Anti-inflammatory Treatment of Atopic Asthma Guided by Exhaled Nitric Oxide: A Randomized, Controlled Trial

• Published in: The journal of allergy and clinical immunology in practice 2013, Vol.1 (6), p.639-648.e8
• Main Authors: Syk, Jörgen, MD, Malinovschi, Andrei, MD, Johansson, Gunnar, MD, Undén, Anna-Lena, PhD, Andreasson, Anna, PhD, Lekander, Mats, PhD, Alving, Kjell, PhD
• Format: Article
• Language: English
• Subjects: Adolescent; Adrenal Cortex Hormones - therapeutic use; Adrenergic beta-2 Receptor Agonists - therapeutic use; Adult; Allergy and Immunology; Anti-Asthmatic Agents - therapeutic use; Anti-Inflammatory Agents - therapeutic use; Asthma; Asthma - complications; Asthma - prevention & control; Asthma - psychology; Atopy; Breath test; Breath Tests - methods; Clinical trials; Confidence intervals; Corticosteroid; Drug therapy; Exacerbation; Female; FENO; Humans; Internal Medicine; Leukotriene Antagonists - therapeutic use; Leukotriene receptor antagonist; Male; Medicin och hälsovetenskap; Middle Aged; Nitric Oxide - analysis; Primary care; Quality of Life; Questionnaires; Rhinitis, Allergic, Perennial - complications; Rhinitis, Allergic, Perennial - prevention & control; Rhinitis, Allergic, Perennial - psychology; Studies; Treatment Outcome; Young Adult
• ISSN: 2213-2201; 2213-2198; 2213-2201
• DOI: 10.1016/j.jaip.2013.07.013

Background Atopic asthma is characterized by Th2 cytokine–driven inflammation of the airway mucosa, which is signaled by the fraction of exhaled nitric oxide (FE NO). Objective We tested whether an FE NO-guided anti-inflammatory treatment algorithm could improve asthma-related quality of life and asthma symptom control, and reduce exacerbations in atopic asthmatics within primary care. Methods Altogether, 187 patients with asthma and who were nonsmokers (age range, 18-64 years) with perennial allergy and who were on regular inhaled corticosteroid treatment were recruited at 17 primary health care centers, randomly assigned to 2 groups and followed up for 1 year. For the controls (n = 88), FE NO measurement was blinded to both operator and patient, and anti-inflammatory treatment was adjusted according to usual care. In the active group (n = 93), treatment was adjusted according to FE NO. Questionnaires on asthma-related quality of life (Mini Asthma Quality of Life Questionnaire) and asthma control (Asthma Control Questionnaire) were completed, and asthma events were noted. Results The Asthma Control Questionnaire score change over 1 year improved significantly more in the FE NO-guided group (–0.17 [interquartile range {IQR}, −0.67 to 0.17] vs 0 [−0.33 to 0.50]; P  = .045), whereas the Mini Asthma Quality of Life Questionnaire score did not (0.23 [IQR, 0.07-0.73] vs 0.07 [IQR, −0.20 to 0.80]; P  = .197). The change in Asthma Control Questionnaire was clinically important in subpopulations with poor control at baseline ( P  = .03). Furthermore, the exacerbation rate (exacerbations/patient/y) was reduced by almost 50% in the FE NO-guided group (0.22 [CI, 0.14-0.34] vs 0.41 [CI, 0.29-0.58]; P  = .024). Mean overall inhaled corticosteroid use was similar in both groups ( P  = .95). Conclusion Use of FE NO to guide anti-inflammatory treatment within primary care significantly reduced the exacerbation rate and improved asthma symptom control without increasing overall inhaled corticosteroid use.