Current and emerging therapies for eosinophilic esophagitis.

Background: Eosinophilic esophagitis (EoE) is a Type-2 chronic inflammatory food antigen-driven disease of the esophagus, characterized by eosinophilic predominant inflammation and a constellation of symptoms. The incidence and prevalence of EoE has increased over the past 2 decades. There is an unmet need for approved less burdensome treatment options. Objective: To describe the underlying pathophysiology and diagnosis of EoE and discuss the currently available treatment options. We also aim to review the new and emerging therapies for EoE. Methods: A search of a medical literature data base was performed for articles that discuss treatment for EoE. Results: A comparison of current therapies showed that dietary elimination, swallowed topical corticosteroids, and proton-pump inhibitor therapy are all effective for different populations. Emerging therapies that were reviewed include new topical corticosteroids and biologics directed against Type 2 inflammation. Conclusion: EoE is a chronic inflammatory disorder that can be debilitating, with long-term sequelae. There are no current approved therapies in the United States. Numerous new treatments are on the horizon. Increasing amounts of data are helping to tailor treatment for each patient. Ultimately, shared decision-making is the best approach to guide treatment choices with patients to manage the ever-increasing burden of this disease.

Intranasal corticosteroids: the role of patient preference and satisfaction.

Allergic rhinitis (AR) is a disease with a significant global burden, associated with many comorbidities and quality-of-life issues. Overwhelming evidence shows that intranasal corticosteroids are the most effective treatment for AR to control the disease, decrease comorbidities, and decrease costs. Poor adherence is a major barrier to achieving control of AR. This article addresses patient preferences and satisfaction regarding intranasal corticosteroids and factors leading to better adherence. We review and summarize the published literature. Factors affecting patient preference and, ultimately, adherence include a variety of sensory components such as odor, taste, comfort of delivery, delivery devices (aerosol versus aqueous) and patient cost. The intensity of adverse sensory attributes is negatively correlated with patient preference and the likelihood of adherence. Selection of an intranasal steroid (INS) with patient preference and satisfaction in mind can influence patient outcomes and cost. Providers need to assess each patient to determine which inhaled INS will lead to the best adherence, thereby improving outcomes in our patients and ultimately reducing the overall global burden of this disease.

Older adults with asthma: does age of asthma onset make a difference?

OBJECTIVE: Older adults with asthma can develop symptoms early in life or during adulthood. Differences between these groups may have diagnostic and therapeutic implications. Our goal was to identify differences in demographics, control, quality of life and healthcare utilization between those with long-standing asthma (LSA) and late-onset asthma (LOA). METHODS: Data from a cross-sectional study of asthma patients over age 65 were analyzed. LSA or LOA was based on age of diagnosis (before or after age 40). Demographic and asthma specific information were analyzed, and allergy prick tests and lung function testing (spirometry and FENO) were performed. RESULTS: After regression analysis, LSA subjects were more likely to demonstrate positive prick tests (92 versus 71%, p = 0.04), with both groups demonstrating higher levels of atopy than previously reported. LSA subjects were also more likely to have received a peak flow meter (p = 0.07). LOA subjects were more likely to have moderate or severe asthma (OR = 3.1, p = 0.05), and had higher FENO readings (p = 0.02). They also had more hospitalizations (p = 0.04), though significance was lost after regression analysis. No differences were noted in demographic information, medical comorbidities, spirometry, compliance, asthma control, or asthma quality of life between LSA and LOA subjects. CONCLUSION: LSA subjects are more atopic and more likely to be given a peak flow meter, while LOA subjects have higher FENO levels and more severe asthma. Defining age of asthma onset may help improve treatment recommendations and outcomes for older adults.

A randomized controlled trial of a self-regulation intervention for older adults with asthma.

OBJECTIVES: To evaluate a self-regulation intervention for asthma for older adults. DESIGN: A blinded randomized controlled trial. SETTING: Single-center tertiary care academic center. PARTICIPANTS: Seventy older adults aged 65 and older with persistent asthma randomized to an intervention or control group. INTERVENTION: Participants participate in a six-session program conducted over the telephone and in group sessions. Participants selected an asthma-specific goal, identified problems, and addressed potential barriers. MEASUREMENTS: Outcomes were assessed at 1, 6, and 12 months and included the mini-Asthma Quality of Life Questionnaire (mAQLQ), Asthma Control Questionnaire (ACQ), healthcare utilization, exhaled nitric oxide (FENO), and percentage of predicted forced expiratory volume in 1 second (FEV1%). RESULTS: The mAQLQ score was significantly higher in the intervention group at 1, 6, and 12 months, even after controlling for confounding factors. The between-group difference decreased over time, although at 12 months, it remained greater than 0.5 points. The ACQ was better in the intervention group than in the control group at 1, 6, and 12 months. At 12 months, those in the intervention group were 4.2 times as likely as those in the control group to have an ACQ score in the controlled range. Healthcare utilization was lower in the intervention group, although no difference was observed in FENO or predicted FEV1%. CONCLUSION: A self-regulation intervention can improve asthma control, quality of life, and healthcare utilization in older adults.

A 50-year old woman with nasal congestion, cough, and dyspnea.

We present a 50-year-old woman with progressive dyspnea, cough, and nasal congestion. Evaluation revealed positive skin tests (IgE) to trees and dust mites, early glottic closure on spirometry, and sinus opacities on CT. Diagnostic considerations included allergic and nonallergic rhinitis, asthma, aspirin-exacerbated respiratory disease, vocal cord dysfunction, chronic sinusitis secondary to gastroesophageal reflux disease, and systemic inflammatory and immunologic diseases, including vasculitis. Progresson of her symptoms prompted further investigation, and a biopsy yielded an unexpected diagnosis.

Quality of life, health care utilization, and control in older adults with asthma.

BACKGROUND: Older adults with asthma have worse quality of life, asthma control and increased health care utilization than do healthy peers. Factors that contribute to this are currently unknown. OBJECTIVE: To identify demographic, psychological or physiologic characteristics associated with asthma quality of life, control and health care utilization in older adults. METHODS: By using a cross-sectional design, subjects older than 65 years with a history of physician-diagnosed asthma were enrolled. Demographic, psychological and physiological characteristics (including spirometry, atopy testing and exhaled nitric oxide) were collected. Correlations between these factors and the mini Asthma Quality of Life Questionnaire, Asthma Control Questionnaire and health care utilization were assessed. RESULTS: Seventy subjects were enrolled in the study, with a mean age of 73.3 years and mean duration of asthma diagnosis of 28.5 years. Higher depression screening scores and self-reported depression were strongly correlated with poorer quality of life and asthma control after controlling for confounding effects through a regression model. In addition, worse overall functional status was correlated with poorer asthma quality of life (P < .01), presence of atopy was associated with decreased health care utilization (P < .01) and subjects who lived alone were more likely to have unscheduled visits to a physician's office (P = .06). CONCLUSIONS: Comorbid depression is strongly associated with poorer asthma quality of life and control in older adults. In addition, worse functional status and living alone may be associated with poorer outcomes. Screening for these conditions is important in the care of the elderly asthmatic population.