Advance In Asthma 2009


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Advance In Asthma 2009

  1. 1. Advance in asthma 2009 w.pongsak,MD
  2. 2. introduction <ul><li>Recent studies in 2009 </li></ul><ul><li>Asthma and obesity </li></ul><ul><li>Genetics </li></ul><ul><li>Biomarkers </li></ul><ul><li>Environment </li></ul><ul><li>Therapeutics </li></ul>
  3. 3. Obesity and asthma <ul><li>Obesity and lung physiology </li></ul><ul><li>- reduction in pulmonary compliance,lung </li></ul><ul><li>volume,diameter of small airway, </li></ul><ul><li>circulation,perfusion </li></ul><ul><li>- How about effect on spirometry ? </li></ul><ul><li>decrease FVC,FEV1 but FEV1/FVC unchange </li></ul><ul><li>decrease FRC esp . ERV </li></ul><ul><li>- decrease diameter of small airway due to </li></ul><ul><li>alteration of actin myosin cross bridge </li></ul><ul><li>cycle => increase obstruction and BHR </li></ul>
  4. 6. <ul><li>Obesity and inflammatory mediators </li></ul><ul><li>- increase TNF- α (present in adipocyte)=>link </li></ul><ul><li>to Th2 cytokine </li></ul><ul><li>- increase IL-6 increase in both obesity and </li></ul><ul><li>asthma </li></ul><ul><li>- increase leptin from adipocyte => in animal </li></ul><ul><li>model increase lung inflammation and BHR </li></ul><ul><li>- decrease adipokines => anti-inflam. </li></ul><ul><li>property </li></ul>
  6. 10. <ul><li>Prospective studies </li></ul><ul><li>- Ford et al. N= 317/9,456 f/u 9 yrs </li></ul><ul><li>obesity increase risk of asthma </li></ul><ul><li>Eur Resp J. 2004;24:740-4 . </li></ul><ul><li>- Nystad et al N = 4218/135405 8 yrs </li></ul><ul><li>increase BMI increase risk of asthma </li></ul><ul><li>both male and female </li></ul><ul><li>Am J Epidemiol. 2004;160:969-76. </li></ul><ul><li>- McLachan et al N= 925 increase BMI </li></ul><ul><li>associate with asthma in female </li></ul><ul><li>J Allergy ClinImmunol. 2007 Mar;119 (3):634-9. </li></ul>
  7. 11. 1.56
  8. 12. Conclusion = failed to find an association between obesity and asthma control in an urban population with asthma .
  9. 13. 1.57 Conclusion = weight gain decrease in lung function in asthmatic patients N=638
  10. 14. 1.58 Conclusion = positive association between BMI and asthma risk that was similar in magnitude to those observed in longitudinal studies of white women
  11. 15. J Allergy Clin Immunol 2009;123:1328-34 . 1.59 N= 1,265
  12. 16. J Allergy Clin Immunol 2009;123:1328-34 . 1.59 Conclusions: Increased BMI is not associated with clinically significant worsening of impairment in subjects with mild to moderate persistent asthma.
  13. 17. Asthma and genetic Genetics
  14. 18. Asthma and genetic
  15. 21. Genetics <ul><li>Several genetic studies suggest possible therapeutic application </li></ul><ul><li>TSLP varients associate with asthma and bronchial hyperresponsiveness </li></ul><ul><li>Urokinase plasminogen activator receptor gene (PLAUR) </li></ul><ul><li>Varient of IL-4 gene </li></ul><ul><li>Arg 16 phenotype of β 2-adrenergic receptor agonist gene (ADRB2) associate with asthma exacerbation </li></ul>
  16. 22. 1.14 J AllergyClin Immunol 2009;124:1188-94 N= 1,182
  17. 23. J AllergyClin Immunol 2009;124:1188-94 1.14 Conclusion: The Arg16 genotype of ADRB2 is associated with exacerbations in asthmatic children and young adults exposed daily to b2-agonists
  18. 24. Biomarker for asthma <ul><li>Exhaled nitric oxide level : absolute level or personal best ? </li></ul><ul><li>FeNO and cost effectiveness </li></ul><ul><li>IgE level and asthma </li></ul><ul><li>IgE level correlate with asthmatic </li></ul><ul><li>symptom only in atopic asthma </li></ul><ul><li>J Allergy Clin Immunol 2009;124:447-53 </li></ul><ul><li>Biomarker of chronic persistant asthma </li></ul><ul><li>Bronchial provocation test </li></ul><ul><li>- mannitol bronchoprovocation test </li></ul><ul><li>- sensitivity and specificity </li></ul>
  19. 25. 1.19 N=73
  20. 26. Conclusion : Targeting FENO on reference values is not justified.
  21. 27. 1.20
  22. 30. Conclusion : Conventional asthma management resulted in good control of symptoms in most participants. The addition of fraction of exhaled NO as an indicator of control of asthma resulted in higher doses of inhaled corticosteroids, without clinically important improvements in symptomatic asthma control.
  23. 31. 1.22
  24. 32. 1.23 N=34
  25. 34. middleton 6 th edition
  26. 35. J Allergy Clin Immunol 2009;124:928-32 . 1.25 N=238
  27. 36. J Allergy Clin Immunol 2009;124:928-32 . 1.25 Area = 0.89 Conclusions : In an unselected sample of young adults, bronchial provocation with inhaled dry-powder mannitol had a high diagnostic specificity for the diagnosis of asthma .
  28. 37. Environment <ul><li>Pollution ,viral infection and social stress are studied in 2009 </li></ul><ul><li>Air pollution </li></ul><ul><li>- positive correlation of FEV1 and </li></ul><ul><li>distance from roadways </li></ul><ul><li>- ozone increase risk of asthma </li></ul><ul><li>Difference of viral infection in asthma and non asthma </li></ul>
  29. 38. 1.31
  30. 40. Conclusions: These findings suggest that subjects with mild allergic asthma and healthy subjects have similar cold symptoms and inflammatory and antiviral responses.
  31. 41. Therapeutics <ul><li>Leukotriene modifiers </li></ul><ul><li>- increase risk of suicide or not </li></ul><ul><li>- effect on behavior </li></ul><ul><li>ICSs </li></ul><ul><li>- increase dose of ICSs or add LABA </li></ul><ul><li>- high dose or low dose ICSs/LABA </li></ul><ul><li>- early or delay ICSs </li></ul>
  32. 42. J Allergy Clin Immunol 2009;124:699-706 . 1.34
  33. 43. J Allergy ClinImmunol 2009;124:691-6 . 1.35
  34. 44. J Allergy ClinImmunol 2009;123:116-21 1.41
  35. 45. Conclusion: Although symptomatic control and rescue bronchodilator use may be improved by the addition of a LABA to ICS, there may be a lower risk of severe exacerbations and hospitalizations from ICS dose increase. Oral steroid use : lower in ICS group ( 22%vs 27%) Hospitalization : lower in ICS group ( 1.3% vs 1.7%) J Allergy ClinImmunol 2009;123:116-21
  36. 46. 1.42
  37. 48. ns ns ns Conclusion : low dose fixed combination and reliever therapy is associated with higher eosinophil counts, but these remain within the range associated with stable clinical control.
  38. 49. J Allergy Clin Immunol 2009;124:1180-5. 1.43
  39. 51. Conclusions: relative mild asthmatic patients with delay ICS Rx had elevate inflammatory markers but no clinical difference compare with early ICS Rx
  40. 52. Take home message <ul><li>Relationship of asthma and asthma </li></ul><ul><li>New genetic susceptibility for asthma </li></ul><ul><li>Mannitol challenge test </li></ul><ul><li>Early and delayed ICS </li></ul><ul><li>Information for monteleukast </li></ul><ul><li>FENO </li></ul>
  41. 53. Thank you for your attention
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