Remotely Monitored Therapy and Nitric Oxide Suppression Identifies Nonadherence in Severe Asthma

Abstract

Research Impact-These data demonstrate that profiling the FeNO and blood eosinophil response to inhaled corticosteroids (ICS) in subjects with difficult-to-control severe asthma using remote monitoring technology is useful for clinical phenotyping. It differentiates subjects who will respond well with better adherence to high dose ICS/LABA therapy from those subjects who may require progression to additional treatment. This strategy will be of value in identifying ICS-responsive subjects prior to recruitment to clinical trials investigating interventions which are "add-on" treatments to standard care, and to mechanistic studies investigating "true" inhaled steroid-resistant asthma.

Less is more: the impact of maintenance treatment adherence in severe asthma clinical trials

“…Crucially, there is no gold standard method for the measurement of adherence, with figures often generated using various information sources including direct patient questioning, prescription pick-up rates and inhaler dose counters [9]. More recently, inhaler devices designed for objective remote adherence monitoring have been developed and fractional exhaled nitric oxide suppression tests have been suggested as a method of discerning "adherent" from "non-adherent" subgroups [10,11]. Phase III RCTs of biological therapies for asthma typically recruit subjects who, despite being prescribed high-dose ICS/ LABA and sometimes frequent OCS courses or maintenance OCS, remain symptomatic with ongoing exacerbations and evidence of type 2 high airway inflammation.…”

Beyond T2-inflammation: What Does the Future Hold for Severe Asthma?

“…The electronic monitoring device INhaler Compliance Assessment (INCA™) was used in combination with a 7-day period of daily FeNO monitoring (the FeNO Suppression Test) in difficult-to-control, severe asthmatics with FeNO > 45ppb. Positive FeNO suppression test (as defined by a reduction in FeNO of ≥ 42%), in the setting of appropriate inhaler use, prior to one month of monitoring was associated with significant improvements in lung function that were not observed in those who did not suppress their FeNO, although both groups demonstrated improvement in symptom scores 25 , and these results suggest that there may be benefit to implementing systematic adherence assessments in the clinical setting. "Smart inhalers" with the ability to objectively monitor and prompt inhaler use present an opportunity to improve outcomes in asthma, and the potential benefits have been recognised by bodies such as Asthma UK 27 although challenges would be faced in effectively implementing this technology into healthcare systems.…”

Exhaled volatile organic compounds for better asthma control: could it be a future noninvasive adherence test?

“…As inhaled corticosteroids act in part by decreasing local eosinophilic inflammation, this suggests that VOCs are promising biomarkers that would possibly be used to detect poor adherence to ICS. Fractional exhaled nitric oxide (F eNO ), another exhaled biomarker, has also been suggested as a good surrogate marker for sputum eosinophil counts [9] and adherence to ICS [10]. Certain considerations should, however, be applied when interpreting F eNO values as they are influenced by various factors [11].…”