Budesonide/Formoterol or Budesonide/Albuterol as Anti-Inflammatory Reliever Therapy for Asthma.

Overuse of reliever as short-acting beta-agonist and associated underuse of controller as inhaled corticosteroid (ICS) administered via separate inhalers results in worse asthma outcomes. Such discordance can be obviated by combining both controller and reliever in the same inhaler. So-called anti-inflammatory reliever (AIR) therapy comprises the use of a single inhaler containing an ICS such as budesonide (BUD) in conjunction with a reliever as either albuterol (ALB) or formoterol (FORM), to be used on demand, with variable dosing driven by asthma symptoms in a flexible patient-centered regimen. Global guidelines now support the use of BUD-ALB as AIR therapy to reduce exacerbations, either on its own in mild asthma or in conjunction with fixed-dose maintenance ICS-long-acting beta-agonist in moderate to severe asthma. Using BUD-FORM on its own allows patients to seamlessly move in an intuitive flexible fashion between AIR and maintenance and reliever therapy, by stepping up and down the dosing escalator across a spectrum of asthma severities. Head-to-head clinical studies are indicated to compare BUD-FORM versus BUD-ALB as AIR in mild asthma, and also BUD-FORM as maintenance and reliever therapy versus BUD-ALB as AIR plus maintenance ICS-long-acting beta-agonist in moderate to severe asthma. Patients should be encouraged to make an informed decision in conjunction with their health care professional regarding the best therapeutic option tailored to their individual needs, which in turn is likely to result in long-term compliance and associated optimal asthma control.

5-Item sino-nasal outcome test and 22-item sino-nasal outcome test relationship with endoscopic and radiologic scores in chronic rhinosinusitis with nasal polyps.

BACKGROUND: The 22-item sino-nasal outcome test (SNOT-22) is a frequently used patient-recorded outcome measure in patients with chronic rhinosinusitis with nasal polyps (CRSwNPs). Objective findings of nasal polyps and paranasal sinus inflammation are frequently graded using nasal polyp score (NPS) and Lund-Mackay Score (LMS), respectively. OBJECTIVE: To evaluate a novel, abbreviated, rhinology-focused, five-domain SNOT-5 questionnaire because we had anecdotally noticed a relative disconnect between SNOT-22 and endoscopy and imaging scores. METHODS: We performed a retrospective, cross-sectional, single-center review of patients with CRSwNPs who had filled out a SNOT-22, along with post hoc-derived SNOT-5 scores, which were then assessed in relation to NPS and LMS. RESULTS: A total of 129 patients were included in the analysis. SNOT-5 but not SNOT-22 scores significantly correlated vs either NPS (P < .005) and LMS (P < .001), whereas only SNOT-5 differed significantly when comparing the cohort's lowest and highest tertiles for mean LMS: 11.8 vs 16.8 (95% CI, 1.5-8.4; P < .01) and for mean NPS 12.4 vs 15.6 (95% CI, 0.5-5.9; P < .05). CONCLUSION: In a retrospective, real-life cohort study of CRSwNP, there was a relative disconnect between the significant association of SNOT-5 but not SNOT-22 in relation to objective endoscopy and imaging measures. We, therefore, propose that further prospective intervention studies are indicated in CRSwNP to evaluate the SNOT-5 score including establishing the minimal clinically important difference.

Should Airway Hyper-Responsiveness Be Included in the Definition of Clinical Remission With Biologic Therapy in Severe Asthma.

Airway hyper-responsiveness (AHR) is a tenet of the persistent asthma phenotype along with reversible airway obstruction and type 2 (T2) inflammation. Indirect acting challenges such as mannitol are more closely related to the underlying T2 inflammatory process as compared with direct challenges. In this review article, we summarise the current literature and explore the future role of mannitol AHR in clinical remission with biologics.

Medium-term repeatability for airwave oscillometry in patients with severe asthma taking benralizumab.

Background: The effort-independent tidal breathing test used by oscillometry presents a viable alternative for following up patients whose condition is stable while they are receiving biologic therapy. Objective: We aimed to determine intrasession and intersession repeatability values for airwave oscillometry (AOS) and spirometry in patients who were already taking benralizumab. Methods: In all, 21 patients with severe eosinophilic asthma attended the Scottish Centre for Respiratory Research as part of a clinical trial (EudraCT identification number 2019-003763-22). Paired AOS and spirometry values were obtained at 3 separate visits (baseline and days 28 and 56) with no change in asthma therapy. Results: Intrasession agreement between repeated measurements for AOS and spirometry was excellent (intraclass correlation coefficient ≥ 0.90) at all 3 visits. Intersession agreement was also excellent (intraclass correlation coefficient ≥ 0.80). Conclusion: In this study we report medium-term intrasession and intersession repeatability values for airwave oscillometry and spirometry in a cohort of severely asthmatic patients receiving benralizumab therapy. Oscillometry can be used to follow up patients with asthma who are taking biologics.

Real-life effects of benralizumab on airway oscillometry in severe eosinophilic asthma.

INTRODUCTION: Eosinophil depletion with benralizumab reduces exacerbations and improves disease control and FEV1 in patients with severe eosinophilic asthma. However, few studies have investigated the effect of biologics on small airways dysfunction (SAD) even though the latter correlates better with poor asthma control and type 2 inflammation. METHODS: 21 GINA-defined severe asthma patients who were treated with benralizumab and who had baseline oscillometry-defined SAD were included in this study. Here, SAD was diagnosed only if patients satisfied both R5-R20≥0.10 kPa/L/s and AX≥1.0 kPa/L. The mean duration of follow-up between pre-benralizumab versus post-benralizumab clinical measurements was 8 months. RESULTS: Mean values for FEV1% and FVC% but not FEF25%-75% significantly increased following benralizumab, along with significant reductions in Asthma Control Questionnaire (ACQ). There were no significant improvements in R5-R20, X5 or AX, while the mean (SEM) PBE count fell to 23 (14) cells/µL. In a responder analysis, n=8/21 and n=12/21 patients experienced improvements exceeding biological variability of 0.04 kPa/L/s and 0.39 kPa/L in R5-R20 and AX, respectively, in severe asthma. N=10/21, n=10/21 and n=11/21 patients experienced improvements in FEV1, FEF25-75 and FVC exceeding biological variability of 150 mL, 0.210 L/s and 150 mL, respectively. In contrast, n=15/21 patients experienced an improvement in ACQ greater than minimal clinical important difference of 0.5 units. CONCLUSION: Eosinophil depletion with benralizumab improves spirometry and asthma control but does not improve spirometry-measured or oscillometry-measured SAD in severe asthma in a real-life setting.

Phenotypic associations of medical polypectomy and revision surgery following endoscopic sinus surgery: a retrospective study of a single-centre experience in Scotland.

BACKGROUND: Some chronic rhinosinusitis with nasal polyps patients undergo revision surgery at some point following initial functional endoscopic sinus surgery. This review aimed to identify the predictive factors for recurrence of nasal polyps requiring oral corticosteroids or revision surgery in chronic rhinosinusitis with nasal polyps following functional endoscopic sinus surgery. METHOD: A retrospective analysis of 221 patients who underwent functional endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps in a tertiary rhinology centre, between January 2015 and December 2018, was undertaken. RESULTS: Forty-four (21.6 per cent) patients underwent medical polypectomy, 19 (9 per cent) underwent revision surgery and 51 (24.3 per cent) underwent combined polypectomy during the mean follow-up time of 5.3 years. Patients aged less than 55 years of age, with a history of previous functional endoscopic sinus surgery, peripheral blood eosinophil counts of 300 cells/µl or higher, a Lund-Mackay score of more than 17 and concomitant aspirin-exacerbated respiratory disease had significantly increased odds for medical polypectomy, revision surgery and combined polypectomy. CONCLUSION: Knowing these predictive factors, clinicians can better identify patients with an increased likelihood of severe polyp recurrence and therefore arrange closer follow-up to optimise therapy.