil counts provide useful information for assessing and treating patients with adult-onset asthma. These granulocyte counts reflect the underlying inflammatory pattern and reveal important differences in asthma clinical features and outcomes.” Additional research “regarding biomarkers used to identify different endotypes of asthma” is needed.

The study was sponsored by a number of research foundations in Finland as well as hospital research center funds. Several of the authors disclosed associations with pharmaceutical companies, including Astra Zeneca, Boehringer-Ingelheim, GSK, Novartis, and Sanofi.

The clinical features and inflammatory mediators of adult-onset asthma were associated with distinct endotype groups defined by eosinophil and neutrophil levels, based on data from a real-life long term study of 203 patients.

Asthma is a chronic condition from lower respiratory tract inflammation composed of complex, heterogeneous endotypes with T2 helper cells being one way to distinguish between them. Endotypes have previously been suggested to have differing risks for asthma exacerbations and severity. However, clinical and biomarker information used for recognizing and targeting treatment is largely lacking in those subgroups other than eosinophilic asthma, according to Ella Flinkman, faculty of medicine and health technology, of Tampere University (Finland), and colleagues.

In a study published in The Journal of Allergy and Clinical Immunology: In Practice the researchers reported on their single-center 12-year follow-up phase II Seinäjoki Adult Asthma Study (SAAS). The included cohort of 203 patients had a median age of 58 years and 58% were women; all participants were originally diagnosed by a respiratory specialist physician as having new adult-onset asthma during the years 1999-2000 using asthma symptoms and objective lung function measurements.

To evaluate the association between clinical features and inflammation mediators to venous blood granulocytes this cohort was divided into paucigranulocytic (n = 108), neutrophilic (n = 60), eosinophilic (n = 21), and mixed granulocytic (n = 14) endotype subgroups based on eosinophil and neutrophil levels. Objective comparisons between groups were made using measurements from forced expiratory volume in 1 second (FEV₁), fraction of exhaled nitric oxide (FeNO), immunoglobin E (IgE), high-sensitivity C-reactive protein (hsCRP), IL-6, resistin, MMP-9, plasma soluble urokinase plasminogen activator receptor (suPAR), leptin, HMW adiponectin, and periostin tests. Asthma-related medications and disease exacerbation data were collected from medical records accumulated over the 12-year study period.

The neutrophilic group was defined by high (≥ 4.4×10^9/L) neutrophil but low (< 0.30×10⁹/L) eosinophil counts and conversely the eosinophilic group had low (< 4.4×10⁹/L) neutrophil but high (≥ 0.30×10⁹/L) eosinophil counts. The paucigranulocytic was low and the mixed granulocytic group was high for both eosinophil and neutrophil levels, respectively. Each group was associated with a unique profile of features related to asthma prognosis and treatment. The paucigranulocytic endotype was used as the base comparison group in regression analysis as it was the least likely to meet the definition of severe asthma. This was indicated by the lowest use of inhaled corticosteroid (ICS), antibiotics, and occurrence of unplanned respiratory visits. The other three groups were more likely to fulfill a severe asthma classification.

Negative binomial regression analysis showed significant association of increased incidence rate ratio (IRR) of unplanned respiratory visits, highest body mass index (BMI), and highest dispensed doses of ICS with neutrophilic asthma. Additional significantly associated factors included smoking history and gender. Adjustment for dispensed ICS 2 years prior to the 12-year follow-up visit resulted in a change from borderline to significant association of increased IRR for the eosinophilic group. Both the eosinophilic and neutrophilic groups were associated with the most antibiotic use over the 12-year follow-up period. The authors suggested their data may indicate that antibiotics are overprescribed for asthma and further investigation is required.

Multiple linear regression analysis showed a decline in lung function associated with the eosinophilic but not the neutrophilic group. Connections between specific blood endotypes and molecular features were also identified. Highest periostin and FeNO levels found in the eosinophilic group were consistent with other studies on patients specifically diagnosed with eosinophilic asthma.

The neutrophilic group was distinguished by the highest hsCRP, MMP-9, IL-6, leptin, and suPAR levels. Highest resistin levels were found in both the mixed granulocyte and neutrophilic groups.

This study was strengthened by its real life long-term nature and method for cohort selection, according to the authors, though the value of a larger population to raise numbers particularly in the smaller sized groups was noted.

The authors concluded: “Our study indicates that assays of blood eosinophil and neutrophil counts provide useful information for assessing and treating patients with adult-onset asthma. These granulocyte counts reflect the underlying inflammatory pattern and reveal important differences in asthma clinical features and outcomes.” Additional research “regarding biomarkers used to identify different endotypes of asthma” is needed.

The study was sponsored by a number of research foundations in Finland as well as hospital research center funds. Several of the authors disclosed associations with pharmaceutical companies, including Astra Zeneca, Boehringer-Ingelheim, GSK, Novartis, and Sanofi.

Peripheral airway response to methacholine was similar among obese adults with and without asthma, although forced expiratory volume was lower for those with asthma, based on data from 53 individuals.

Obesity remains a risk factor for asthma, and obese individuals with asthma tend to have worse control and more severe disease, compared with nonobese asthma patients, wrote Anne E. Dixon, BM, BCh, of the University of Vermont, Burlington, and colleagues.

Previous studies have shown that airway reactivity can occur in obese individuals without airway inflammation, but studies characterizing obese asthma based on lung function are lacking, they said. “Combining spirometry and oscillometry might reveal abnormalities in lung mechanics particularly pertinent to people with obesity and asthma,” the researchers noted.

In a cross-sectional study published in the journal CHEST, the researchers reviewed data from 31 obese adults with asthma and 22 obese adults without asthma. The participants were aged 18 years and older, with forced expiratory volume (FEV₁) of at least 60% of predicted. All had class III obesity, with an average BMI of 47.2 kg/m² for those with asthma and 46.7 kg/m² for nonasthma controls. Demographic characteristics were similar between the groups.

Airway reactivity was defined as a 20% decrease in FEV₁ and/or a 50% change in resistance or reactance at 5 Hz (R5 and X5), at a concentration of 16 mg/mL or less of methacholine. Patients were assessed using spirometry and oscillometry.

Overall, most obese individuals with and without asthma showed significant changes in peripheral airway resistance. For those with asthma, the resistance at 5 Hz, measured by oscillometry, increased by 52% in response to the PC20 methacholine challenge, with an area under the reactance curve (AX) of 361%. For controls without asthma, the resistance at 5 Hz increased by 45%, with an AX of 268% in response to 16 mg/mL of methacholine.

This finding suggests that obesity predisposes individuals to peripheral airway reactivity regardless of asthma status, the researchers wrote in their discussion.

The researchers also identified two distinct groups of asthma patients categorized by respiratory system impedance based on more concordant vs. discordant bronchoconstriction in the central and peripheral airways. The baseline AX for these two groups was 11.8 and 46.7, respectively, with interquartile ranges of 9.9-23.4 and 23.2-53.7, respectively.

The discordant group included only women, and these patients reported significantly more gastroesophageal reflux, increased chest tightness, and more wheezing and asthma exacerbations than the concordant group, which may be related to air trapping, shown on previous studies of obese individuals with asthma, the researchers wrote.

The findings were limited by several factors, including the measurement of airway impedance only at the peak methacholine dose and the measurement of oscillometry after spirometry, the researchers noted. Other limitations included the relatively small study population at a single center, and the focus on obese individuals only.

More research is needed in larger and more diverse patient populations, but the results support the characterization of a subgroup of obese asthma patients with significant peripheral airway dysfunction, the researchers wrote.

“Oscillometry testing can reveal a physiologic phenotype of asthma in obesity that may be related to worse symptoms and more severe disease, and also reveal subclinical abnormalities in people with obesity, but without clinically diagnosed lung disease,” they concluded.

The study was supported in part by the National Institutes of Health. The researchers declared no financial conflicts.

A version of this article first appeared on Medscape.com.

Peripheral airway response to methacholine was similar among obese adults with and without asthma, although forced expiratory volume was lower for those with asthma, based on data from 53 individuals.

Obesity remains a risk factor for asthma, and obese individuals with asthma tend to have worse control and more severe disease, compared with nonobese asthma patients, wrote Anne E. Dixon, BM, BCh, of the University of Vermont, Burlington, and colleagues.

Previous studies have shown that airway reactivity can occur in obese individuals without airway inflammation, but studies characterizing obese asthma based on lung function are lacking, they said. “Combining spirometry and oscillometry might reveal abnormalities in lung mechanics particularly pertinent to people with obesity and asthma,” the researchers noted.

In a cross-sectional study published in the journal CHEST, the researchers reviewed data from 31 obese adults with asthma and 22 obese adults without asthma. The participants were aged 18 years and older, with forced expiratory volume (FEV₁) of at least 60% of predicted. All had class III obesity, with an average BMI of 47.2 kg/m² for those with asthma and 46.7 kg/m² for nonasthma controls. Demographic characteristics were similar between the groups.

Airway reactivity was defined as a 20% decrease in FEV₁ and/or a 50% change in resistance or reactance at 5 Hz (R5 and X5), at a concentration of 16 mg/mL or less of methacholine. Patients were assessed using spirometry and oscillometry.

Overall, most obese individuals with and without asthma showed significant changes in peripheral airway resistance. For those with asthma, the resistance at 5 Hz, measured by oscillometry, increased by 52% in response to the PC20 methacholine challenge, with an area under the reactance curve (AX) of 361%. For controls without asthma, the resistance at 5 Hz increased by 45%, with an AX of 268% in response to 16 mg/mL of methacholine.

This finding suggests that obesity predisposes individuals to peripheral airway reactivity regardless of asthma status, the researchers wrote in their discussion.

The researchers also identified two distinct groups of asthma patients categorized by respiratory system impedance based on more concordant vs. discordant bronchoconstriction in the central and peripheral airways. The baseline AX for these two groups was 11.8 and 46.7, respectively, with interquartile ranges of 9.9-23.4 and 23.2-53.7, respectively.

The discordant group included only women, and these patients reported significantly more gastroesophageal reflux, increased chest tightness, and more wheezing and asthma exacerbations than the concordant group, which may be related to air trapping, shown on previous studies of obese individuals with asthma, the researchers wrote.

The findings were limited by several factors, including the measurement of airway impedance only at the peak methacholine dose and the measurement of oscillometry after spirometry, the researchers noted. Other limitations included the relatively small study population at a single center, and the focus on obese individuals only.

More research is needed in larger and more diverse patient populations, but the results support the characterization of a subgroup of obese asthma patients with significant peripheral airway dysfunction, the researchers wrote.

“Oscillometry testing can reveal a physiologic phenotype of asthma in obesity that may be related to worse symptoms and more severe disease, and also reveal subclinical abnormalities in people with obesity, but without clinically diagnosed lung disease,” they concluded.

The study was supported in part by the National Institutes of Health. The researchers declared no financial conflicts.

A version of this article first appeared on Medscape.com.

Peripheral airway response to methacholine was similar among obese adults with and without asthma, although forced expiratory volume was lower for those with asthma, based on data from 53 individuals.

Obesity remains a risk factor for asthma, and obese individuals with asthma tend to have worse control and more severe disease, compared with nonobese asthma patients, wrote Anne E. Dixon, BM, BCh, of the University of Vermont, Burlington, and colleagues.

Previous studies have shown that airway reactivity can occur in obese individuals without airway inflammation, but studies characterizing obese asthma based on lung function are lacking, they said. “Combining spirometry and oscillometry might reveal abnormalities in lung mechanics particularly pertinent to people with obesity and asthma,” the researchers noted.

In a cross-sectional study published in the journal CHEST, the researchers reviewed data from 31 obese adults with asthma and 22 obese adults without asthma. The participants were aged 18 years and older, with forced expiratory volume (FEV₁) of at least 60% of predicted. All had class III obesity, with an average BMI of 47.2 kg/m² for those with asthma and 46.7 kg/m² for nonasthma controls. Demographic characteristics were similar between the groups.

Airway reactivity was defined as a 20% decrease in FEV₁ and/or a 50% change in resistance or reactance at 5 Hz (R5 and X5), at a concentration of 16 mg/mL or less of methacholine. Patients were assessed using spirometry and oscillometry.

Overall, most obese individuals with and without asthma showed significant changes in peripheral airway resistance. For those with asthma, the resistance at 5 Hz, measured by oscillometry, increased by 52% in response to the PC20 methacholine challenge, with an area under the reactance curve (AX) of 361%. For controls without asthma, the resistance at 5 Hz increased by 45%, with an AX of 268% in response to 16 mg/mL of methacholine.

This finding suggests that obesity predisposes individuals to peripheral airway reactivity regardless of asthma status, the researchers wrote in their discussion.

The researchers also identified two distinct groups of asthma patients categorized by respiratory system impedance based on more concordant vs. discordant bronchoconstriction in the central and peripheral airways. The baseline AX for these two groups was 11.8 and 46.7, respectively, with interquartile ranges of 9.9-23.4 and 23.2-53.7, respectively.

The discordant group included only women, and these patients reported significantly more gastroesophageal reflux, increased chest tightness, and more wheezing and asthma exacerbations than the concordant group, which may be related to air trapping, shown on previous studies of obese individuals with asthma, the researchers wrote.

The findings were limited by several factors, including the measurement of airway impedance only at the peak methacholine dose and the measurement of oscillometry after spirometry, the researchers noted. Other limitations included the relatively small study population at a single center, and the focus on obese individuals only.

More research is needed in larger and more diverse patient populations, but the results support the characterization of a subgroup of obese asthma patients with significant peripheral airway dysfunction, the researchers wrote.

“Oscillometry testing can reveal a physiologic phenotype of asthma in obesity that may be related to worse symptoms and more severe disease, and also reveal subclinical abnormalities in people with obesity, but without clinically diagnosed lung disease,” they concluded.

The study was supported in part by the National Institutes of Health. The researchers declared no financial conflicts.

A version of this article first appeared on Medscape.com.

Six subtypes of asthma that may facilitate personalized treatment were identified and confirmed in a large database review of approximately 50,000 patients, according to a recent study.

Previous studies of asthma subtypes have involved age of disease onset, the presence of allergies, and level of eosinophilic inflammation, and have been limited by factors including small sample size and lack of formal validation, Elsie M.F. Horne, MD, of the Asthma UK Centre for Applied Research, Edinburgh, and colleagues wrote.

In a study published in the International Journal of Medical Informatics, the researchers used data from two databases in the United Kingdom: the Optimum Patient Care Research Database (OPCRD) and the Secure Anonymised Information Linkage Database (SAIL). Each dataset included 50,000 randomly selected nonoverlapping adult asthma patients.

The researchers identified 45 categorical features from primary care electronic health records. The features included those directly linked to asthma, such as medications; and features indirectly linked to asthma, such as comorbidities.

The subtypes were defined by the clinically applicable features of level of inhaled corticosteroid use, level of health care use, and the presence of comorbidities, using multiple correspondence analysis and k-means cluster analysis.

The six asthma subtypes were identified in the OPCRD study population as follows: low inhaled corticosteroid use and low health care utilization (30%); low to medium ICS use (36%); low to medium ICS use and comorbidities (12%); varied ICS use and comorbid chronic obstructive pulmonary disease (4%); high ICS use (10%); and very high ICS use (7%).

The researchers replicated the subtypes with 91%-92% accuracy in an internal dataset and 84%-86% accuracy in an external dataset. “These subtypes generalized well at two future time points, and in an additional EHR database from a different U.K. nation (the SAIL Databank),” they wrote in their discussion.

The findings were limited by several factors including the retrospective design, the possible inclusion of people without asthma because of the cohort selection criteria, and the possible biases associated with the use of EHRs; however, the results were strengthened by the large dataset and the additional validations, the researchers noted.

“Using these subtypes to summarize asthma populations could help with management and resource planning at the practice level, and could be useful for understanding regional differences in the asthma population,” they noted. For example, key clinical implications for individuals in a low health care utilization subtype could include being flagged for barriers to care and misdiagnoses, while those in a high health care utilization subtype could be considered for reassessment of medication and other options.

The study received no outside funding. Lead author Dr. Horne had no financial conflicts to disclose.

Six subtypes of asthma that may facilitate personalized treatment were identified and confirmed in a large database review of approximately 50,000 patients, according to a recent study.

Previous studies of asthma subtypes have involved age of disease onset, the presence of allergies, and level of eosinophilic inflammation, and have been limited by factors including small sample size and lack of formal validation, Elsie M.F. Horne, MD, of the Asthma UK Centre for Applied Research, Edinburgh, and colleagues wrote.

In a study published in the International Journal of Medical Informatics, the researchers used data from two databases in the United Kingdom: the Optimum Patient Care Research Database (OPCRD) and the Secure Anonymised Information Linkage Database (SAIL). Each dataset included 50,000 randomly selected nonoverlapping adult asthma patients.

The researchers identified 45 categorical features from primary care electronic health records. The features included those directly linked to asthma, such as medications; and features indirectly linked to asthma, such as comorbidities.

The subtypes were defined by the clinically applicable features of level of inhaled corticosteroid use, level of health care use, and the presence of comorbidities, using multiple correspondence analysis and k-means cluster analysis.

The six asthma subtypes were identified in the OPCRD study population as follows: low inhaled corticosteroid use and low health care utilization (30%); low to medium ICS use (36%); low to medium ICS use and comorbidities (12%); varied ICS use and comorbid chronic obstructive pulmonary disease (4%); high ICS use (10%); and very high ICS use (7%).

The researchers replicated the subtypes with 91%-92% accuracy in an internal dataset and 84%-86% accuracy in an external dataset. “These subtypes generalized well at two future time points, and in an additional EHR database from a different U.K. nation (the SAIL Databank),” they wrote in their discussion.

The findings were limited by several factors including the retrospective design, the possible inclusion of people without asthma because of the cohort selection criteria, and the possible biases associated with the use of EHRs; however, the results were strengthened by the large dataset and the additional validations, the researchers noted.

“Using these subtypes to summarize asthma populations could help with management and resource planning at the practice level, and could be useful for understanding regional differences in the asthma population,” they noted. For example, key clinical implications for individuals in a low health care utilization subtype could include being flagged for barriers to care and misdiagnoses, while those in a high health care utilization subtype could be considered for reassessment of medication and other options.

The study received no outside funding. Lead author Dr. Horne had no financial conflicts to disclose.

Six subtypes of asthma that may facilitate personalized treatment were identified and confirmed in a large database review of approximately 50,000 patients, according to a recent study.

Previous studies of asthma subtypes have involved age of disease onset, the presence of allergies, and level of eosinophilic inflammation, and have been limited by factors including small sample size and lack of formal validation, Elsie M.F. Horne, MD, of the Asthma UK Centre for Applied Research, Edinburgh, and colleagues wrote.

In a study published in the International Journal of Medical Informatics, the researchers used data from two databases in the United Kingdom: the Optimum Patient Care Research Database (OPCRD) and the Secure Anonymised Information Linkage Database (SAIL). Each dataset included 50,000 randomly selected nonoverlapping adult asthma patients.

The researchers identified 45 categorical features from primary care electronic health records. The features included those directly linked to asthma, such as medications; and features indirectly linked to asthma, such as comorbidities.

The subtypes were defined by the clinically applicable features of level of inhaled corticosteroid use, level of health care use, and the presence of comorbidities, using multiple correspondence analysis and k-means cluster analysis.

The six asthma subtypes were identified in the OPCRD study population as follows: low inhaled corticosteroid use and low health care utilization (30%); low to medium ICS use (36%); low to medium ICS use and comorbidities (12%); varied ICS use and comorbid chronic obstructive pulmonary disease (4%); high ICS use (10%); and very high ICS use (7%).

The researchers replicated the subtypes with 91%-92% accuracy in an internal dataset and 84%-86% accuracy in an external dataset. “These subtypes generalized well at two future time points, and in an additional EHR database from a different U.K. nation (the SAIL Databank),” they wrote in their discussion.

The findings were limited by several factors including the retrospective design, the possible inclusion of people without asthma because of the cohort selection criteria, and the possible biases associated with the use of EHRs; however, the results were strengthened by the large dataset and the additional validations, the researchers noted.

“Using these subtypes to summarize asthma populations could help with management and resource planning at the practice level, and could be useful for understanding regional differences in the asthma population,” they noted. For example, key clinical implications for individuals in a low health care utilization subtype could include being flagged for barriers to care and misdiagnoses, while those in a high health care utilization subtype could be considered for reassessment of medication and other options.

The study received no outside funding. Lead author Dr. Horne had no financial conflicts to disclose.