Remotely Monitored Therapy and Nitric Oxide Suppression Identifies Non-Adherence in Severe Asthma.

Rationale Poor adherence is common in difficult-to-control asthma. Distinguishing patients with difficult-to-control asthma who respond to inhaled corticosteroids (ICS) from refractory asthma is an important clinical challenge. Objectives Suppression of fractional exhaled nitric oxide (FeNO) with directly observed ICS therapy over 7 days can identify non-adherence to ICS treatment in difficult-to-control asthma. We examined the feasibility and utility of FeNO suppression testing in routine clinical care within UK severe asthma centres using remote monitoring technologies. Methods A web-based interface with integrated remote monitoring technology was developed to deliver FeNO suppression testing. We examined the utility of FeNO suppression testing to demonstrate ICS responsiveness and clinical benefit on electronically-monitored treatment with standard high dose ICS and long-acting β2-agonist (LABA) treatment. Measurements and Main Results Clinical response was assessed using the Asthma Control Questionnaire (ACQ-5), spirometry and biomarker measurements (FeNO and peripheral blood eosinophil count). Of 250 subjects, 201 completed the test with 130 positive suppression tests. Compared to a negative suppression test, a positive test identified a FeNO-low population when adherent with ICS/LABA (median 26ppb [IQR 16-36] v 43ppb [IQR 38-73]) with significantly greater FEV1% (mean 88.2±16.4 v 74.1±20.9], p<0.01). ACQ-5 improved significantly in both groups (positive test, mean difference 1.2, 95% CI -0.9, -1.5, negative test, mean difference 0.9, 95% CI -0.4, -1.3). Conclusions Remote FeNO suppression testing is an effective means of identifying non-adherence to ICS in subjects with difficult-to-control asthma and the substantial population of subjects who derive important clinical benefits from optimised ICS/LABA treatment

A randomised trial of a T2-composite-biomarker strategy adjusting corticosteroidtreatment in severe asthma, a post- hoc analysis by sex.

Background Approximately 5–10% of patients with asthma have severe disease with a consistent preponderance in females. Current asthma guidelines recommend stepwise treatment to achieve symptom control with no differential treatment considerations for either sex. Objectives To examine whether patient sex affects outcomes when using a composite T2-biomarker score to adjust corticosteroid treatment in patients with severe asthma compared to standard care. Methods Post-hoc analysis stratifying patient outcomes by sex of a 48-week, multicentre, randomised controlled clinical trial comparing a biomarker-defined treatment algorithm with standard care. The primary outcome was the proportion of patients with a reduction in corticosteroid treatment (inhaled (ICS) and oral (OCS) corticosteroids). Secondary outcomes included exacerbation rates, hospital admissions and lung function. Results Of 301 patients randomised; 194 (64.5%) were females and 107 (35.5%) were males. The biomarker algorithm led to a greater proportion of females being on a lower corticosteroid dose vs standard care which was not seen in males (effects estimate females: 3.57, 95% CI: 1.14, 11.18 vs. males 0.54, 95% CI: 0.16, 1.80). In T2-biomarker low females, reducing corticosteroid dose was not associated with increased exacerbations. Females scored higher in all ACQ-7 domains, but with no difference when adjusted for BMI/ anxiety and/or depression. Dissociation between symptoms and T2-biomarkers were noted in both sexes, with a higher proportion of females being symptom high/T2-biomarker low (22.8% vs. 15.6%; p=0.0002), whereas males were symptom low/T2-biomarker high (11.4% vs. 22.3%; p Conclusion This exploratory post-hoc analysis identified females achieved a greater benefit from biomarker-directed corticosteroid optimisation versus symptom-directed treatment.</p