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Press Releases

Take a look at a selection of our recent media coverage:

Study links poorly controlled asthma to excessive greenhouse gas emissions

1st March 2024

Poorly controlled asthma significantly contributes to greenhouse gas (GHG) emissions, with these patients contributing eight times more excess GHG than those with well-managed asthma, new research has found.

In a first-of-its-kind study, the researchers also found that patients with poorly controlled asthma produce the same quantity of GHG as 124,000 homes each year in the UK.

The researchers – a consortium from the NHS, UK and international universities and AstraZeneca – say that 90% of the excess GHG emissions from asthma care in the UK are the result of inappropriate use of short-acting β2-agonist (SABA) reliever inhalers.

Published in the BMJ journal Thorax, the findings highlight how the improvement of care of people with asthma could substantially reduce carbon emissions and help the NHS meet its net zero targets.

The NHS aims to reduce its carbon footprint by over 80% over the next 15 years and reach net zero by 2045, and better management of asthma could help achieve this goal.

This retrospective cohort study, based on the SABA use IN Asthma (SABINA) I UK study, used anonymised health records of 236,506 people with asthma from the Clinical Practice Research Datalink, collected between 2008 and 2019, to examine the environmental footprint of asthma care in the UK.

Patients were all aged 12 and over, with a validated record of a current asthma diagnosis and current asthma at 12 months prior to baseline.

GHG emissions were retrospectively analysed by measuring carbon dioxide equivalent (CO2e) for asthma-related medication use, healthcare resource utilisation and severe exacerbations during follow-up of patients with asthma for both well-controlled and poorly controlled asthma at base level.

Well-controlled asthma was categorised as fewer than three prescriptions of SABA reliever inhalers per year and no episodes where symptoms became severe.

Poorly controlled asthma included patients who needed three or more SABA prescriptions per year and experienced one or more episodes of severe symptoms, which involved either a course of oral corticosteroids and any general practice and outpatient visits within 10 days of hospitalisation or emergency department visit.

Asthma was poorly controlled in just under half (47.3%) of the patients analysed. At baseline, patients with poorly controlled asthma versus those with well-controlled asthma received a greater number of prescriptions for SABA, inhaled corticosteroid (ICS) monotherapy and ICS in conjunction with long-acting bronchodilator inhalers.

Scaled to the national level, the overall carbon footprint of asthma care in the UK was 750,540 tonnes CO2e/year, with poorly controlled asthma contributing excess GHG emissions of 303,874 tonnes CO2e/year.

GHG emissions were eight times higher on average for a person with poorly controlled asthma than those with well-controlled asthma.

One outcome of inadequate asthma control is the increased use of SABA reliever therapy. The analysis shows that 90% of the excess GHG emissions resulted from inappropriate SABA use in patients with poorly managed asthma.

Due to worsening symptoms, the remaining excess emissions resulted from healthcare utilisation, such as GP or hospital visits.

Although SABAs provide immediate bronchodilation, they lack anti-inflammatory activity and contribute minimally to achieving asthma control. In addition, SABA prescriptions of more than three canisters per year are associated with an increased risk of exacerbations, asthma-related mortality and increased use of healthcare resources.

The researchers stated: ‘Our study indicates that poorly controlled asthma contributes to a large proportion of asthma-care related greenhouse gas emissions with inappropriate SABA use emerging as the single largest contributor.’

The Global Initiative for Asthma no longer recommends SABA inhalers are used alone as the preferred reliever for acute asthma symptoms.

The researchers concluded that efforts to implement evidence-based treatment recommendations for asthma patients and curtail inappropriate SABA use could result in substantial carbon savings for the NHS.

In November 2023, it was announced that a low-carbon salbutamol metered-dose inhaler that could reduce greenhouse gas emissions from inhaler use by around 90% was advancing to phase 3 trials in the first half of 2024.

Significant shortfalls in recommended asthma follow-up care after hospitalisation

12th January 2024

Over 80% of asthma patients hospitalised following an asthma attack are not getting appropriate follow-up care, a new study has found.

Data collected by the University of Birmingham, and published in the British Journal of General Practice, shows that only 18% of hospitalised asthma patients had a GP appointment within the recommended 48-hour period post-discharge.

The findings were worse for black patients, and the researchers suggest there are ‘serious inequalities’ in the follow-up care received.

Using electronic healthcare records collected between 2017 and 2019, the researchers analysed data from more than 17,000 patients over the age of five.

The findings show that the current recommendations for follow-up care of asthma patients are not being met, and primary care appointments after hospitalisation are falling far outside the 48-hour window for most asthma patients, with many waiting months for a review.

While 82% did not receive the recommended follow-up care within 48 hours, only 60% of patients had a primary care follow-up within 28 days post-hospitalisation.

Further evidence suggests that while just over half of patients received medication following an appointment, only 13% of patients were offered asthma reviews, and just 8% were offered management plans.

Senior author of the study, Dr Shamil Haroon, clinical epidemiologist and associate clinical professor of public health at the University of Birmingham‘s Institute of Applied Health Research, said: ‘Not only are most patients not getting care in the recommended time frame of 48 hours, but patients are being left for months and more before being reviewed.

‘We recommend that robust plans be put in place to ensure that these recommendations are being followed more closely, and greater scrutiny where they are not.’

The inequalities highlighted in the study also showed that black patients receive less care associated with their asthma management. The researchers estimate that depending on their age, black patients were between 27% and 54% less likely to receive the level of care that their white peers were provided.

Dr Prasad Nagakumar, paediatric respiratory consultant at Birmingham Children’s Hospital and senior author, added: ‘Our study highlights significant shortfalls in implementing the recommendations of the 2014 national review of asthma deaths for follow-up of hospitalised asthma patients.

‘It is time for policy makers to review the recommendations to reduce the health inequalities experienced by black and ethnic minority groups who also have a high risk of fatal and near fatal asthma attacks.’

A version of this article was originally published by our sister publication Nursing in Practice.

European Respiratory Society issues consensus statement on climate change and respiratory health

11th September 2023

Guidance on how global warming can be addressed in clinical practice has been outlined by the European Respiratory Society (ERS) in its latest consensus statement on climate change and respiratory health.

Published in the European Respiratory Journal, the statement describes climate change as ‘an unfolding major planetary and health crisis’, and a major threat to those with common lung conditions.

This, it says, is linked to the frequent and extreme weather events, prolonged aeroallergen seasons and poorer air quality associated with climate change, which can lead directly to a worsening of health and an increased risk of death.

Traditionally, clinicians have been involved in climate change adaptation strategies such as identifying vulnerable groups and providing advice on how they can protect themselves during heatwaves, for example.

However, the ERS says this clinical role has now expanded to focus on both human and planetary health, which includes contributing to the reduction in greenhouse gas emissions.

According to the ERS, subsequent changes to clinical practice could therefore include promoting green prescriptions such as inhalers; focusing efforts on smoking eradication; and encouraging patients, where appropriate, to engage with nature, take active modes of transport and make more sustainable food choices.

Professor Zorana Jovanovic Andersen, chair of the ERS Environment and Health Committee and professor of environmental epidemiology at the University of Copenhagen, who was one of the authors, said: ‘As respiratory doctors and nurses, we need to be aware of these new risks and do all we can to help alleviate patients’ suffering. We also need to explain the risks to our patients so they can protect themselves from adverse effects of climate change.‘

Climate change and lung health

The consensus statement also highlights that climate change will have a disproportionately greater adverse effect on individuals living with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD).

It outlines some of the health risks of climate change such as a decline in lung function, increases in allergic responses and/or new cases of chronic (asthma, COPD, lung cancer) or infectious (pneumonia, influenza, tuberculosis, Covid-19) respiratory diseases.

It also identifies a higher risk of exacerbations for existing respiratory diseases, increased use of medication, emergency department visits, hospitalisations and death.

The fact that children are more susceptible to the impact of climate change on lung health is also highlighted, including the fact that the prevention of chronic respiratory disease should start as early as possible as many chronic lung diseases in adults have childhood origins.

The burden of global warming

Several previous reviews have provided extensive summaries of the different mechanisms by which climate change affects respiratory health, as well as outlining adaptation strategies. The latest statement provides an overview of all major pathways linking climate change with lung health.

While it summarises all of the available evidence, the authors also recognise some gaps in current knowledge. For instance, there is the need for further research to fully map the burden of climate change on respiratory diseases under different global warming scenarios and to understand underlying biological mechanisms, as well as identifying pathways of adaptation that can be translated into public health policies.

Professor Jovanovic Andersen, added: ‘Climate change affects everyone’s health, but arguably, respiratory patients are among the most vulnerable. These are people who already experience breathing difficulties and they are far more sensitive to our changing climate. Their symptoms will become worse, and for some this will be fatal.

‘Air pollution is already damaging our lungs. Now the effects of climate change are becoming a major threat to respiratory patients.’

Indeed, the deleterious respiratory effects of the particulate matter contained within air pollution, are already known to provide a mechanism through which lung cancer can develop among individuals who have never smoked.

Gut microbiome changes uniformly linked to allergic disease development in childhood

4th September 2023

Delays in gut microbiome maturation in young children are uniformly associated with distinct allergic diagnoses at five years of age, according to the findings of a study by Canadian researchers.

The study, which was published in the journal Nature Communications, revealed how specific gut microbiome features and early life influences are associated with children developing any of four common allergies: atopic eczema, asthma, food allergy and/or allergic rhinitis.

It is possible, therefore, that these findings could lead to methods for predicting whether a child would develop an allergic disease. They could also form the foundation of strategies to prevent them from developing, especially given that food allergies in particular continue to be a major source of life-threatening reactions in children.

Courtney Hoskinson, PhD candidate at the University of British Columbia (UBC) and the study‘s lead author said: ‘Typically, our bodies tolerate the millions of bacteria living in our guts because they do so many good things for our health. Some of the ways we tolerate them are by keeping a strong barrier between them and our immune cells and by limiting inflammatory signals that would call those immune cells into action.‘

‘We found a common breakdown in these mechanisms in babies prior to the development of allergies.‘

In the study, researchers evaluated the four clinically distinct allergic diseases diagnosed at five years of age in the large, deeply characterised CHILD cohort study. The team adopted a multi-omics approach to profile infant stool collected at study visits scheduled for ages three months and one year.

Gut microbiome and allergic diseases

The study used a deeply phenotyped cohort of 1,115 children. A total of 523 participants could be defined as a ‘healthy‘ control group in that they did not develop allergic sensitisation at any time in their life up to five years of age.

Some 592 children had been diagnosed by an expert physician at the five-year scheduled visit with one or more allergic disorders: atopic eczema (n = 367), asthma (n = 165), food allergy (n = 136) and allergic rhinitis (n = 187). There were gut microbiome features uniformly associated with these allergic diagnoses at five years of age.

When evaluating the association between early-life factors and a diagnosis of allergic disease at age five, male sex, a history of either maternal of paternal atopy and antibiotic usage before age one were all significantly linked with an increased risk of developing an allergic disease.

In contrast, breastfeeding up to age six months and self-identifying as Caucasian were negatively associated with an allergy diagnosis.

Dr Stuart Turvey, professor in the department of pediatrics at UBC, investigator at British Columbia Children‘s Hospital Research Institute and co-senior author on the study, added: ‘There are a lot of potential insights from this robust analysis. From these data we can see that factors such as antibiotic usage in the first year of life are more likely to result in later allergic disorders, while breastfeeding for the first six months is protective. This was universal to all the allergic disorders we studied.

‘Developing therapies that change these interactions during infancy may therefore prevent the development of all sorts of allergic diseases in childhood, which often last a lifetime.‘

Study suggests lower vitamin K levels linked to reduced lung function

14th August 2023

Patients who have low vitamin K levels have a reduced ventilatory capacity and are more likely to self-report asthma, COPD or wheezing, according to a study by researchers from Copenhagen University Hospital and the University of Copenhagen.

The study, which was published in the journal ERJ Open Research, set out to assess whether lower vitamin K status was associated with lung function and lung disease/symptoms. The researchers focused on the measurement of dephosphorylated-uncarboxylated MGP (dp-ucMGP), which serves as an inverse plasma biomarker for vitamin K status.

The team recruited members of the general population and invited them to a health examination to complete questionnaires and undergo spirometry, together with measurement of plasma dp-ucMGP. Lung function assessments were the forced expiratory volume during the first second (FEV1) and forced vital capacity (FVC). FEV1/FVC-ratio was calculated as the ratio between these two measurements.

In the questionnaires, researchers asked participants whether they had ever been diagnosed with either asthma or COPD, or whether they had experienced wheezing during the last 12 months. They then used multivariable logistic regression to assess the associations between dp-ucMGP and the dichotomous variables, COPD, asthma and wheezing.

Vitamin K status and lung function

A total of 4,092 individuals aged 24-77 years were included in the analysis.

Lower vitamin K status, reflected by higher dp-ucMGP levels, was associated with lower FEV1 and FVC. However, dp-ucMGP was not associated with the FEV1/FVC-ratio. A lower status was significantly associated with COPD (Odds ratio, OR = 2.24, 95% CI 1.53 – 3.27), wheezing (OR = 1.81 95% CI 1.44 – 2.28) and asthma (OR = 1.44 95% CI 1.12 – 1.83).

Lead author of the study, Dr Torkil Jespersen, said: ‘We already know that vitamin K has an important role in the blood, and research is beginning to show that it’s also important in heart and bone health, but there’s been very little research looking at vitamin K and the lungs.

‘To our knowledge, this is the first study on vitamin K and lung function in a large general population. Our results suggest that [it] could play a part in keeping our lungs healthy.‘

The vitamin is found in leafy green vegetables, vegetable oils and cereal grains. It plays a role in blood clotting, although, clinically, vitamin K antagonists are used as anticoagulants to control bleeding.

Oral dexpramipexole significantly lowers absolute eosinophil count in asthma

8th August 2023

Oral dexpramipexole significantly reduced blood absolute eosinophil count (AEC) after 12 weeks compared to placebo in patients with eosinophilic asthma, highlighting the potential value of oral therapy for these patients.

The EXHALE trial, published in the Journal of Allergy and Clinical Immunology, was a randomised, double-blind, placebo-controlled proof-of-concept trial, in adults with inadequately controlled moderate to severe asthma and an AEC greater than or equal to 300/μL.

Patients were randomly assigned to one of three dexpramipexole doses: 37.5 mg, 75 mg and 150 mg, or matching placebo, all given twice daily. The primary endpoint was the relative change in AEC from baseline to week 12.

The prebronchodilator FEV1 week-12 change from baseline was a key secondary endpoint, and the nasal eosinophil peroxidase level was used an exploratory endpoint.

Absolute eosinophil counts

A total of 103 subjects were included and randomised to one of the four treatment arms.

At week 12, dexpramipexole significantly reduced the placebo-corrected AEC ratio to baseline by 77% and 66% for the 150 mg and 75 mg doses, respectively (ratio = 0.23, 95% CI, 0.12 – 0.43, p < .0001, ratio = 0.34, 95% CI 0.18 – 0.65, p = 0.0014).

Dexpramipexole also reduced the exploratory endpoint of nasal eosinophil peroxidase, a biomarker of airway eosinophilia, at week 12 compared to baseline in the both the 150 mg and 75 mg dosage groups (p = 0.020 and 0.021 respectively).

Placebo-corrected FEV1 increases were observed starting at week four, although this increase was not significant. Dexpramipexole displayed a favourable safety profile.

Dexpramipexole and asthma

Dexpramipexole is a small, oral eosinophil-lowering drug currently in Phase 3 development for eosinophilic asthma. The drug inhibits the maturation of eosinophils in the bone marrow based on evidence from cell cultures and human biopsies, thereby lowering peripheral blood eosinophil levels.

According to the Global Initiative for Asthma, asthma affects more than 300 million people worldwide. Estimates suggest half to two-thirds of those with severe asthma have the eosinophilic phenotype, in which there is an increased level of eosinophils.

Although moderate-to-severe disease can be managed by monoclonal antibodies such as tezepelumab, these drugs are only available for injection. If approved, oral dexpramipexole could provide a compelling alternative to injectable biologics and could potentially be used earlier in the asthma treatment paradigm to prevent progression of disease.

Working with primary care to optimise severe asthma management

11th May 2023

Professor Adel Mansur specialises in asthma, leading one of the largest severe asthma clinics in the UK. Here, he discusses the centre’s involvement in primary care diagnostic hubs and his most recent practice-altering research.

Adel Mansur is a consultant physician at University Hospitals Birmingham NHS Foundation Trust and honorary professor in respiratory medicine at the University of Birmingham. Originally from Libya, where he attended medical school, Professor Mansur completed a research PhD in asthma genetics at the University of Leeds and joined Heartlands Hospital as a consultant in 2002.

Asthma is where Professor Mansur’s specialist interest lies, and he leads the trust’s severe asthma service – one of the largest and busiest centres of its kind in the UK, serving a local population of over 1.5 million and a regional population of 7.3 million.

Please tell us about your institution and the work it is doing in respiratory medicine

We are a regional hub centre for severe asthma, so we receive referrals from across the region, from the West Midlands and beyond. Because of that, it’s a busy centre. There are currently just over 1,000 patients with severe asthma seen at the hub, and on a weekly basis we see 50 to 60 patients. We have a multidisciplinary team looking after our patients, comprised of doctors, specialist asthma nurses, physiotherapists, psychologists and speech therapists.

Our service is geared to deal with the complex and multifactorial disease of difficult to treat asthma, which forms a minority group of all asthma. However, most patients with asthma in primary care have mild or moderate disease but still many remain uncontrolled due to inadequate access to good quality diagnostics and treatment optimisation rather than because of disease severity. On this basis, we piloted with our primary care colleagues in Birmingham a respiratory community diagnostic hub. This provided a service of high-quality diagnostic and specialist input to optimise treatment and triage patients when necessary to our severe asthma network. We were pleased with the pilot outcomes, which led to its adoption by NHS locally and was also quoted by NHS England as an exemplar model.

We believe that we have now a good integrated pathway model in our locality to build on. The University Hospitals Birmingham NHS Foundation Trust still, however, receives 2,000 admissions every year due to asthma – the majority of which would be preventable with proper management in the community, thus arguing for increased capacity of this service model. 

What are the wider benefits of this approach for patients and clinicians?

In many respects what we’re trying to do is to filter out those who are sub-optimally managed before they come to us. However, poorly controlled asthma can become severe, and that’s the danger that people will end up with sub-optimally managed disease that deteriorates to become more severe. It’s about being able to find those patients first, and that’s what the diagnostic hubs are doing.

Uncontrolled asthma is serious on its own because patients are exposed to potentially fatal attacks. A study looking at fatality in asthma found almost 60% of patients who sadly died from asthma attacks did not have severe asthma, but instead had uncontrolled asthma and weren’t on appropriate medication. This is a major current issue for which there are guidelines aimed at improving asthma management and outcomes. However, the implementation of such guidelines has been a challenge across the board, although I believe that progress has been made in terms of recognition of this issue and provision of clearer asthma management pathways for patients.

When you’ve optimised patients with uncontrolled asthma, you are left with around 10-20% who have severe asthma and will need, for example, a biologic treatment. For the majority of the others, regular preventer inhalers are usually adequate to control their asthma.  

I would say up to 90% of asthma is a primary care issue that, with the right treatment and support, should be controlled. Those patients’ management would be best served in the community and wouldn’t require referral to come to severe asthma centres.

Does your institution have any preceptorship or training programmes for clinicians?

Yes, for example we have a research fellowship where junior doctors could do research with us as well as getting clinical experience. That could be for year, or two or three. We have visitors from different disciplines who come to sit in our clinics and shadow our multidisciplinary team members for experience. They’re not just doctors, we have visitors from various disciplines including pharmacists, physiotherapists, speech therapists and nurses who come from primary or secondary care, or even tertiary severe asthma centres, looking for exchange of expertise. We currently have a pharmacist from Saudi Arabia spending three years with us doing his PhD on treatment adherence in severe asthma.

What are the main active areas of clinical research your centre?

At Heartlands, we have a respiratory research clinical trials unit, where we take part in various clinical trials that include cystic fibrosis, COPD, interstitial lung disease, occupational lung disease, asthma and some other acute presentation conditions such as pneumonia. It’s an active and large R&D department, so there are many other disciplines. Sometimes there is some overlap with other departments, for example, research into infectious diseases, Covid and viruses. 

Primarily, I do clinical work, but I take part in research as an academic as well. With clinical work you have more direct interaction with patients, and more insight into patients’ needs. We can use that to explore the main research questions, and that will lead to conducting trials or taking part in studies locally. That could be through collaborations with other centres, either in the UK or internationally. 

We then apply that in the clinic because clinical trials allow us to adopt cutting-edge treatments for our patients. They allow us to take the lead in providing our patients with access to cutting-edge and novel treatments, which, in many ways, transform the lives of many of our patients.

Can you tell us about a key clinical paper that your organisation has published recently, and what was the rationale and outcome?

We developed in-house an assay for measuring prednisolone and cortisol simultaneously in the blood using high-performance liquid chromatography and spectrometry methodology. There are currently about four centres in the UK who provide this test clinically.  

One of the issues in severe asthma is that 40% of patients are on oral maintenance steroids, and we assume that if a patient is prescribed 30mg prednisolone daily, for example, that is what they take. But with the assay we developed, we could actually look for adherence to prednisolone. We’ve done a case-controlled study using this assay among patients who are on steroids and patients who aren’t. We found that 40% of patients who are meant to be on maintenance steroids are not taking it. The assay results from non-adherent patients were similar to those who were not on maintenance prednisolone.  

Now, we use the assay in practice and around our network, and it has been advocated by NHS England as well. We don’t really want our patients to be on maintenance steroids because there are newer treatments available now, and steroids are a legacy treatment that should be a last resort.  

But we still have a substantial number of patients who are prescribed maintenance steroids, and knowing if they are taking the treatment or not is crucial – if they’re not we’ll stop the prescription of prednisolone and look for other treatments. The assay has also proved useful in managing adherent patients by allowing us to taper the prednisolone dose in a more controlled way. So, this is an example of something we developed here that has been quite crucial for the way we manage our severe asthma patients.

Tell us about your research on the severe asthma registry

We have a registry for all of our severe asthma patients. There’s a local one and a national one, and the registry nationally produced more than 20 papers in good-impact journals in the last 10 years or so. One of the recent publications, of which I was the primary author, was on the UK practice of biologics in asthma. It looked at variation in practice between different centres, using registry data. We also looked at the outcomes of various biologics and observed that seven to eight in 10 patients do get a worthwhile benefit from biologic treatments. 

The aim of having the registry for severe asthma is to promote standardisation of care across the country as well as cross-learning between different centres and adding to debate. We complemented the severe asthma registry analysis with a survey of specialists across the UK. We asked specialists why they choose a certain biologic over others, and which one they would start with and why, and we found variation in practice. It largely stems from the fact that there wasn’t a head-to-head trial to say one biologic is better than another one.

Looking forward, what are the current unmet needs in severe asthma and how will these challenges be tackled?

There is always going to be unmet need. We are not going to run out of jobs here, that’s for sure! One thing is the adherence issue, either to a biologic or to other preventer treatments. As humans we don’t like to adhere to things consistently. Some people can master it, but a lot of us can’t. So how can we really help people to have a treatment regime that works for them, and which they can maintain?

There are things like the interconnected digital inhaler, with sensors connected to the inhaler itself, which we are working on. I feel future practice in severe asthma will mean that the majority of patients will have smartphone apps with sensors connected to their inhalers. They’ll have their management plan and their treatment records on their app, which the physician can see on a separate platform, so we know when there are gaps in treatment.

The cost of severe asthma management to health services is high. Ensuring basic treatment in the form of regular use of preventer inhaler therapy may prove effective in controlling asthma without the need to escalate to expensive biologic treatment, as well as reducing burden to the NHS through a reduction in emergency room visits and hospital admissions. The adoption of digital inhalers as routine in severe asthma services is likely to be a much cheaper way of making sure patients’ disease remains under control. I think most severe asthma patients should be, at least in part, on this type of electronically monitored treatment.

Another unmet need is biologics – we still don’t have long-term data on those. I have seen patients whom, after two or three years, will have a viral illness or other trigger and then they feel the treatment is not working as it used to be. Or they suddenly start to flare up, so we look at switching biologics. Sometimes that works, but why does it happen in asthma? Why do some people have a super response, like remission, while others have had some response but still get exacerbations, and they still have residual disease of significance?

We have patients who have not been lucky enough to get a biologic treatment because of their disease type. They are not what we call T2-high, which is a type-2 inflammation that responds well to currently available biologic agents. About 20-30% of patients within the service are in this T2-low class, and these are the ones for whom there is unmet treatment need. Unfortunately, the asthma-related clinical outcomes of this group of patients remain significantly worse than those who could have, and respond well to, biologic treatments.

What other treatments do you see becoming available in the coming years for severe asthma?

Things have moved on hugely in terms of the availability of good treatment for patients with severe asthma since I started practising 20 years ago. Our main treatment was lots of steroids, which, as lifesaving as they are, have short- and long-term serious side effects. We then had other things of questionable efficacy such as continuous terbutaline infusion. Nowadays, treatment for severe asthma has been transformed by a precision medicine era with the development of effective yet safe treatment options in the form of biologic treatments. There are currently six NICE-approved biologics and these cover around 60-70% of patients with severe asthma.

Tremendous progress has been made in dissecting the immunological cascades and mechanistics of inflammation in asthma. This provided plethora of therapeutic targets with many currently being trialled for asthma in general and severe asthma in particular. For example, there is a drug called masitinib, which is a tyrosine-kinase inhibitor that is being trialled as a possible treatment for asthma. Another example is the ongoing trialling of JAK-family inhibitors as a treatment option in asthma.

How is your organisation adapting to the demand and developments in this area of medicine?

In addition to us being the hub here at Heartlands, we created a severe asthma network that included various centres – or spokes – within the West Midlands, Derbyshire and Gloucestershire, which covers a total population of 7.3 million people. Currently, the network is comprised of about 10 spokes. The spokes can initiate biologics in their respective hospital following approval from a monthly conducted regional multidisciplinary meeting with the hub. This model increased our region service capacity so patients can get the treatment in a quicker time and could have it initiated closer to home than if all patients have to travel to the hub in Birmingham.

This model provided resilience to service delivery due to the high number of asthma specialists included in the running of the service. We have 10 physicians, for example, and more than 10 nurses, who serve the network, contrasted to a small group in any single centre. So, that has been one of the strong points for our service – having a good, strong network. We are maintaining the quality through the performance and standardisation of patients being presented. That’s led to a successful network. It’s still a work in progress, as always, but we think we have good infrastructure.

Research suggests asthmatics at increased risk of cancer

Asthmatics have a higher risk of developing cancer, though use of inhaled steroids may have a slight protective effect, according to a US study.

Globally, cancer is the leading cause of mortality, with nearly 10 million recorded deaths in 2020. Data suggests that infection and inflammation contribute to a quarter of all cancers. In fact, the inflammatory milieu within a tumour seems to be an indispensable participant in tumour progression. In asthmatics, the inflammatory nature of their condition increases the risk of lung cancer. Nevertheless, other data either demonstrate a positive association or no association with the risk of other cancers.

In the current study, researchers sought to better understand the relationship between asthma and cancer risk. They analysed electronic health records in a US claims database. The team developed a matching cohort of those with and without asthma which served as the control group. Using regression models, researchers searched for any relationship between asthma and the subsequent development of cancer. The primary outcome was the time to a cancer diagnosis after the date of an asthma diagnosis. 

Asthmatics and risk of cancer

The asthma cohort included 90,021 individuals matched to 270,063 without the disease. In multivariable analysis, asthmatics were more likely to develop cancer (hazard ratio, HR = 1.36, 95% CI 1.29 – 1.44). For example, significantly higher risks were observed for melanoma, blood, kidney and lung cancers. However, in contrast, risks were non-significant for bladder, colorectal and prostate cancers.

In a separate analysis examining the effect of inhaled steroid use, the overall cancer risk was slightly lower among steroid users (HR = 1.60 vs 1.11, inhaled steroid vs no steroid). Taken together, cancer risk was higher for nine of 13 cancers in asthmatics not using inhaled steroids but in only two cancers among steroid users. These findings suggest a possible protective effect of inhaled steroid use on cancer risk that requires further evaluation.

Abdominal and general obesity linked with asthma and COPD in women

10th May 2023

An analysis suggests that both abdominal and general obesity are independently associated with asthma and COPD in women but not men.

There are several recognised co-morbidities associated with obesity including hypertension and asthma. In addition, the accumulation of more fat mass, is strongly associated with functional limitation among those with COPD. Moreover, other data suggest a positive association between abdominal obesity (AO) and asthma. This association appears to apply equally to both sexes. But whether abdominal or general obesity has a stronger association with either asthma or COPD is unclear.

The Respiratory Health in Northern Europe (RHINE) III study explored the independent association of abdominal and general obesity with asthma and COPD. In addition, the researchers examined any sex-related differences in these associations. In a cross-sectional study, the team used self-measured waist circumference (WC) as an index of AO. General obesity (GO) was a BMI ≥ 30.0 kg/m2. For the purposes of the analysis, a WC > 102 cm in males and ≥88 cm in females defined AO. Participants completed several questionnaires asking about respiratory symptoms and directly about a diagnosis of asthma and COPD.

Abdominal obesity and asthma or COPD

The study included data from a total of 12,290 participants of whom, 34.7% had AO and 6.7% GO. Abdominal obesity independently associated with the presence of wheeze (adjusted odds ratio, aOR = 1.40, 95% CI 1.24 – 1.58). This independent relationship was also present for GO (aOR = 1.96, 95% CI 1.70 – 2.27). There was a significant association between asthma and both AO and GO. In contrast, the association was only significant between COPD and GO (aOR = 2.14, 95% CI 1.54 – 2.99).

In relation to sex-related differences, asthma significantly associated with both AO (OR = 1.56) and GO in women (OR = 1.95) but not in men. This association also applied for COPD.

RSV infection during infancy increases subsequent asthma risk

2nd May 2023

RSV infection in healthy children during the first year of life increases the risk of developing asthma at age five.

Respiratory syncytial virus (RSV) is a viral pathogen leading to acute lower respiratory infection in young children. Global estimates suggest that the virus causes 6.6 million infections in those aged 0-6 months and over 45,000 deaths.

Whether RSV infection during this crucial period of lung development could subsequently lead to asthma is uncertain. INSPIRE was a surveillance study including children with or without an RSV infection (RSVI) during infancy. Monitoring of children took place over the next five years.

The main hypothesis was that avoiding an RSVI during infancy reduces the risk of childhood asthma. The primary outcome was five-year current diagnosed asthma and finding from the INSPIRE study have been recently published.

RSV infection and development of asthma

A total of 1,741 children had available data during the first year of life. Among the entire cohort, 54% had an RSVI during that first year.

Over the next five years, not having an RSVI gave rise to a 26% lower risk of developing asthma (relative risk, RR = 0.74, 95% CI 0.58 – 0.94, p = 0.016). The authors estimated that 15% (95% CI 2.2-26.8) of current five-year asthma cases could be prevented by avoiding a RSVI.

The researchers commented that among healthy children, not being infected with RSV in the first year of life was associated with a substantially reduced risk of developing childhood asthma. However, they recognise that their study was unable to establish a causal relationship.