Data from The Asthma Report - Curated by EPG Health - Last updated 31 October 2018
The final day of ERS 2018 and for today’s Asthma Report, we have chosen a session on phenotyping
looking at the ongoing work to develop asthma phenotypes including clinical features and genetics, plus a session covering both COPD and asthma, covering eosinophils in the airways.
Does phenotyping improve treatment
Dr Bright Nwaru, Gothenburg, Sweden started the session discussing oral steroid exposure in a Swedish cohort. Oral corticosteroids (OCS) have known side effects but longitudinal data is scarce. Regular users of OCS were older and likely to be in more treatments. 15% of asthma patients had at least one course of OCS per year, and the chance was higher in females. Regular users of OCS have a hazard ratio of 1.45 for mortality after adjustment for age, sex, comorbidity and baseline Inhaled corticosteroids (also known as inhaled steroids or ICS).
Dr Laurits Frøssing investigated gene profiles of inflammation to help identify Type 2 (T2) phenotypes. Groups were decided by fractional exhaled nitric oxide (FeNO), eosinophil count. 11 genes were assessed from sputum plugs and compared to FeNO and eosinophil levels. Gene panels as shown below can distinguish Between groups with high AUCs over 0.8.
Evgeniia Makarova presented on asthma and obesity in Russia. Over 50% of the over 65s in Russia are obese, the prevalence of asthma is higher in over 65s and obesity is known to be a risk factor for asthma. A study to compare IL-6, BMI, Leptin and lung function was conducted in asthmatic postmenopausal women. Obese women had lower FEV1 (forced expiratory volume over 1 second), FVC (forced vital capacity) and PEFR (peak expiratory flow rate). Leptin was far higher in the obese group (61 vs 29 Ng/mL) but IL-6 was not significantly different.
Chanel Kwok, Queen's University at Kingston, delivered data on emergency department asthma pathway including assessment, treatment and follow up. In a pilot study, treatment and documentation improved. Roll-out occurred between 2008-2011. Provincial healthcare databases were reviewed and compared with surveys of sites. Outcomes did not seem to depend on available specialty staff. Availability of PEFR or spirometer assessment was associated with reduced chance of readmission. 28% of hospitals were using the pathway, and this was more common in teaching hospitals. Time series analysis showed no significant improvement in repeat ED admission in community sites, but there were significant improvement in teaching sites with an absolute risk reduction of readmission of 2%.
Dr Anna Freeman, University of Southampton, UK presented on findings from the WATCH cohort, particularly on sex differences. 380 patients were described, and no sex differences were seen in FeNO, atopy and IgE (Immunoglobulin E). Males were older at enrolment. Obesity was more prevalent in females. Females were less obstructed with higher FEV1s and ratios. Females were more salicylate sensitive but less eosinophilic and less likely to have bronchiectatic. Females were more likely to have raised ACQ, Nijmegen and anxiety/depression.
Amani Mansour presented to asthmatic patients with small airway instruction. Defining small airway obstruction spirometrically as reduced mid expiratory flow without large airway obstruction, those with small airway obstruction were more likely to be atopic, and less severe but no different in terms of asthma control. Unfortunately, no other tests were available to confirm the small airway disease in the group, or the lack of it in the other so the results are hard to interpret.
Eosinophils in airway disease
Mona Bafadhel started by discussing the effect of budesonide in protecting COPD patients against clinically important deteriorations. Using pooled data from AZ budesonide/formoterol trials, those with low-very low eosinophils have very little benefit from budesonide.
Marina Kevirkova continued the theme, discussing the effects of blood eosinophils in acute exacerbations. In patients with severe COPD hospitalised with acute exacerbations, eosinophilic patients were less hypoxic, less tachyoneoc and had lower C‐reactive protein (CRP). Length of stay, NIV and O2 requirements were lower but readmission rates were higher.
Robson Prudente, São Paulo State University, then presented on the effect of peripheral eosinophils and mortality in COPD. In this Brazilian cohort, lower levels of blood eosinophils were associated with higher risk of death over the next nine years. This is in contradiction with previous work, suggesting different mechanisms a in this cohort
Professor Chris Brightling, University of Leicester, UK presented data on transcriptomics from asthma and COPD from the UBIOPRED and EVA studies. Regression analysis of bronchial brushing genetics was the compared against eosinophils. Only 12 genes were unregulated in eosinophilic COPD, compared to 266 in asthma - only one of these was found to be common, the CST1 gene. This study suggests that the mechanisms underlying eosinophilia in asthma and COPD are distinct.
Dr Anthony Yii presented data showing that, in life threatening exacerbations of asthma, blood eosinophils correlate with severity of exacerbation. Eosinophilic patients were more likely to be male, smokers, younger, and be on less asthma treatment. Both blood gas pH and PaCO2 were worse in increasing tertiles of eosinophil count. Those with the highest eosinophil counts had the highest risk of death or recurrent admission after discharge.
Dr Mateja Malorvh presented on induced sputum findings in asthmatics with accelerated decline in FEV1. Those with rapid decline had higher sputum eosinophils, IL-5 and IL-8 despite good control of symptoms.
Professor Nicola Hanania finished the session discussing the testing of biomarker levels, specifically eosinophil count and IgE, in severe asthma. Patients starting biologics were identified and data in the twelve months prior was retrieved. 1001 patients were initiated, 829 on xolair, 156 on mepolizumab and 16 on reslizumab. Approximately 60% if patients had not had an exacerbation in the six months prior to initiation. 40% of patients started on mepolizumab were OCS dependent, more than reslizumab or omalizumab. Only around half of patients had relevant biomarker tested in six months prior to initiation.